Breast Cancer Prevention and Early Detection

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Paying for breast cancer screening

This section gives a brief overview of the laws that require private health plans, Medicaid, and Medicare to cover early detection services for breast cancer screening.

Federal law

Coverage of mammograms for breast cancer screening is mandated by the Affordable Care Act, which provides that these be given without a co-pay or deductible in plans that started after August 1, 2012. This doesn’t apply to health plans that were in place before the law was passed (called grandfathered plans). You can find out the date your insurance plan started by contacting your health insurance plan administrator. Even grandfathered plans may still have coverage requirements based on state laws, which vary, and other federal laws.

State efforts to ensure private health insurance coverage of mammography

Many states require that private insurance companies, Medicaid, and public employee health plans provide coverage and reimbursement for specific health services and procedures. The American Cancer Society (ACS) supports these kinds of patient protections, particularly when it comes to evidence-based cancer prevention, early detection, and treatment services.

The only state without a law ensuring that private health plans cover or offer coverage for screening mammograms is Utah. Of the remaining 49 states, only 22 cover mammograms yearly for women 40 and older. The remaining 27 have less generous coverage. Laws on coverage may vary slightly from state to state, so check with your insurer to see what’s covered. Note that state laws don’t affect self-insured (self-funded) health plans.

Source: National Women’s Law Center. Screening Coverage Mandates: Mammogram. Accessed at http://hrc.nwlc.org/policy-indicators/mammogram on September 10, 2014.

Self-insured plans

Self-insured or self-funded plans do not have to follow state laws about breast cancer screening. They are governed by the Affordable Care Act (ACA), and are required to cover breast cancer screening. The exception is any self-insured plan that was in effect before the ACA was passed. These plans are called grandfathered, and they don’t have to provide coverage based on what the ACA says.

Many employers offer self-insured plans. These plans pay employee health care costs from the employer’s own funds, even though they usually contract with another company to track and pay claims. You can find out if your health plan is self-insured by contacting your insurance administrator at work or reading your Summary of Plan Benefits. Women covered by self-insured employer plans should check with their health insurance administrator to see what breast cancer early detection services are covered.

Medicaid

All state Medicaid programs plus the District of Columbia cover screening mammograms. This coverage may or may not conform to American Cancer Society guidelines. State Medicaid offices should be able to provide screening coverage information to interested individuals. The Medicaid programs are governed by state legislation and regulation, so assured coverage is not always apparent in legislative bills.

In addition, all 50 states plus the District of Columbia have opted to provide Medicaid coverage for all women diagnosed with breast cancer through the Centers for Disease Control and Prevention’s (CDC’s) National Breast and Cervical Cancer Early Detection Program (see the next section), so that they may receive cancer treatment. States vary in the age, income and other requirements that women must meet in order to qualify for treatment through the Medicaid program. (All 50 states, 4 U.S. territories, the District of Columbia, and 13 American Indian/Alaska Native organizations participate in the National Breast and Cervical Cancer Early Detection Program.)

National Breast and Cervical Cancer Early Detection Program

States are making breast cancer screening more available to medically underserved women through the National Breast and Cervical Cancer Early Detection Program (NBCCEDP). The NBCCEDP attempts to reach as many women in medically underserved communities as possible, including older women, women without health insurance, and women who are members of racial and ethnic minorities. Age and income requirements vary by state.

The program provides both screening and diagnostic services to low-income, uninsured, and underserved women for free or at very low cost, including:

  • Clinical breast exams
  • Mammograms
  • Pap tests
  • Diagnostic testing for women whose screening results are abnormal
  • Surgical consultations
  • Referrals to treatment

Though the program is administered within each state, tribe, or territory, the Centers for Disease Control and Prevention (CDC) matches funds and support to each program.

Since 1991 when the program began, it has provided millions of screening exams to underserved women and diagnosed more than 60,000 breast cancers. Due to limited resources, though, less than 1 in 8 eligible women aged 40 to 64 is able to be screened for breast cancer through this program nationwide.

In 2000, Congress passed the Breast and Cervical Cancer Prevention and Treatment Act, giving states the option to offer women in the NBCCEDP access to treatment through Medicaid. All 50 states plus the District of Columbia provide Medicaid coverage for women diagnosed with breast cancer through the NBCCEDP, so that they have a way to pay for treatment.

Each state’s Department of Health will have information on how to contact the nearest CDC screening and early detection program in your area. For more information, please contact the CDC at 1-800-CDC-INFO (1-800-232-4636) or through their website at www.cdc.gov/cancer.

Medicare

As a part of the Affordable Care Act, Medicare covers the full cost of a screening mammogram once every 12 months for all women with Medicare aged 40 and over. Diagnostic mammograms are covered with a 20% copay after the part B deductible is met. (Medicare also pays for a clinical breast exam when it is done for screening or prevention.


Last Medical Review: 09/10/2014
Last Revised: 09/10/2014