Paying for breast cancer screening

This section provides a brief overview of laws assuring coverage for private health plans, Medicaid, and Medicare coverage of 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 beginning with plan years starting after August 1, 2012. This doesn’t apply to health plans that were in place before it was passed (called grandfathered plans). Those plans are covered by 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 (see table below). Of the remaining 49 states that have enacted either assured benefits or ensured offerings for mammography coverage, many states do not conform to ACS guidelines and are either more or less "generous" than ACS recommendations. Some states like Rhode Island, however, specifically state in their legislative language that mammography screening should be covered according to the ACS guidelines.

State mammography screening coverage laws

Other state efforts and self-insured plans

Other types of health coverage also provide screening mammograms. Public employee health plans are governed by state regulation and legislation, and many cover screening mammograms. Self-insured plans are not regulated at the state level, which means women in these plans do not necessarily get screening mammogram benefits, even if there are laws in the state to cover such benefits. Self-insured plans are typically large employers. Women who have self-insured-based health insurance should check with their health plans 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. This option allows states to receive significant matching funds from the federal government. 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). This program provides breast and cervical cancer screening to low-income, uninsured, and underserved women for free or at very low cost. 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, 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) provides matching funds and support to each program.

Since 1991 when the program began, it has provided more than 10 million screening exams to underserved women and diagnosed more than 51,000 breast cancers, more than 142,000 pre-cancerous cervical lesions, and more than 2,900 cervical cancers. Now that the program is firmly established, doctors are detecting new cancers at their earliest stages, leading to longer-term survival. These accomplishments demonstrate a truly nationwide effort. Unfortunately, however, due to limited resources, only about 1 in 7 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 have opted to 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 web site at www.cdc.gov/cancer.

Medicare

As a part of the Affordable Care Act, Medicare covers the full cost of a mammogram once every 12 months for all women with Medicare aged 40 and over. (Women are eligible for Medicare if they are age 65 and older, are disabled, or have end-stage renal disease.) Medicare also pays for a clinical breast exam when it is done for screening or prevention.