Mammograms are screening tests used for early breast cancer detection and for breast evaluation. State law requires that all disability, group disability, health maintenance organizations, and health service contractor (collectively known as health carriers) plans provide coverage for screening or diagnostic mammography services upon the recommendation of the patient's physician or advanced registered nurse practitioner.
Under the Affordable Care Act, health benefit plans must provide, at a minimum, coverage with no cost sharing, for preventive or wellness services that have a rating of A or B in the current recommendations of the United States Preventive Services Task Force (USPSTF). The USPSTF currently recommends, at a B grade, biennial screening mammography for women aged 50 to 74 years.
For non-grandfathered health plans issued or renewed on or after January 1, 2024, that include coverage of supplemental and diagnostic breast examinations, health carriers may not impose cost sharing on these examinations. For health plans that are offered as a qualifying health plan for a health savings account, the health carrier must establish the plan's cost sharing for coverage of these examinations at the minimum level necessary to preserve the enrollee's ability to claim tax exempt contributions from their health savings account under federal laws and regulations.
A "diagnostic breast examination" is a medically necessary and appropriate examination of the breast, including an examination using diagnostic mammography, breast magnetic resonance imaging, or breast ultrasound that is used to evaluate an abnormality that is seen or suspected from a screening examination or detected by another means. A "supplemental breast examination" is a medically necessary and appropriate examination of the breast, including an examination using breast magnetic resonance imaging or breast ultrasound that is used to screen for breast cancer when there is no abnormality seen or suspected and based on personal or family medical history or additional risk factors.
(In support) Screening mammography has reduced cancer by 40 percent and this bill is about the next step. These tests are often requested when something is seen or suspected through screening or the patient is at higher risk. This bill does not require coverage of these services because it is already required and so no defrayal is needed. The United States Preventive Services Task Force (USPSTF) is reviewing this issue now. One in eight women will be impacted by breast cancer. This bill is an equity bill. Your income or ability to access testing should not impact your ability to survive cancer.
The costs associated with diagnostic exams prevent people from following up on screening tests that indicate something may be wrong. This increases the number of people who discover cancer at later stages. This bill will increase access to timely treatment and prevent the devastating costs of late stage diagnoses. People should not have to make the choice of putting food on the table or getting diagnostic images completed when the choice could mean their life.
Cancer does not care if you can afford it and it does not care about your life. The ability to pay for these tests saves lives. Early diagnosis is supported by making these tests more available and it is the number one way to reduce costs down stream, get people back to work, and get them healthy. This bill supports the women of the state.
(Opposed) While the conversation around this bill is about cost sharing and not a benefit mandate, it still impacts costs and all of the health plan benefit requirements the Legislature is considering this year need to be thought through together. The USPSTF is looking at the analysis for mammography and the Legislature should wait until the analysis is complete to make a decision.
The Appropriations Committee recommended the following changes:
(In support) This bill addresses diagnostic imagining, which is the next step for patients after an abnormal mammogram or those with high-risk factors. Screening mammograms are cost free under the Affordable Care Act. The costs associated with diagnostic exams prevent people from following up on screening tests that indicate something may be wrong. This increases the number of people who skip tests and discover cancer at later stages when it is more expensive and harder to treat. Out-of-pocket costs are typically in the hundreds for diagnostic screenings and in the thousands for magnetic resonance imaging (MRIs), which are performed less often. This bill will increase access to timely treatment and prevent the devastating costs of late-stage diagnoses. People should not have to make the choice of putting food on the table or getting diagnostic images completed when the choice could mean their life. Your income or ability to access testing should not impact your ability to survive cancer.
This bill eliminates cost-sharing for these tests. The fiscal impact of this bill will affect low-income people enrolled in the Public Employees Benefits Board and the School Employees Benefits Board by allowing access to these tests. The impacts in commercial insurance markets will be greater, where people generally have lower coverage. There are fiscal benefits to the state from increases in insurance premium tax revenues. There are also fiscal benefits from catching cancer earlier which lowers costs for patients, payers, and the health care system. Intangible benefits include saving lives, keeping families together, and giving patients the best chance to survive.
The United States Preventive Services Task Force (USPSTF) is reviewing these tests to determine whether they will be categorized as preventative. Similar bills have passed in nine states already.
(Opposed) Many plans already cover these MRIs and ultrasounds when they are medically necessary. There are several bill proposals impacting the cost of care and all of the health plan benefit requirements the Legislature is considering this year need to be thought through together. California passed a similar bill where the estimated costs were $117 million, but the bill was vetoed. The USPSTF is looking at the analysis for mammography and the Legislature should wait until the analysis is complete to decide.