State legislation addresses gaps in breast imaging coverage, ensures affordable diagnostic exams
In a significant move to address gaps in insurance coverage for diagnostic breast imaging exams, 20 states across the nation have enacted legislation to ensure that women receive these crucial screenings without facing exorbitant out-of-pocket costs.
The absence of federal policy covering diagnostic mammograms had led to a coverage gap, leaving many women burdened with unexpected expenses. This legislative push has been driven by the advocacy efforts of organizations such as the Susan G. Komen organization, aiming to improve access to vital healthcare services.
Radiology Business Management Association President Kit Crancer, and executive director of the Rayus Quality Institute, spoke with Radiology Business about this policy trend at the Radiological Society of North America 2023 meeting.
"The Komen Foundation estimates that the out-of-pocket cost for women is typically around $1,200 when they come in for some of those more advanced and sensitive screenings in order to diagnose whether or not that finding under the screening is significant enough to require a biopsy, or whether or not that woman has breast cancer. Other studies have found that around 20% plus of these women simply don't come back after they find out about cost that is associated with those diagnostic mammograms. So, state legislatures have really stepped up," Crancer explained.
Current scenario for diagnostic vs. screening breast exams
Under the Affordable Care Act, mammograms for women are covered at 100%, making them essentially free. However, approximately 10%-15% of women undergoing mammograms receive a callback for a diagnostic mammogram, which is not covered by the ACA. The high cost and low compliance rate of patients in getting this additional imaging can lead to poorer breast cancer outcomes later on.
Recognizing the challenges faced by women in accessing affordable diagnostic breast exams, state legislatures have taken matters into their own hands with the urging of breast imaging advocacy groups. As a result, around 20 states have now passed legislation to close the coverage gap, ensuring that women receive diagnostic mammograms without additional financial strain, Crancer said.
He emphasized that the lack of federal action on this issue prompted states to step up and address the "surprise coverage gap." Many women were shocked to discover that while screening mammograms were covered, diagnostic mammograms were not. The confusion surrounding the difference between the two types of exams for most people further compounds the issue and frustrates patients.
Dave Fornell has covered healthcare for more than 17 years, with a focus in cardiology and radiology. Fornell is a 5-time winner of a Jesse H. Neal Award, the most prestigious editorial honors in the field of specialized journalism. The wins included best technical content, best use of social media and best COVID-19 coverage. Fornell was also a three-time Neal finalist for best range of work by a single author. He produces more than 100 editorial videos each year, most of them interviews with key opinion leaders in medicine. He also writes technical articles, covers key trends, conducts video hospital site visits, and is very involved with social media. E-mail: dfornell@innovatehealthcare.com