2024 Breast Screening Changes
2024 Brings changes to Breast Screening insurance coverage rules
Effective January 1, 2024 – We are excited to share that additional exams are required to be covered 100% by state insurance plans. This includes the following exams:
- Follow-up imaging after an abnormal screening mammogram
- Diagnostic mammograms
- Breast MRIs/Ultrasounds for patients at high risk for breast cancer
Washington State Bill 5396 will require state health insurers to cover these exams with the hope that women will be less likely to skip medically necessary testing because of cost. Please check with your insurance provider for your exact benefits and eligibility.
Breast Density and the Risk for Breast Cancer
People with higher density breast are 4-6 times more likely to get breast cancer than those with the least dense breasts.
Breast density refers to the amount of fibroglandular tissue relative to fatty tissue in a woman’s breast. A woman is considered to have dense breasts if she has a lot of fibroglandular tissue and not much fatty tissue. The density of your breast will be identified by a radiologist and reported as either almost entirely fatty (which is not dense), scattered areas of fibroglandular density (which is not dense), heterogeneously dense (breast tissue is dense), or extremely dense (breast tissue is dense). If it is reported that you have heterogeneously or extremely dense breast tissue, supplemental screening with a breast MRI is recommended.
The new legislation that goes into effect early next year ensures that insurance covers 100% of the costs for additional screening exams such as MR and US. This translates to no out-of-pocket expenses for those supplemental tests.
Talk to Your Insurance Provider
Medical necessity is dictated by your health insurance provider. We encourage you to talk to your insurance provider to understand your specific plan’s coverage of breast imaging.
When speaking to your insurance provider, please reference one of the following CPT codes for MRI breast: 77046, 77047, 77048, or 77049.
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Summary of Amended Washington State Bill SSB 5396 / RCW 48.43.076
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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.
The provisions related to preventing deductible and copayment provisions are removed from the requirements to provide coverage for screening and diagnostic mammography services.
A “diagnostic breast examination” is a medically necessary and appropriate examination of the breast, including an examination using diagnostic mammography, digital breast tomosynthesis, 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.
* Grandfathered plans include some self-insured plans through employers. Check with your employer’s benefits administrator or insurance provider to verify coverage.
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General Medical Necessity Criteria for Insurance Providers
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Please note: This is general criteria. Medical necessity is dictated by your health insurance provider. We encourage you to talk to your insurance provider to understand your specific plan’s coverage of breast imaging.
Magnetic Resonance Imaging (MRI) of the breast for individuals who are high risk for breast cancer as defined as having any of the following:
- Prior thoracic radiation therapy between the ages of 10 and 30
- Lifetime risk estimated at greater than or equal to 20% as defined by models that are largely dependent on family history (e.g., Gail, Claus, Tyrer-Cuzick or BRACAPRO)
- Personal history of breast cancer (not treated with bilateral mastectomy)
- Personal history with any of the following:
- Li-Fraumeni Syndrome (TP53 mutation)
- Confirmed BRCA 1 or BRCA 2 gene mutations
- Peutz-Jehgers Syndrome (STK11, LKB1 gene variations)
- PTEN gene mutation
- Family history with any of the following:
- At least one first-degree relative who has BRCA 1 or BRCA 2 mutation
- First-degree relative who carries a genetic mutation in the TP53 or PTEN genes (Li-Fraumeni Syndrome and Cowden and Bannayan-Riley-Ruvaicaba Syndromes, or Peutz-Jehgers Syndrome)
- At least two first-degree relatives with breast or ovarian cancer
- One first-degree relative with bilateral breast cancer, or both breast and ovarian cancer
- First or second-degree male relative (father, brother, uncle, grandfather) diagnosed with breast cancer.