2024 Breast Screening Changes
2024 brings changes to breast screening insurance coverage rules; this law only applied to state commercial insurance plans. Medicare plans are not included in this and patients may still have to meet their deductible.
Effective January 1, 2024 changes to breast screening insurance coverage rules may impact your coverage for certain exams, and may be covered by your state insurance plan.
These exams include follow-up:
- imaging after an abnormal screening mammogram
- diagnostic mammograms
- breast MRIs/ultrasounds for patients at high risk of breast cancer
Talk to Your insurance Provider
The new law, Washington State bill 5396, will require WA state health insurers to cover these exams with the hope that women will be less likely to skip medically necessary testing because of cost. 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.
Summary of Amended Washington State Bill SSB 5296/RCW 48.43.076
This law only applies to state commercial insurance plans.
It’s important to discuss your specific plan’s coverage with your insurance provider. Medical necessity for all of these exams is determined by your insurer. When contacting your insurance provider, refer to one of the following CPT codes for MRI breast: 77046, 77047, 77048, or 77049.
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 (if deemed medically necessary).
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 (if deemed medically necessary).
The provisions related to preventing deductible and copayment provisions are removed from the requirements to provide coverage for screening and diagnostic mammography services (if deemed medically necessary).
A “diagnostic breast examination” is an 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” deemed as medically necessary and appropriate examination of the breast, may include 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
- 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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