Women’s Health

I am 35 and I think that I am at higher risk for breast cancer because my mother had it. What services must my insurer cover?

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If you believe you are at higher risk, you should discuss with your provider. There are a number of breast cancer screenings and preventive services that insurers must cover for women. If you are enrolled in an ACA-compliant, non-grandfathered plan, your insurance must pay for your provider to assess whether you have a have a family history that makes you at higher risk for certain genetic mutations that are associated with increased risk of breast cancer (BRCA1 and BRCA2). If your provider determines that your family history makes you at increased risk for genetic mutations, your plan must cover the full cost of genetic counseling and genetic testing if recommended. If you end up having one of these genetic mutations, your insurer is also required to cover the full cost of certain preventive medications which can greatly reduce your risk of getting breast or ovarian cancer.

The coverage rule for mammography is based on the Women’s Preventive Services Initiative, adopted by HRSA, that recommends screening mammography every one to two years for women age 40 – 74 years. Since you are under age 40, federal rules do not specify whether your plan must cover the costs of the screening mammogram without cost sharing.

Short-term health insurance policies do not have to provide benefits required by the ACA, including preventive services such as mammography.

While we have made every effort to provide accurate information in these FAQs, people should contact the health insurance Marketplace or Medicaid agency in their state for guidance on their specific circumstances.