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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You should consult with your provider if you believe you are at higher risk. 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 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.

Plans are required to cover a variety of services related to breast cancer prevention, but the rules vary by age and risk status for the different services. Plans are required to cover 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.  However, plans are required to cover preventive medications and genetic screening services for women of younger ages who are at higher risk for breast cancer. You would need to talk to a clinician about whether these services would be beneficial to you.  If your provider recommends them based on your family history or other risk factors, then you should be eligible for full coverage.

If you are covered by a plan that was in effect on or before March 23, 2010, it may be a “grandfathered plan.” These plans are not required to cover preventive services, or they may require cost sharing. If you are not sure if your plan is grandfathered, check with your employer or your insurance plan. Short-term health insurance policies do not have to provide benefits required by the ACA, including preventive services such as mammography. Health care sharing ministries, which are membership groups usually affiliated with a religion that help members pay for health care (not insurance), are also not subject to ACA benefit requirements.

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.

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