Expanding the definition of breast cancer screening

October 17, 2023

Mammograms are important breast cancer screening tools, which are covered as preventive under the ACA. As such, they have no cost share to employees or their dependents. In order to support women’s health even more, many employers are now also considering making breast cancer screening MRIs and ultrasounds preventive as well, which would allow them to waive cost sharing for these procedures.

MRIs and ultrasounds are routinely used clinically as part of breast cancer screening to get a better image of the breast tissue, particularly for the 50% of women with dense breasts. Despite that, the US Preventive Services Task Force (USPSTF) gives screening MRIs and ultrasounds a grade of “I”, for insufficient data. Since only procedures with a grade of “A” or “B” can routinely have no cost share, self-insured employers will need to manually add these procedures onto their preventive list to avoid them without cost sharing.

If MRIs or ultrasounds are used as part of cancer screening, then the screening could be considered preventive and may not risk HSA-eligibility. On the other hand, if dense breast tissue is interpreted to mean there is an “illness or condition”, then it would likely not be preventive and could not be covered at zero cost share without risking tax advantaged status of health savings accounts associated with high deductible health plans. Employers would need to confirm this position with their legal counsel before expanding their list of preventive procedures.

Eliminating employee cost share will increase overall costs to employers. Employers may want to mitigate those costs by limiting the preventive use of MRIs or ultrasounds to the highest risk individuals. Those might include individuals with the highest 20% of risk in the population, those with known risk factors, or those with the highest density breast tissue. However, medical carriers might not be able to put such restrictions in place, and this would likely require some element of prior authorization.

Implications for Employers:

1. Employers should continue to encourage all of their employees and dependents to have age- or risk-appropriate breast cancer screening.

2. Employers can consider expanding their Preventive Services list if their budget allows and their compliance team feel it’s appropriate. They should be aware that MRIs are expensive and there is substantial cost variation. Breast MRIs can also have high rates of false positives.

3. If employers want to expand their Preventive Services list but only target the highest risk individuals, then they should have a conversation with their carrier as to what is operationally feasible.

Today’s post written by my colleague Patricia Toro, MD MPH.

Tomorrow: Compelling reasons not to routinely screen those without symptoms for heart disease.

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Illustration by Dall-E