Private insurers cover some cancer screenings at 100%—not all

The Patient Protection and Affordable Care Act (ACA) requires that most group health plans, as well as policies sold in the Health Insurance Marketplace and in the small group and individual markets cover a set of essential health benefits, including certain preventive screenings with no out-of-pocket costs to patients. Considered appropriate care for people at “average risk” of cancer, the fully covered screenings include:

• Breast Cancer - screening mammogram every 1-2 years for women ages 40-74*
• Cervical/Gynecologic Cancer - Pap test (also called a Pap smear) every 3 years for women ages 21-65; Human Papillomavirus (HPV) test combined with a Pap smear every 5 years for women ages 30-65 who don’t want a Pap smear every 3 years
• Colon Cancer - colonoscopy every 10 years or other methods of colorectal cancer screening for people age 45 and older

Full coverage of the ACA preventive services applies to in-network providers only. Seeing out-of-network providers—and preventive services not included in the ACA’s essential health benefits—may result in out-of-pocket costs.

More information about the ACA and other policies affecting insurance coverage of health services is available in the Laws & Protections section of our website.

Most health insurers will cover medically necessary screening and preventive services not required by the ACA for people at increased risk of cancer—but coverage does not mean 100% payment by the insurance company. For example, no national laws require private health plans to cover:

• prostate, pancreatic or ovarian cancer screening
• clinical breast exams
• mammograms for women before age 40
• colonoscopies before age 45, or more frequently than every 10 years
• other screening interventions such as breast MRI or ultrasound

Patients frequently have out-of-pocket costs for these screenings because deductibles, coinsurance and copays apply.

State Laws

Some states have laws requiring health insurance coverage of 3D mammograms and “supplemental” screenings such as MRIs and ultrasounds for women with dense breast tissue and those at increased risk of breast cancer. Similarly, many states have laws requiring health insurers to cover prostate cancer screening tests, including prostate-specific antigen (PSA) tests and digital rectal exams (DRE). Most state laws provide annual coverage for men ages 50 and over and for high-risk men, ages 40 and over. FORCE is actively engaged in state and federal advocacy efforts to eliminate patient out-of-pocket costs for all the cancer screenings needed by members of our community. Check with your health plan or state insurance commission for more information.

If your health insurer denies coverage of recommended cancer screenings, visit our Health Insurance Appeals webpage for information on appealing the decision.