Paying for Cancer Screening

Insurance coverage varies based on many factors, including:

• the specific screening, medication or treatment
• age
• gender
• type of insurance
• health plan specifics, such as benefits, exclusions, deductibles, coinsurance and copay amounts

Private insurance

Some private insurers cover some cancer screenings at 100 percent.

Cancer screenings that are covered with no patient out-of-pocket costs

The Patient Protection and Affordable Care Act (ACA) requires most group health plans and policies sold in the Health Insurance Marketplace and the small group and individual markets to cover essential health benefits, including certain preventive screenings, with no out-of-pocket costs to patients.  

The following screenings are considered appropriate care for the general population and are fully covered:

• Breast Cancer — one screening mammogram every 1-2 years for women ages 40-74
• Cervical/Gynecologic Cancer — one Pap test (also called a Pap smear) every 3 years for women ages 21-65; one 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 — one colonoscopy every 10 years or other, less invasive colorectal cancer screening at more frequent intervals for people age 45 and older. Consult with your physician to determine the appropriate test based on your personal and family history.

Full coverage of these services applies only to in-network providers. Seeing out-of-network providers OR receiving preventive services not included in the ACA’s essential health benefits will incur out-of-pocket costs. Visit the Laws & Protections section of our website for detailed information about the ACA and other health policies.

Cancer screenings that may not be fully covered

Most health insurers will ALSO cover medically necessary screening and preventive services for people at increased risk of cancer. However, coverage does not mean 100 percent payment by the insurance company. 

Screenings that may not be covered at 100 percent by insurance include:

• gastric, endometrial, prostate, pancreatic or ovarian cancer screenings
• clinical breast exams
• mammograms for women before age 40
• mammograms for men
• 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

A growing number of states have laws requiring health insurance coverage of services needed by the high-risk, hereditary cancer community, including:

• “supplemental” breast screenings, such as MRIs and ultrasounds
• diagnostic breast exams and imaging
• colonoscopies before age 45
• prostate screenings for high-risk individuals age 40 and over
• all National Comprehensive Cancer Network (NCCN) or other guideline-recommended screenings

Laws vary by state. Some laws require health plans to cover 100 percent of fees with no cost to the patient. Others require some coverage (deductibles, coinsurance and copays apply). Certain health plans (i.e., self-funded employer plans, high-deductible health plans and Medicaid) are exempt from state laws. 

Check with your health plan or state insurance commission for more information. FORCE is building a database of state laws. Information on breast cancer screening laws is now available.

Medicare

Medicare covers the following cancer screenings at 100 percent when provided by a participating provider:

• Breast Cancer — one baseline mammogram for women ages 35-39; annual screening mammograms and 3D mammograms for women age 40 and older. As part of the “well-woman” pelvic exam, Medicare covers a clinical breast exam to check for breast cancer. 
• Cervical/Gynecologic Cancer — one Pap test and pelvic exam every 24 months. Medicare covers these screening tests every 12 months if you are at high risk for cervical or vaginal cancer or you are of childbearing age and had an abnormal Pap test in the past 36 months.
• Prostate Cancer — one screening with digital rectal exams (DREs) and prostate-specific antigen (PSA) blood tests every 12 months for men age 50 and over.
• Colon Cancer — one screening colonoscopy every 24 months for those at high risk of colorectal cancer with no minimum age requirement. If you are not considered high risk for colorectal cancer, colonoscopy is covered once every 6 years or once every 4 years after a previous flexible sigmoidoscopy. Less invasive screening tests are covered at more frequent intervals.

Medicare generally does not cover cancer screenings beyond those outlined above, although some Medicare Administrative Contractors (MACs) are more flexible and some people have succeeded in getting coverage. Other cancer screenings or more frequent screenings may be denied or considered diagnostic, requiring a Part B deductible plus 20 percent of the Medicare-approved amount.

Visit the Medicare website or call 1-800-MEDICARE (1-800-633-4227) to learn more about its coverage of cancer screenings.

Medicaid

Medicaid coverage of cancer screenings varies by state. Individuals who qualify for Medicaid based on their state’s expansion of Medicaid under the ACA are entitled to the same screening and preventive services as those covered by private insurance. For people who qualify based on traditional Medicaid eligibility pathways, cancer screening and preventive services are considered “optional,” and the scope of coverage is determined by the state. However, most Medicaid programs cover basic screening for breast, cervical, prostate and colorectal cancer.

Contact your Medicaid office to learn more about coverage of cancer screenings in your state.