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

A growing number of states have laws requiring health insurance coverage of high-risk, “supplemental” screenings such as MRIs and ultrasounds for those at increased risk of breast cancer, colonoscopies before age 45 for those at increased risk of colorectal cancer, prostate screenings for high-risk individuals age 40 and over, etc.  Some laws stipulate no cost-sharing—meaning there is no cost to the patient—but others simply require coverage, which means deductibles, coinsurance and copays apply. Note that some health plans (i.e., self-funded employer plans and high-deductible health plans) may be exempt from state laws. 

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.