Originally published in HR Executive
Employers have increased their efforts to meet women’s health needs, including improved coverage of fertility services, maternity leave, menopause support and rates of evidence-based cancer screenings. As they promote more breast cancer screening, employers are now receiving new requests from employees and their families to waive cost sharing for breast ultrasounds or MRIs (magnetic resonance images). Clinicians are increasingly considering these tests for women with dense breast tissue or a higher risk of cancer.
Addressing benefit coverage for screening MRIs and ultrasounds is more urgent than ever. The U.S. Preventive Services Task Force (USPSTF) recently expanded its breast cancer recommendation for all women to start routine screening at age 40. Younger women have denser breasts, and mammograms are less reliable to exclude breast cancer in this group. Up to half of women who are screened, and 60% of those ages 40-49, will receive information that they have dense breast tissue and might be recommended to have an ultrasound or MRI as a second imaging test after a mammogram.
Employee requests for waived cost-sharing will likely increase in 2024. While 39 states currently require some notification around breast density, the Food and Drug Administration will require this as a routine part of mammogram reports in all states starting in September.
This issue is not just confined to dense breast tissue and routine screening. In particular, MRIs are recommended for high-risk women starting as early as age 25. Thus, women at high risk must pay out of pocket for screening breast MRIs. It is not surprising that many women are confused by these seemingly preventive screenings subject to cost sharing, and an increasing number are asking their HR team to eliminate out-of-pocket costs and remove financial barriers for these tests.
The following are key considerations for employers when evaluating employee or family requests to waive the cost share for these additional tests.
While some women need MRIs and ultrasounds to better evaluate their breast tissue, these tests require out-of-pocket cost sharing, even though mammograms and other cancer screening tests are fully covered with no cost sharing. This is especially important for women who have not met their insurance deductibles and would be required to pay the entire cost of these tests.
The reason for the difference in cost sharing is that screening mammograms are recommended by the USPSTF and thus are required by the Affordable Care Act (ACA) to be offered without cost sharing. However, health plans are not required to cover these exams without cost-sharing because the USPSTF has said there is “not yet enough evidence” to recommend MRIs or ultrasounds for breast cancer screening.
Based on the ACA requirements, most health plans and employers require member cost-sharing for breast MRIs and ultrasounds. Deductibles, coinsurance and potentially additional copayments up to the out-of-pocket maximum would apply. Increasingly, this causes confusion as members believe that they had a preventive screening test for breast cancer and are surprised when they receive a bill.
Some states have mandated coverage without cost sharing for screening breast MRIs and ultrasounds, but these requirements only apply to fully insured health plans. Self-insured companies are not regulated by state law and can make their own decisions about the level of coverage for these screening tests. Self-insured companies have, essentially, two potential paths to take.
The first response is for self-insured companies to maintain their current approach of requiring cost share for screening breast MRIs and ultrasounds. This is aligned with the USPSTF guidance and general insurance benchmarking. Women who need these additional tests can still access them. They will be covered, but patients will incur out-of-pocket costs unless they have reached their annual out-of-pocket maximum. The challenge to this approach is that companies will face increasing pushback from their employees on this issue, and some women may forgo recommended tests due to their higher out-of-pocket costs.
Alternatively, employers can enhance their benefits by offering these additional breast cancer screening tests with no cost sharing. Given the clinical landscape, employers who go this route can consider waiving the cost share for both breast MRIs and ultrasounds, as both tests are sometimes recommended for women with dense breast tissue. Employers that make this change will be seen as market-leading on an issue sometimes framed around women’s health equity.
Utilization of these tests will likely increase due to the lowered out-of-pocket cost for patients. Providing this coverage is unlikely to jeopardize the tax advantages of health savings accounts (HSAs) associated with high-deductible health plans, since breast cancer screening is listed as a “safe harbor” by the Internal Revenue Service. Since these additional tests have not been specifically addressed by the IRS to date, this conclusion should be discussed with legal counsel prior to implementation.
There is potential for this more generous approach to influence coverage in other areas. The rationale to add these services at no cost share could easily be extended to other tests and services. For example, colonoscopies in members with a history of a polyp or rectal bleeding are currently not considered screening tests and incur out-of-pocket costs. Likewise, mammograms in those with a personal history of breast cancer also incur out-of-pocket costs, as they are considered diagnostic and not preventive tests. In both examples, however, members have been previously diagnosed and treated for a related condition.
Employers may open themselves to additional screening costs for breast cancer and beyond as employees request a waiver of cost sharing for a growing number of tests. The total additional costs for any employer would depend on the demographic composition of their workforce. Operationally, employers should dialog with their carriers before deciding to expand coverage for preventive screening tests to be sure that such an expansion is feasible and will not lead to processing errors, including paying for MRIs or ultrasounds ordered for non-screening purposes.
Requests for enhanced breast cancer screening benefits will become more common as screening practices evolve and members look to save money while receiving much-needed preventive health services. The latest USPSTF guidelines and changes in mammogram reporting will only accelerate these requests in 2024. How a particular company approaches this issue will depend on their priorities, their budget and the larger needs of their workforce and community.
