Illinois Will Require Insurers to Cover Diagnostic Mammogram Follow-Ups to Initial Screenings in 2020

In a few days, Illinois will require insurers within its purview to cover follow-up imaging of breast tissue as part of regular mammogram screenings. Currently, federal law under the Affordable Care Act only requires that insurers provide free coverage of initial screenings.

When abnormalities are detected, a more thorough diagnostic mammogram is often ordered, which can set patients back hundreds of dollars.

"A diagnostic mammogram should be covered in the same manner as a routine screening mammogram," Illinois State Senator Linda Holmes, who sponsored the legislation, said in a press release. "About 10 percent of initial mammogram results require a subsequent diagnostic mammogram, which can arguably be the most important test in the screening process. This new law can save lives."

At least one other state, Texas, also requires insurers to cover diagnostic follow-ups without additional charge. New York, in addition to multiple other states, is currently considering similar legislation.

Reforms for insurance coverage of diagnostic mammography, in addition to other standards for breast cancer screening, are frequently developed by the Susan G. Komen Foundation, which advocates for women's health.

The foundation is behind the new Illinois law, and diagnostic mammography in the state can cost up to $600 or $700, according to Holmes. Women who need a more thorough exam after the initial screening can be discouraged by the hefty co-pay and forgo diagnostic imaging or the initial procedure altogether.

In Illinois, the cost-reductions won't apply to some high-deductible insurance plans where mandatory coverage would result in disqualification from participation in health savings accounts.

In a 2017 survey conducted by Kaiser Women's Health, 16 percent of women with private insurance and 3 percent of women with Medicaid said that they paid out-of-pocket costs for mammography, which could include diagnostic imaging, out-of-network procedures or initial screenings exempt from federal law.

Researchers with IBM Watson Health published a study in 2018 finding that, nationwide, patients pay on average $349 in out-of-pocket costs for diagnostic mammograms.

Susan G. Komen commissioned a series of phone interviews to better understand how pricing impacts decision-making and, ultimately, the provision of care. Multiple patients reported delaying or canceling mammography once the costs were made known.

"I had to pay $549 out of pocket for my ultrasound, but they let me pay it off monthly. I'm still making payments," a woman identified as Brittany from Chicago told the foundation. "It makes me hesitant to go in the future... knowing how much it will cost me makes me think, maybe I can put it off a little longer until I get my finances together... Some of my friends are even hesitant to go to the [gynecologist] because they think everything will cost too much. They want to wait until they feel something."

Mammogram images of breasts of a female patient. - stock photo mofles/iStock / Getty Images Plus/Getty