New York State Breast Cancer Screening Law

What does the New York State law do?

The law requires most health insurance plans to cover breast cancer screening and diagnostic imaging with no out-of-pocket costs to the patient. The law prevents most insurers in New York from requiring cost-sharing for these services. More information about the law can be found here.

What does cost-sharing mean?

Cost-sharing means that the patient (or policyholder) pays for part of the medical care and the insurance company pays the rest. Cost-sharing can include deductibles, copayments, and coinsurance. People with health insurance policies covered by this law do not have to pay for breast cancer screening and diagnostic imaging. This means that insurers cannot apply the services against annual deductibles and also cannot charge patients a copayment or coinsurance. Important note: no cost-sharing applies only when services are delivered by a provider in your health plan's network. Services may not be covered at all if delivered by a provider outside of your health plan's network.

What services does the law cover?

The law removes cost-sharing for mammograms, including:

• a single, baseline mammogram for individuals 35 to 39 years old,
• yearly mammograms for individuals 40 years of age or older, and
• mammograms for individuals at any age who are at an increased risk of breast cancer because they have a prior history of breast cancer, or they have a first degree relative (e.g., parent, sibling, child) with breast cancer when a physician recommends the mammogram.

The law also removes cost-sharing for those in need of imaging tests other than standard mammograms - such as diagnostic mammograms, breast ultrasounds, and breast magnetic resonance imaging (MRI) for the detection of breast cancer.

Does the New York State law require insurers to cover digital tomosynthesis (also known as 3D mammograms) breast ultrasounds, and breast MRIs?

No. Each insurer may determine whether a 3D mammogram, breast ultrasound, or breast MRI is medically necessary. If an insurer determines any of these tests are medically necessary, the law requires the service to be covered at no cost to the patient when it is provided by a participating provider. If an insurer determines any of these tests are not medically necessary, the insured individual has the right to an internal and external appeal of that decision. An internal appeal is made directly to your insurer. An external appeal is made to the Department of Financial Services. For information regarding external appeals, please go to https://www.dfs.ny.gov/complaints/file_external_appeal

Does the New York State law apply to all health insurers?

All plans that are subject to New York State law, including plans that are offered through the New York State of Health (the state's Marketplace) are required to follow this law. But not all health plans are governed by state laws. Some types of health plans (often called self-insured plans, or ERISA plans) are governed only by federal laws. These self-insured health plans are not required to follow the New York law, although some may choose to do so. The New York State breast cancer law does not apply to Medicaid, Medicare or Medicare Advantage plans.

How do I know if my services will be covered?

Coverage depends on the type of health plan you have, the services you will be receiving, and your individual risk factors or medical situation. That is why it is important to check with your health insurer before you have the tests done, to make sure the services are covered under your health plan.

What other breast cancer-related services are insurers already required to cover in New York State?

Insurers are required by law to cover surgery for people diagnosed with breast cancer, including:

• Lumpectomy or lymph node dissection -- Removing lump(s) and nearby tissues or lymph nodes.
• Mastectomies -- Removing one or both breasts and physical complications of all stages of the mastectomy, including lymphedemas.
• Preventive mastectomies – Removing one or both breasts for individuals at high risk for breast cancer.
• In-patient hospital care after surgery -- For physical complications.
• Reconstruction -- Rebuilding one or both breasts.
• Prostheses -- A breast form that can be worn after a mastectomy.

Insurers may charge cost-sharing for these services.

Insurers must also cover at no cost to the patient:

• Screening (also known as genetic testing) for BRCA 1 or 2 gene mutations, for people at high risk of breast cancer or those with relatives with breast, ovarian, tubal or peritoneal cancer.
• Genetic counseling and more BRCA testing for individuals with positive BRCA test results.
• Medicine to lower breast cancer risk for individuals at increased risk for breast cancer.

To learn more about breast cancer screening and treatment rights, visit the Department of Financial Services.