Breast MRI and Insurance: How to Get Your Procedure Covered

Breast cancer screening and prevention services are crucial for early detection and treatment. While insurance coverage for these services varies, guidelines and programs are in place to ensure access to mammograms, genetic testing, and preventive medication.

This article provides information on how to navigate insurance coverage for breast MRI and highlights programs that assist uninsured and underserved women.

Let us get right into it.

How to get insurance to pay for Breast MRI?

How to get insurance to pay for Breast MRI?

Check the table below. Here is how you can get insurance to cover a breast MRI:

S.No.Insurance TypeCoverage for Breast Cancer Screening and Prevention Services
1)Private Individual and Group Plans– Must cover preventive services rated “A” or “B” by USPSTF without cost-sharing.
– Coverage includes mammograms starting at age 40, genetic screening, and breast cancer preventive medication for high-risk individuals.
2)Medicaid– Coverage depends on the state’s decision to expand Medicaid under the ACA.
– People qualifying for Medicaid expansion receive the same services as private insurance.
– Traditional Medicaid programs may consider these services “optional,” and coverage varies by state.
3)Medicare– Medicare Part B covers annual screening mammograms for individuals aged 40 and older.
– Coverage for BRCA genetic testing is not nationally required but may be covered based on local determinations.
– Medicare Part D drug plans may provide coverage for chemoprevention drugs, but cost-sharing may apply.
4)TRICARE– TRICARE covers screening mammography, BRCA genetic counseling, and chemoprevention.
– Cost-sharing varies based on an individual’s TRICARE coverage and active duty status.
5)NBCCEDP– Assists low-income, uninsured, and underinsured individuals in accessing breast and cervical cancer screenings, diagnostics, and treatment referrals.
– Eligibility based on income (at or below 250% Federal Poverty Level) and age (40 to 64 for breast cancer screenings).
– Serves only a fraction of eligible people despite a significant number of eligible individuals.
6)BCCPTA– Allows states to extend Medicaid coverage to uninsured people under 65 diagnosed with breast or cervical cancer through NBCCEDP screening programs.
– Eligibility requirements vary by state, with different criteria related to screening and diagnosis.

The United States Preventive Services Task Force (USPSTF) and the Health Resources and Services Administration (HRSA) both issue recommendations for breast cancer screening and prevention, but private insurance coverage of preventive services under the Affordable Care Act is governed by those recommendations.

The following breast cancer screening and prevention services must be covered by a private group and individual insurance plans, as well as state Medicaid expansion programs, without any additional cost to the customer:

  • Women/Non-binary folks/Trans people ages 40 to 74 with an average risk for breast cancer should undergo screening mammography at least every 2 years and as frequently as once a year.
  • Other women/non-binary folks/trans people with a personal or family history of breast, ovarian, fallopian tube, or peritoneal cancer may benefit from genetic counseling and testing for mutations of the BRCA1 and BRCA2 genes.
  • Lastly, some people with elevated risk for breast cancer may benefit from preventive medication if there is a low risk of adverse medication side effects.
  • Other services that some doctors advise, such as screening MRIs for patients with higher breast cancer risks, are now not required to be covered under the ACA’s preventive services mandate.

Conclusion

To sum up, being aware of out-of-pocket costs and coverage limitations can help individuals navigate the process of getting insurance to pay for breast MRI and ensure comprehensive breast cancer screening and prevention.

Also, read Can you go to Kaiser without Kaiser Insurance?

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