A.1696-B/S.2465-B – Breast Cancer and Dense Breast Additional Mammogram Mandate

This legislation, S.2465-B/A.1696-B, would require health plans to cover additional mammograms for persons having a prior history of breast cancer or dense breast tissue, when recommended by a physician and when supported by nationally recognized clinical practice guidelines. New York’s health plans support early detection and early treatment of breast cancer — and all cancers. While this bill is well intended, the New York Health Plan Association (HPA) believes it is unnecessary as health plans provide coverage for breast cancer screenings that align with nationally recognized clinical practice guidelines.

Health plans support appropriate use of mammography as a method of detecting breast cancer, and plans cover a variety of mammography methods. However, plans support and promote the use of evidence-based, best practices as it relates to cancer screenings, and develop coverage criteria of which modalities are “medically necessary” based on these best practices. This is aligned with the recently issued FDA rule[1] that requires the inclusion of breast density assessments in mammography reports for all women in the U.S., starting September 10, 2024, which requires mammography facilities to notify patients about the density of their breasts and encourages supplemental screening.

However, there are numerous and sometimes conflicting guidelines offering recommendations for breast cancer screenings. The American Congress of Obstetricians and Gynecologists, the American Medical Association, the American Cancer Society, and the American College of Radiology/Society of Breast Imaging all have their own recommendations that are similar but not the same.  This can create confusion for patients.

Health plans largely rely on the United States Preventive Services Task Force (USPSTF), an independent, volunteer panel of national experts in disease prevention and evidence-based medicine, is widely recognized for its efforts to develop evidence-based recommendations about clinical preventive services. When questions arise as to coverage of a particular preventive screening, the Affordable Care Act determined only those receiving a rating of “A” or “B” in the current recommendations of the USPSTF should be required. Breast ultrasounds do not meet this standard. According to its latest recommendations for breast cancer screening, “[t]he USPSTF found insufficient evidence to assess the balance of benefits and harms of adjunctive screening for breast cancer using breast ultrasonography, MRI, DBT, or other methods in women identified to have dense breasts on an otherwise negative screening mammogram.”[2] While the bill makes reference to nationally recognized clinical guidelines, we are concerned about its potential to conflict with and override the recommendations of the USPSTF.

HPA also opposes the bill because it creates a new mandated benefit, which disproportionately fall on small employers, adding to the challenge they face to find affordable health care options. Large companies typically “self-insure,” providing employee health benefits by directly paying health care claims to providers. They are governed by the federal Employee Retirement Income Security Act (ERISA) and are not subject to state mandated benefits. Mandated benefit bills pertain only to fully-insured policies, which are purchased either by individuals who purchase coverage on their own or receive it through a small or medium-sized business.

Today, nearly 55 percent of the commercial market in New York is covered under a self-insured plan. As more employers self-insure, state laws mandating specific types of benefits and services, or expanding existing mandates as this bill would, affect an increasingly smaller portion of the privately insured marketplace.

For these reasons, HPA opposes S.2465-B/A.1696-B.

[1] https://www.federalregister.gov/documents/2023/03/10/2023-04550/mammography-quality-standards-act

[2] https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/breast-cancer-screening