Breast cancer is a serious concern in women’s health, accounting for approximately 30% of all cancers experienced by women. For many years, regular mammograms were considered to be the cornerstone of breast cancer prevention. Now, however, after new research has called this into question, legislation has passed that does not require insurance companies to include mammograms for women under 50. Insurance companies can now choose whether or not to provide coverage, and although many companies will continue to do so, it’s important to check with your ensurer to find out if they will cover the cost of your mammogram and other healthcare needs.

Health Insurance and Preventative Care

Traditionally, health insurance companies allow their insureds to pursue basic preventative treatments without cost. This includes an annual physical examination and certain gender-specific screening measures. For example, prostate exams and pap smears are both included under free preventative care in most insurance policies.

Health insurance companies are willing to pay for preventative care because it reduces their likelihood of needing to pay for more expensive medical costs later on. By preventing medical conditions from arising or treating them before they become severe, insurers are able to avoid expensive long-term care payments in the future.

Preventative measures that are not found to be effective or universally necessary are not covered under insurance, which is why mammograms are currently an object of debate.

What is a Mammogram?

A mammogram is different from a breast exam. During a breast exam, a doctor will palpate the breasts to search for lumps or abnormalities. A mammogram, on the other hand, is a type of x-ray that looks at the breast tissue. This enables doctors to discover lumps and abnormalities long before they would be visible during a regular exam.

Traditionally, a yearly or bi-annual mammogram was considered to be standard practice for all women over 40. Some younger women also qualified for frequent mammograms and other breast exams, especially if they had risk factors for breast cancer.

For the most part, young women do not require a mammogram; doctors will usually agree that women in their 20s and 30s have a low enough risk of breast cancer that a regular breast exam should be sufficient. If the doctor finds cause for concern during a breast exam, or if a woman finds an irregularity during a self-examination, a mammogram can be ordered to get a clearer image of what may be going on.

Since at that point the mammogram is not part of routine preventative care but is instead a diagnostic tool, mammograms in that situation may not be wholly covered by insurance. The insurance company may or may not pay a percentage of the cost, depending on whether the insured has met her deductible, but the diagnostic mammogram would no longer qualify as routine preventative care.

This is also true of frequent mammograms or any other preventative care that occurs more than once in a year. Treatments beyond what are detailed in the policy may not be covered or may be covered only partially by the insurer. These details should be spelled out in the policy itself, and an insured can clarify any questions she may have with the insurance company in regards to these treatments.

Why Health Insurance Doesn’t Always Cover a Mammogram

Mammograms are useful in detecting certain types of breast cancer, but they are less effective than was once thought. They often provide incorrect results, especially false negatives, and the radiation from the x-ray may actually be a contributing factor to certain types of cancer.

Additionally, not all breast cancers can be effectively treated through early detection. Only a small percentage of breast cancers are affected by early detection and treatment. Others are untreatable, benign or equally treatable at later stages of detection.

Because of the unreliability and potential risks associated with mammograms, insurance companies are not required to pay for these screenings for women under 50. As further research is completed, this may be changed or overruled. In the meanwhile, it’s the prerogative of the insurer to decide whether or not to cover these expenses.

If you have health insurance, be sure to check with your insurer to see exactly what is covered under your annual well-woman exam. This will help you avoid unexpected charges so that you are prepared for your doctor visit. If a mammogram or other preventative care that you find necessary is not covered by your insurer, it may be worthwhile to shop for another insurance company that will meet your needs.