Navigating health insurance can be confusing, especially when it comes to essential screenings like mammograms. If you have Community Health Care Choice and are concerned about the cost of a diagnostic mammogram, you’re not alone. Understanding your health plan’s coverage for breast cancer diagnostic services is crucial for proactive health management. This article breaks down what you need to know about whether Community Health Care Choice covers diagnostic mammograms, particularly in light of New York State law, which mandates certain coverages for breast cancer screening and diagnostic imaging.
Understanding Diagnostic Mammograms and Why They Matter
A diagnostic mammogram is a specialized type of breast imaging used to investigate a potential issue, such as a breast lump, pain, or changes in breast size or shape. It’s different from a screening mammogram, which is a routine annual check for women without symptoms. Diagnostic mammograms are essential for early detection and diagnosis of breast cancer when symptoms arise, or when a screening mammogram reveals an area of concern. Early detection significantly improves the chances of successful treatment and recovery.
What is Cost-Sharing and How Does It Affect You?
Cost-sharing refers to the expenses that patients pay out-of-pocket for healthcare services, even when they have insurance. These costs can include deductibles, copayments, and coinsurance. For many, cost-sharing can be a significant barrier to accessing necessary medical care. Fortunately, laws like the one in New York State aim to reduce or eliminate these barriers for crucial services like breast cancer screenings and diagnostic imaging.
Community Health Care Choice and the New York Law
New York State has a law in place designed to ensure that most health insurance plans cover breast cancer screening and diagnostic imaging without cost-sharing. This means that for plans subject to New York law, patients should not have to pay deductibles, copayments, or coinsurance for these services when received from in-network providers.
However, it’s important to determine if Community Health Care Choice plans are subject to New York State law. Generally, plans purchased through the New York State of Health Marketplace are required to comply with state laws. However, some types of health plans, known as self-insured or ERISA plans, are governed by federal law and may not be required to follow New York State mandates. It’s also important to note that New York State law does not apply to Medicaid, Medicare, or Medicare Advantage plans.
Services Covered Under the New York Law (Diagnostic Mammograms, etc.)
The New York law specifically removes cost-sharing for various mammograms, including:
- Baseline Mammograms: A single baseline mammogram for individuals aged 35 to 39.
- Yearly Mammograms: Annual mammograms for individuals 40 years of age or older.
- Mammograms for High-Risk Individuals: Mammograms at any age for individuals at increased risk due to personal or family history of breast cancer, when recommended by a physician.
- Diagnostic Mammograms: Mammograms performed to investigate breast issues or abnormal findings from a screening mammogram.
Beyond standard mammograms, the law also covers other diagnostic breast imaging without cost-sharing, such as breast ultrasounds and breast Magnetic Resonance Imaging (MRI) when needed for breast cancer detection. Therefore, diagnostic mammograms are indeed included in the services for which cost-sharing is removed under New York law.
What About 3D Mammograms, Ultrasounds, and MRIs with Community Health Care Choice?
The New York law doesn’t mandate that insurers must cover 3D mammograms (digital breast tomosynthesis), breast ultrasounds, or breast MRIs in every case. Instead, it states that if an insurer, including Community Health Care Choice, determines these tests are medically necessary, they must be covered at no cost to the patient, provided the service is delivered by an in-network provider.
If Community Health Care Choice denies coverage for a 3D mammogram, breast ultrasound, or MRI because they deem it not medically necessary, you have the right to appeal their decision. You can pursue an internal appeal directly with Community Health Care Choice and, if needed, an external appeal to the New York State Department of Financial Services.
Plans Subject to the New York Law (and exceptions like ERISA, Medicaid, Medicare)
It’s crucial to confirm whether your specific Community Health Care Choice plan is subject to New York State law. Plans obtained through the state marketplace generally are. However, self-insured plans (ERISA plans) are federally regulated and might not be obligated to follow state laws, although some may choose to do so. Remember that Medicaid, Medicare, and Medicare Advantage plans are not covered by this New York State law.
To determine if your Community Health Care Choice plan is subject to New York law, you should:
- Contact Community Health Care Choice directly. Inquire whether your specific plan adheres to the New York State Breast Cancer Screening Law.
- Review your plan documents. Look for information regarding coverage for preventive and diagnostic services and cost-sharing policies.
- Check with your employer’s HR department, if your insurance is through your job. They can often provide details about the type of plan you have (state-regulated or self-insured).
How to Verify Your Community Health Care Choice Coverage
The best way to ascertain your coverage for a diagnostic mammogram with Community Health Care Choice is to directly contact your insurer before scheduling the procedure. Ask them specifically:
- “Does my Community Health Care Choice plan cover diagnostic mammograms with no cost-sharing (meaning no deductible, copayment, or coinsurance) when performed by an in-network provider?”
- “Are diagnostic mammograms considered preventive services under my plan in accordance with the New York State Breast Cancer Screening Law?”
- “If a diagnostic mammogram is deemed medically necessary by my doctor, will it be fully covered if I use an in-network provider?”
Getting confirmation in writing can also be beneficial in case of any billing discrepancies.
Other Breast Cancer Services Covered by New York Law
Beyond screenings and diagnostic imaging, New York law also mandates coverage for a range of other breast cancer-related services, although cost-sharing may apply to some of these unless explicitly stated otherwise by law:
- Breast Cancer Surgery: Including lumpectomies, mastectomies (including preventive mastectomies), and lymph node dissections.
- Reconstruction and Prostheses: Coverage for breast reconstruction surgery and prostheses following mastectomy.
- Inpatient Hospital Care: For complications arising from breast cancer surgeries.
- Genetic Testing and Counseling: No-cost coverage for BRCA 1 and 2 gene mutation screening for high-risk individuals, along with genetic counseling and further testing for those with positive results.
- Risk-Reducing Medications: No-cost coverage for medications to lower breast cancer risk for high-risk individuals.
Conclusion
Understanding your health insurance coverage for diagnostic mammograms is essential for your health and peace of mind. While New York State law aims to eliminate cost-sharing for diagnostic mammograms under many plans, particularly those from Community Health Care Choice purchased through the state marketplace, it’s crucial to verify the specifics of your plan. Always contact Community Health Care Choice directly to confirm your coverage details and ensure you can access the necessary diagnostic services without unexpected costs. Proactive engagement with your health plan empowers you to take control of your breast health and utilize the benefits available to you under the law.
