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New payer guidelines on preventive mammogram screenings could affect 17M women

Mammograms would not be covered at no cost for women in their 40s, based on evidence that screenings lead to overdiagnosis

Health insurers won't have to pay for biennial mammograms for female members until they're 50 years old if an independent panel of medical experts moves forward with its new breast cancer screening guidelines, according to a new analysis from Avalere Health.

The Affordable Care Act currently requires insurers to cover preventive services, including mammograms, at no cost to their members if the procedures or services have an "A" or "B" rating. But the United States Preventive Services Task Force (USPSTF) is finalizing new guidelines that would rate screening women in their 40s using mammograms a "C," which means they would not be covered for free. 

The USPSTF is considering altering the guidance because of the belief that mammogram screening can lead to overdiagnosis and treatment. In fact, a recent study found that false-positive mammograms and overdiagnoses of breast cancer could cost about $4 billion a year, FierceHealthIT previously reported.

If the U.S. Department of Health and Human Services adopts the new guidance, about 17 million people will lose coverage for mammograms. Of the 17 million, most are covered by employer-based plans, about 1.2 million women are enrolled in plans sold on health insurance exchanges and another 1.1 million have coverage through Medicaid expansion, The Hill reported.

"The USPSTF is working to balance the life-saving benefits of breast cancer screening against the potential risks for over-diagnosis and unnecessary treatment of lower-risk women," Avalere Senior Vice President Caroline Pearson said in the analysis. "By linking the ACA rules to USPSTF decisions, coverage for preventive services will continue to evolve as new research and evidence becomes available."

To learn more:
- see the Avalere Health analysis
- read The Hill article

Related Articles:
How $25 gift cards are driving women to get mammograms
The blurred line between preventive care and treatment
U.S spends $4 billion annually on mammogram follow-up testing and treatment
False-positive mammograms, overdiagnosis could cost US $4B a year