Mammograms: Mandated Insurance Coverage
In 1990, Wisconsin enacted a law that requires most health insurance policies issued or renewed on or after July 1, 1990, to provide coverage to women of certain ages for examination by low-dose mammography to detect for the presence of breast cancer. The following is a list of commonly asked questions and answers about the law.
What types of health insurance policies must provide coverage for mammograms?
The law requires most, but not all, insured disability policies that provide coverage to women age 45 and over to provide periodic coverage for mammograms. This includes policies offered by health maintenance organizations (HMOs).
What is a disability policy?
A "disability policy" is any insured policy that provides surgical, medical, hospital, major medical, or other health service coverage but does not include:
- Hospital indemnity policies.
- Policies that provide ancillary coverage such as income continuation, loss of time, or accidental benefits.
- Policies that provide coverage of certain specified diseases such as cancer.
- Policies offered by limited service health organizations.
- Medicare supplement, Medicare replacement, or long-term care policies.
Are health plans self-funded by an employer required to provide coverage for mammograms?
Plans that are self-funded by an employer and subject to the Federal Employee Retirement Income Security Act (ERISA) and plans that are self-funded by a governmental body for government employees, except a plan self-funded by the state for its employees, are not required to comply with the law.
Must Medicare supplement, Medicare replacement, or long-term care policies provide coverage for mammograms?
No. The law specifically states that those policies are exempt from the mandate.
What is "low-dose mammography"?
"Low-dose mammography" means the x-ray examination of a breast using equipment dedicated specifically for mammography, including the x-ray tube, filter, compression device, screens, films, and cassettes, with an average radiation exposure delivery of less than one rad mid-breast with two views for each breast.
Who is eligible for a mammogram?
Women between the ages of 45 to 49 are eligible for two examinations, and women 50 and over are eligible for an annual examination by low-dose mammography to screen for the presence of breast cancer if they are covered under a disability policy subject to the mandate.
Must a woman show symptoms of breast cancer to be eligible for the coverage?
No. A disability policy subject to the law must provide coverage whether or not the woman shows any symptoms of breast cancer.
May an insurer require that the mammography examination be performed by certain health care providers?
Yes. An insurer may require that the examination be performed at the direction of a licensed physician or a nurse practitioner. However, an insurer also must provide coverage for an examination by low-dose mammography if all of the following conditions are met:
- The woman does not have an assigned or regular physician or nurse practitioner when the examination is performed;
- The woman designates a physician to receive the results of the examination; and
- Any examination by low-dose mammography previously obtained by the woman was at the direction of a licensed physician or nurse practitioner.
Does the mandate cover examinations performed by mobile units?
The mandate will provide coverage for an examination performed by a mobile unit if the mobile unit administers a low-dose mammography examination and if the examination meets the conditions outlined in the previous question.
What is a "nurse practitioner"?
The law defines a "nurse practitioner" as a registered nurse who satisfies any of the following:
- Is certified as a primary care nurse practitioner or clinical nurse specialist by the American Nurses' Association or by the National Board of Pediatric Nurse Practitioners and Associates.
- Holds a master's degree in nursing from an accredited school of nursing.
- Before March 31, 1990, has successfully completed a formal one-year academic program that prepares registered nurses to perform an expanded role in the delivery of primary care, includes at least four months of classroom instruction and a component of supervised clinical practice, and awards a degree, diploma, or certificate to individuals who successfully complete the program.
- Has successfully completed a formal education program that is intended to prepare registered nurses to perform an expanded role in the delivery of primary care but that does not meet the above requirements and has performed an expanded role in the delivery of primary care for a total of 12 months during the 18-month period immediately before July 1, 1978.
May an insurer apply a copayment or deductible to a mammography examination or may it place restrictions on excessive charges?
Yes. An insurer may apply the same deductible or copayment to an examination for low-dose mammography or apply restrictions on excessive charges that apply to other radiological examinations covered under the policy.
Must a policy provide coverage for a mammography even if it provides no coverage for other radiological examinations? If so, can the insurer restrict payment to a certain amount?
Any disability policy subject to the mandate must provide coverage for a mammography examination even if it does not provide coverage for other radiological benefits. An insurer may not restrict payment to a specified amount but can apply usual, customary, and reasonable rates to the charges.
May a prepaid plan impose any special restrictions on the mandated coverage?
A prepaid health plan, such as an HMO or a preferred provider plan (PPP), may require a woman covered under the plan to select a primary provider and to obtain a referral from the primary provider for the mammogram.
Is a woman aged 45 to 49 ever entitled to less than two mammograms?
An insurer may refuse to provide coverage for an examination by low-dose mammography for a woman aged 45 to 49 if she has had such an examination within the previous two years. An insurer may apply any mammogram obtained during that age period, even if obtained prior to coverage under the policy, toward the two mandated examinations.
For information on filing insurance complaints call:
(608) 266-0103 (In Madison)
For your convenience, a complaint form is included on OCI's Web Site.