Health insurance carriers in Pennsylvania will soon be required to cover breast cancer screenings and diagnostic imaging without any cost-sharing, under Senate Bill 88 introduced June 6, 2025. The bill, which amends The Insurance Company Law of 1921, aims to provide broader access to breast imaging by removing financial barriers for individuals at average or higher risk of breast cancer.
The legislation repeals the previous Section 632, replacing it with a new mandate that all health insurance policies offered, issued, or renewed in the Commonwealth must cover the full cost of mammographic examinations for individuals aged 40 and older. It also extends coverage to those under 40 when a physician recommends it.
Coverage must also include supplemental breast screenings and diagnostic breast examinations for individuals classified as being at average risk or higher. These screenings may involve standard or abbreviated magnetic resonance imaging (MRI) or ultrasound, as appropriate.
Insurance carriers must verify that facilities performing mammograms are certified under 42 U.S.C. § 263b, which pertains to the federal certification of mammography facilities.
While the legislation mandates coverage without deductibles, copayments, or coinsurance for minimum required services, insurers retain the ability to apply utilization review as permitted under Article XXI of the act. However, the law does not require coverage for mastectomy procedures.
“Average risk” is defined by several clinical criteria, including having a 15% or lower lifetime risk of breast cancer, no personal or family history of the disease, no known BRCA gene mutation, and no prior therapeutic thoracic radiation therapy, among other factors.
The new requirements take effect 180 days after the bill becomes law. For policies requiring rate or form filings, the law applies to those filed on or after that date. For other policies, the requirement applies to those issued or renewed beginning 180 days post-enactment.
To read more on this, check this link.
