3D Mammography FAQs
On October 5, 2015, Governor Wolf
that under the existing state mammogram law (40 P.S. § 764c) 3D mammograms,
also known as digital breast tomosynthesis, must be covered at no cost to women
in the same manner as traditional two-dimensional mammograms.
What date does this clarification go into effect?
This clarification is effective October
What does the clarification mean?
There should be no cost to patients. As of October 5, 2015, insurers should treat
3D mammograms in the same manner as traditional two-dimensional
However, the Pennsylvania
Insurance Department recognizes that it may take insurers some period of time
to update their systems to reflect this clarification and expects systems to
be updated by January 1, 2016. Until systems are updated, we expect insurers to
make a good faith effort to comply with this clarification.
Does the state mammogram
mandate apply to all health insurance plans?
No, self-insured health insurance plans are not required to provide
coverage under the mandate.
or self-funded, health insurance plans offered by employers are not subject to
this requirement as they are regulated by the Federal government and not by the
state. An employer is self-insured if the employer assumes the financial risk
for providing health care benefits to its employees. Self-insured employers pay
claims using their own money instead of paying an insurance carrier a premium
to assume the risk.
However, check with your employer’s plan administrator to determine if
your plan is self-insured and whether your plan covers 3D mammograms.
Does the department’s
clarification of the mammogram mandate impact the amount insurers reimburse
providers for 3D mammograms?
Pennsylvania’s mammogram mandate does not address the amount of
reimbursement for these services. That is negotiated between the insurance
company and the provider.
What should I do if I receive
a bill for my 3D mammogram?
Consumers should file a complaint with the Pennsylvania Insurance
Department. Consumers may contact the Insurance
Department at 1-877-881-6388, or by visiting
www.insurance.pa.gov. If you would like to file a
complaint with the Insurance Department, you may do so here.