Highmark has introduced no-cost breast imaging as part of an above-and-beyond push to comply with a new Pennsylvania law.
The Pittsburgh-based insurer, which boasts more than 7 million members, began fully covering advanced mammograms, ultrasounds and MRIs in the New Year.
Doctors use these tests to investigate possible signs of breast cancer, often after a routine, no-cost mammogram raises concerns. The disease kills about 42,000 women in the U.S. each year, the American Cancer Society says, but is highly treatable if caught early.
Last year, roughly two-thirds of Highmark members who got advanced breast imaging had to shoulder some of the cost, with typical out-of-pocket payments ranging from $35 to $380.
The price was enough for some patients to delay care, according to Dr. Matthew Miller, director of breast imaging at Allegheny Health Network. The 14-hospital system is Highmark’s integrated health care provider.
“There’s been many times where patients would get their screening mammogram and we’d see something, and then they would be lost to follow-up,” Miller said. “And then they come back a year later, and they have advanced disease.”
Dr. Timothy Law, Highmark’s chief medical officer, said some patients avoid initial screenings altogether because they fear getting a positive result, which could lead to costly additional testing.
Up to 12% of screening mammograms have a positive result, but fewer than 1% end up being cancer, according to the Mayo Clinic.
Highmark has spent years trying to boost screening mammogram rates through billboards, phone calls and other awareness efforts. The rate of eligible patients who get tested has remained stuck around 70%.
“I’m hoping this will be one of our largest percentage bumps,” Law said.
The goal of increased testing is two-fold, Highmark officials say. More people will be able to access care, but insurance costs will also fall in the long run as early detection limits the need for expensive treatment.
The move also put Highmark ahead of a looming state mandate. In November, Gov. Josh Shapiro signed legislation requiring state-regulated insurers to pay for diagnostic breast testing.
The bill, co-sponsored by Hempfield Republican and breast cancer survivor Senate President Pro Tempore Kim Ward, cleared the state Legislature with near-total support. It will apply to insurance policies issued or renewed after July 24.
Thirty-six states plus Washington, D.C., mandate no-cost expanded breast imaging to some extent.
Ward was building on her 2023 legislation requiring coverage of supplemental screening — such as semi-annual MRIs for high-risk women — as well as genetic testing to help determine cancer risk.
Ward was unavailable for comment.
Highmark’s new policy doesn’t apply just to Pennsylvania. Members in Delaware, New York and West Virginia can also access no-cost diagnostics.
Pat Halpin-Murphy, president and founder of the Pennsylvania Breast Cancer Coalition, applauded Highmark for taking swift action and urged other insurers to comply ahead of schedule.
UPMC and Peak Health, an insurance company co-owned by West Virginia University Health System, did not answer questions about their coverage of breast diagnostics.
Screening guidelines
Miller recommended women between 25 and 30 talk to their primary care doctor or obstetrician-gynecologist to assess their breast cancer risk.
A family history of breast cancer, high tissue density, early menstruation and other factors can raise the chance of developing the disease.
High-risk patients should start annual screening mammograms at 30, Miller said.
All other patients, he said, can hold off until 40.
Miller emphasized the importance of annual screenings, which Allegheny Health Network has offered on a walk-in basis for some women since October.
Cancer that’s caught proactively and is localized to the breast has a five-year survival rate of more than 99%, according to the American Cancer Society.
“The best way for patients to survive a breast cancer diagnosis is for us to detect it and treat it earlier,” Miller said. “The longer the breast cancer is in your body, the longer the breast cancer has time to grow and potentially spread.”