3D Mammography FAQs

On October 5, 2015 clarification was provided 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 5, 2015.

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 mammograms. 

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.

Self-insured, 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's Consumer Services Bureau.  Visit the Consumer Services Bureau online for more information.