Mandated Mammography Benefits--Do Exceptions Swallow the Rule?

By Ronald L. Scott

The debate over mandated health benefits usually focuses on whether mandates lead to an increase in the cost of health insurance, perhaps ultimately making insurance unaffordable for many. Proponents of mandated benefits argue they offer critically needed consumer protections. Interestingly, laws that mandate benefits often exclude entire classes of insurance from the coverage mandate. As an example, consider the way the state of Texas deals with mammography.

The Texas Insurance Code, Art. 3.70-2(H) states:

…Each individual policy and group policy of accident and sickness insurance that covers a female 35 years old or older and is delivered, issued for delivery, or renewed in this state, except for policies that provide coverage for a specified disease or other limited benefit coverage must include coverage for an annual screening for low-dose mammography for the presence of occult breast cancer within the provisions of the policy that is not less favorable than for other radiological examinations and subject to the same dollar limits, deductibles and other co-insurance factors. (Emphasis added). Specified disease policies cover a person for a specifically named disease (or diseases), e.g. "cancer-only" policies. Specified disease policies usually provide minimal coverage. Consistent with the low level of coverage, the statute does not require mammograms be covered by specified disease policies.

The Texas Department of Insurance (TDI) has established minimum standards for basic hospital expense coverage, medical and surgical expense coverage, and disability coverage in insurance policies. Limited benefit coverage policies are policies that provide for types or amounts of benefits that are less than the specified minimum standards. TDI regulations require that these policies prominently display the limited nature of the benefits at the top of the "outline of benefits" in the policy. Again, reflective of the limited nature of the benefits provided, mammograms are not mandated under limited benefit policies.

According to TDI, health maintenance organizations (HMOs) are not required to cover mammography,but most HMOs choose to provide mammography as a preventive benefit.

The Small Employer Health Insurance Plan, intended to increase the availability of insurance, establishes a "basic" plan and a "catastrophic" plan for small businesses. The basic plan under "exclusions and limitations" does not cover expenses for mammography. Under the catastrophic plan, mammograms appear to be similarly excluded. However, a preventative care benefit "rider" is required to be offered (at an extra charge) under the basic plan that provides mammography coverage. The rider provides that one annual physical examination is covered, including "screening by low-dose mammography for any female insured age 35 or over."

An HMO Plan is also possible under the Small Employer Health Insurance Plan. An HMO may offer a state-approved health benefit plan that complies with the requirements of the federal Public Health Service Act. This law requires that the HMO provide "diagnostic and radiologic services" as part of the "basic health services" provided by the HMO. The HMO can also offer the prototype small employer group health benefit plan. Mammography is covered under "preventative health services." As a result, mammograms are required if the Small Business Health Insurance Plan follows the HMO prototype policy set forth in the TDI regulations. Mammograms must be paid by any Medicare supplement policy.

Finally, the federal Employee Retirement Income Security Act (ERISA) may preempt state mandates as they relate to employer self-funded insurance.

If mandated benefits such as mammography do indeed provide important consumer protections, it is unfortunate that the benefits of such mandates may only extend to a minority of health plan participants, given the combined federal and state exceptions. The trend, however, may be to further reduce mandates. The Health Insurance Association of America’s "InsureUSA" proposal calls for an exemption from all state benefit mandates. HIAA estimates that allowing insurers to sell policies without expensive state-mandated benefits could extend coverage to 2.4 million uninsured Americans. See