Advocates push to remove cost barriers for follow-up breast imaging; insurers urge actuarial review

Advocates for cancer patients and several national organizations urged Wyoming lawmakers on May 15 to remove out-of-pocket costs that can discourage patients from completing diagnostic workups after an abnormal screening mammogram, and they urged a narrow ban on step therapy for patients with metastatic cancer.

Bobby Well, policy and advocacy manager with Susan G. Komen, told the joint interim committee that most state-regulated health plans already cover screening mammograms at no cost, but follow-up tests—diagnostic mammograms, ultrasound and breast MRI—are often subject to deductibles and copayments. He said a callback after screening affects roughly 12% of women screened and that diagnostic mammograms start in the low hundreds of dollars while breast MRI can run into the thousands. "Cost sharing for follow-up, diagnostic, and supplemental imaging creates a barrier when patients need answers the most," he said, and proposed eliminating cost-sharing for medically necessary diagnostic follow-up and supplemental imaging for high-risk patients.

Advocates also proposed a narrowly tailored exception to existing prior-authorization and step-therapy practices for patients with advanced metastatic disease so oncologists can immediately start the treatment they deem clinically appropriate. "When someone has metastatic cancer, they should be able to start the treatment their physician prescribes without avoidable delays," Well said.

The Department of Insurance and commercial payers urged careful drafting. Deputy Insurance Commissioner Tana Howard said much of Wyoming’s insurance market is governed by federal rules and that adding state-mandated benefits can trigger federal essential-health-benefit obligations—so-called deferral requirements—that could require the state to cover costs for marketplace plans. Blue Cross Blue Shield of Wyoming and other carriers offered to run actuarial analyses and warned that any change that materially increases covered services or reduces cost-sharing would tend to raise premiums or, in some parts of the market, shift costs to the state.

Advocates noted that more than 30 states have enacted laws limiting cost-sharing for follow-up breast imaging; Montana and Kansas were cited as recent examples where advocates said the fiscal impact was modest for state plans. Committee members asked DOI and payers to provide cost estimates and legal analyses; insurers offered to provide actuarial estimates based on draft language. The committee recessed for lunch and requested follow-up materials on estimated state fiscal exposure and projected insurer cost impacts before deciding on statutory language.

If lawmakers move forward, the committee will need to reconcile patient-access goals with federal marketplace rules and quantify any state-funded deferral obligations before finalizing statutory language.