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The Business Council opposes S.2917A (Cleare)/A.2516A (Paulin) which would require health plans provider coverage for breast ultrasounds if the insured has received a “notice of dense breast tissue,” which under this legislation would serve as a determination of medical necessity.
This legislation is well-intentioned. However, it is inconsistent with nationally recognized guidelines issued by The United States Preventive Services Task Force (USPSTF) for breast cancer screening and will increase the cost of health care coverage for small and medium-sized businesses.
On April 30, 2024, USPSTF issued final recommendations on screening for breast cancer after publishing draft recommendations, evidence review and modeling reports, which were open to public comment last spring. They acknowledged that nearly half of all women have dense breast, which increases their risk of breast cancer and that mammograms may not work well for them, however, stressed that there is not yet enough evidence for or against additional screening with breast ultrasound. (https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/breast-cancer-screening)
New health insurance coverage mandates result in increased costs for employees and employers who purchase private health insurance in New York. These costs fall disproportionately on small and medium-sized businesses who purchase private insurance plans. Mandates like this only apply to fully insured policies that are either purchased by individuals on the marketplace or received through a small or medium-sized business.
Large companies generally self-insure, which allows them to customize a plan to meet the specific needs of their employees, contract with providers or provider networks, and directly pay claims to providers. But importantly, self-insured health plans are regulated under federal law (ERISA) and not subject to state health insurance benefit mandates.
In New York, more than 50% of the commercial market is covered under a self-insured plan. Therefore, these mandates only impact small businesses and their employees that make up the other portion of the commercial market.
The collective imposition of over three dozen mandates (and counting) on private insurance purchased by small and medium-sized businesses significantly drives up the cost of health care insurance for employers and their employees. This bill will add to the increasing cost of health care insurance and require health plans to provide coverage that is inconsistent with evidence-based recommendations by the USPSTF.
For these reasons, The Business Council opposes S.2917A (Cleare) / A.2516A (Paulin).