A Survey of State Medicaid Policies for Coverage of Screening Mammography and Pap Smear Services Kathryn G. Moore State Government Relations Representative The American College of Obstetricians and Gynecologists Washington, DC
Abstract In the winter of 1990, we surveyed all states and the District of Columbia to ascertain Medicaid policies on screening mammography and Pap smear--two critical preventive cancer screens for women. Forty-four state Medicaid programs cover screening mammography and all 51 jurisdictions cover Pap smear services. However, the extent of coverage and reimbursement rates vary widely across states. Only a small minority of states reported age or frequency limits for screening; five of these are in conflict with nationally recommended guidelines.
ince its creation in 1965, Medicaid has been the primary source of health insurance for the poor in this country, particularly for poor w o m e n . The states and federal g o v e r n m e n t share the cost of the Medicaid program, and the states administer it within broad federal guidelines. All states are required to cover certain general categories of services---including inpatient and outpatient hospital services, physician and nurse practitioner services, nurse-midwife services, family planning services, and laboratory and x-ray services---and may elect to provide an array of optional services.~ But within these guidelines, each state has wide latitude in deciding which medical and ancillary services it will cover u n d e r its Medicaid program, the duration and scope of services, and the rate of reimbursement. The services that are covered and r e i m b u r s e m e n t rates vary widely, therefore, from state to state. Breast and cervical cancer screening are especially critical services for low-income and minority w o m e n . The poor and minorities have a low cancer survival rate as c o m p a r e d with other populations, primarily because of socioeconomic factors. 2 We k n o w that with m a m m o g r a p h y , higher income and education levels correlate with getting m a m m o g r a m s . 3 Nearly half (43%) of w o m e n over age 40 with h o u s e h o l d incomes u n d e r $15,000 per year and w h o have less than a high school degree have never had a mammograrn. In contrast, less than a quarter (24%) of w o m e n w h o have h o u s e h o l d incomes over $50,000 and hold a high school degree have n e v e r had the test. 3 Similarly, w o m e n with family incomes below the poverty level and with less than a high school education are m u c h less likely to have had a Pap smear in the
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© 1992 by The Jacobs Institute of Women's Health 1049-3867/92/$5.00
WHI Vol. 2, No. t Spring 1992
past 3 years or to have h e a r d of the Pap smear than w o m e n w h o are not p o o r and those w h o have completed high school. 4 Breast cancer accounts for 32% of all cancers in w o m e n in the United States, and one in nine w o m e n - - 1 7 5 , 0 0 0 this year--will get the disease. 5 Although the n u m b e r of w o m e n getting m a m m o g r a m s has risen sharply over the past few years, too few w o m e n are getting t h e m as often as necessary. 6 It has been estimated that if w o m e n had m a m m o g r a m s regularly, the national breast cancer d e a t h rate w o u l d d r o p by 40-50% .7 At the present time, m a m m o g r a p h y is the only screening m e t h o d available to detect subclinical or occult breast cancer, the stage least likely to have spread to regional n o d e s and b e y o n d , and the time w h e n curability is over 90%. M a m m o g r a p h y can also be the most costly of all cancer screens, s This is n o t e w o r t h y because cost is k n o w n to be a deterrent to regular screening. 9 Guidelines on the frequency with which w o m e n should have m a m m o grams, as r e c o m m e n d e d by national medical organizations including the American Cancer Society, the National Cancer Institute, and the American College of Obstetricians and Gynecologists are as follows: W o m e n age 40-49 should have m a m m o g r a m s every 1-2 years and yearly breast exams by their physician. W o m e n age 50 and over should have annual m a m m o g r a m s and breast exams. 10 Invasive cervical cancer accounts for 2.3% of all cancers in w o m e n in the United States. s In 1991, it was estimated that 13,000 w o m e n w o u l d develop invasive cancer of the cervix and some 4,500 would die from their disease, s Deaths from cervical cancer have decreased by more than 70% over the last 40 years, a decrease that has been widely attributed to the use of the Pap smear, s Recent studies have s h o w n that 72% of w o m e n have had a Pap smear within the last year. 4 Although utilization has been g o o d - with black w o m e n in particular making substantial gains in recent years 4--significant n u m b e r s of w o m e n today are not being screened. Hispanic, Spanish-speaking w o m e n , for example, have the poorest utilization rates of all w o m e n for the Pap smear. 4 The Pap smear remains the single most important test for the detection and prevention of cervical cancer. It is a simple, low-cost test that is p e r f o r m e d in a physician's office as part of a w o m a n ' s regular gynecologic or family planning exam. Guidelines on the frequency with which w o m e n should have a Pap smear, as r e c o m m e n d e d by national medical organizations, including the American Cancer Society, the National Cancer Institute, and the American College of Obstetricians and Gynecologists, are as follows: All w o m e n w h o are or w h o have been sexually active or w h o have reached age 18 should have an annual Pap test and pelvic examination. After a w o m a n has had three or more consecutive, satisfactory, normal annual examinations, the Pap test may be p e r f o r m e d less frequently at the discretion of her physician, s Despite w i d e s p r e a d public attention to the value of screening m a m m o g raphy and the Pap smear and concerns about access to these critical preventive cancer screens, information has been unavailable nationally on coverage of screening m a m m o g r a p h y and Pap smear by Medicaid programs and on utilization by Medicaid recipients. The s u r v e y reported here delineates state-bystate Medicaid policies for coverage of screening m a m m o g r a p h y and Pap smear.
METHODS A two-part questionnaire was mailed to the director of the Medicaid program in each state and the District of Columbia that asked about Medicaid coverage
Will Vol. 2, No. 1 Spring 1992
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and reimbursement for screening mammography and Pap smear. We asked about Medicaid coverage for mammography and Pap smear for specific indications to allow for variation in state policies. Respondents were asked to check either yes or no for coverage, to list reimbursement rates, and to check any requirements for coverage and reimbursement that were identified on the questionnaire. The standard Current Procedural Terminology (CPT) codes for each procedure were provided. Completed questionnaires were obtained from all 51 jurisdictions during the period December 1990 through April 1991. Responses reflect Medicaid policies as of, roughly, the latter part of 1990. (Where legislation that affects a state's coverage policy was enacted after the time all questionnaires were received and before the date of this report, it has been noted; see Table 1.)
Table 1.
MEDICAID COVERAGE OF SCREENING MAMMOGRAPHY BY STATES AND DISTRICT OF COLUMBIA AS OF DECEMBER 1990
State
Screening Mammography
Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia
O X1 X X X X X X X X X
Hawaii
X2
Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico
X X X X X X
Age Limits ,/* ,/*
Frequency Limits
Medical Necessity
By Physician Order
Nurse May Order
,/* ,/* ~/
,/
~/~"
v/~
,/* ,/
,/* ~/
0 3
X X X O X X X Xs X O X X6 X
,/
,/ ~/* ,/*
,/* ,/*
J J J
,/ (Continued)
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MOORE: STATE COVERAGE OF MAMMOGRAPHY AND PAP SMEARS
WHI Vol. 2, No. 1 Spring 1992
Table 1. MEDICAID COVERAGE OF SCREENING MAMMOGRAPHY BY STATES AND DISTRICT OF COLUMBIA AS OF DECEMBER 1990 (Continued)
Screening Mammography
Age Limits
New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
X O X X O X X X X X X X X X O X X X X
,/
Totals Covered Not covered
44 7
State
Frequency Limits
Medical Necessity
,/
By Physician Order
Nurse May Order
,/
,/
,/ ,/
,/ ~/* ,/ ,/*
~/ ,/*
,/ ,/ ,/ ,/
,/*
,/*
,/
,/ ,/ ,/ J
Symbols: X = covered; O = not covered; ,/ = state has this particular requirement for coverage; * = comparable to nationally r e c o m m e n d e d guidelines for age/frequency of m a m m o g r a p h y screening. 1Authorizing legislation was enacted June 1991. 2Coverage began February 1, 1991. 3Authorizing legislation was enacted July 1991. 4Will cover for a "suspected condition." SAuthorizing legislation was enacted April 1991. 6Coverage was to have b e g u n in 1991 and follow nationally r e c o m m e n d e d guidelines for age/frequency.
RESULTS
Screening Mammography Each state's coverage of screening mammography is shown in Table 1. The majority (44) of states provide coverage for this procedure; seven states do not. Fourteen states reported age limits for screening mammography and 13 states reported frequency limits. In nine of these states, the ages for screening and the frequency of screening are comparable with the nationally recommended guidelines; in five states they are contradictory. Two states cover screening mammography only if it's medically necessary based on prior or family history of breast cancer. Thirty-one states cover this procedure only if it is ordered by a physician; in three of these states, a certified nurse-midwife or registered nurse may also order a screening mammogram. Table 2 lists each state's reimbursement rate for screening mammography (CPT Code 76092). Reimbursement rates vary widely across states, ranging from a low of $6 to a high of $150. In more than half of the states, the rate is less than the maximum Medicare payment of $55. WHl Vol. 2, No. 1 Spring 1992
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Table 2.
MEDICAID REIMBURSEMENT RATES FOR SCREENING MAMMOGRAPHY BY STATES AND DISTRICT OF COLUMBIA AS OF DECEMBER 1990 State
Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia
Reimbursement Rate*
0 0 $ 69.39 $ 46.44 $ 50.42 $ 28.28 X $ 35.00 $ 53.36 $ 90.001 $ 44.00 X $ 40.61 $ 70.65 $ 88.90 $ 85.401 $115.00 $ 22.00 inpatient/S28.60 outpatient 0 $ 30.00 $ 30.00 $ 49.00 0 $ 82.50
$ 56.00 $ 33.00 $ 96.70 $ 75.00 0 $ 50.0O X $ 7.48 $ 30.00 0 $ 75.OO $ 20.00 0 $ 41.92 $ 6.00 $ 35.00 $ 64.00 X2 $ 48.37 $150.003 approximately $ 30.77 $ 51.00 0
(Continued)
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Table 2.
MEDICAID REIMBURSEMENT RATES FOR SCREENING MAMMOGRAPHY BY STATES AND DISTRICT OF COLUMBIA AS OF DECEMBER 1990 (Continued) State
Reimbursement Rate*
Washington West Virginia Wisconsin Wyoming
X2
$ 31.50 $ 63.99 $ 66.84
Symbols: O = state does not reimburse for this procedure; X = no rate reported. IRate reported is for CPT code 76091, diagnostic mammography, bilateral. 2State reimburses a percentage of physician's usual and customary fee. 3State reimburses physicians on a profile system. *CPT Code 76092, screening mammography, bilateral (two film study of each breast).
Pap Smear Each state's coverage of Pap smear is shown in Table 3. All 51 jurisdictions cover both the Pap smear and follow-up services for an abnormal Pap smear. Five states reported age limits for coverage and 12 states reported frequency limits. In all but one of these states, however, the ages for screening and the frequency of screening contradict nationally recommended guidelines. In 14 states, the Pap smear is covered only when medically necessary, usually as certified by an attending physician. In the majority of states, the Pap smear is covered by physician order only (36 states); however, in four of these, a nurse may also order a Pap smear. Table 4 shows how the Pap smear is reimbursed--whether it is paid for as part of an annual, preventive gynecologic exam, as a separate lab service, or is reimbursed in both cases. The Pap smear is reimbursed as a laboratory service in all 51 jurisdictions. In 39 states, the Pap smear is considered a part of an annual gynecologic or family-planning exam and may also be billed using any of several standard office visit codes or a local family-planning code. In 12 states the Pap smear is not reimbursed as a part of the annual gynecologic or family-planning exam.
Table 3.
MEDICAID COVERAGE OF PAP SMEAR BY STATES AND DISTRICT OF COLUMBIA AS OF DECEMBER 1990
State
Pap Smear
Follow-Up: Abnormal Pap Smear
Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia
X X X X X X X X X X X
X X X X X X X X X X X
Age Limits
Frequency Limits
Medical Necessity
By Physician Order
Nurse May Order
J
J J J J J
J J (Continued)
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Table 3.
MEDICAID COVERAGE OF PAP SMEAR BY STATES AND DISTRICT OF COLUMBIA AS OF DECEMBER 1990 (Continued)
Pap Smear
Follow-Up: Abnormal Pap Smear
Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X
X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X
Totals Covered Not covered
51 0
51 0
State
Age Limits
Frequency Limits
J
J
J
J
Medical Necessity
J
By Physician Order
Nurse May Order
,/
,/
J J ,/ J J J
~
J
,/
J
Symbols: X = covered; ,/ = state h a s this particular r e q u i r e m e n t for coverage; * = comparable with nationally r e c o m m e n d e d g u i d e l i n e s for age/frequency of Pap smear.
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DISCUSSION Poor wo men are less likely to use preventive health services than are other women and have lower cancer screening and survival rates than the nonpoor. u Consequently, Medicaid coverage policies for screening mammography and Pap smear can have a tremendous impact on the health status of poor women. By covering these preventive cancer screens, each state acknowledges their importance for women's health and their commitment to providing access to them for poor women.
TABLE 4.
MEDICAID REIMBURSEMENT METHODOLOGY FOR PAP SMEAR BY STATES AND DISTRICT OF COLUMBIA AS OF DECEMBER 1990
State
Reimburses Pap Smear as Part of Annual Preventive Gynecologic Exam
Reimburses Pap Smear as Separate Lab Service
Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina
No
Yes
Yes Yes No Yes No Yes Yes Yes Yes Yes Yes No No No Yes Yes Yes No Yes Yes Yes Yes Yes Yes Yes Yes Yes No Yes Yes Yes Yes Yes
Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes (Continued)
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TABLE 4.
MEDICAID REIMBURSEMENT METHODOLOGY FOR PAP SMEAR BY STATES AND DISTRICT OF COLUMBIA AS OF DECEMBER 1990 (Continued)
State
North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Reimburses Pap Smear as Part of Annual Preventive Gynecologic Exam
Reimburses Pap Smear as Separate Lab Service
Yes Yes Yes No Yes Yes Yes Yes No No Yes Yes No Yes Yes Yes Yes
Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes
The access issue is especially relevant to this discussion because we've seen remarkable headway made in the last few years with coverage of cancer screening and other preventive health services by insurers. But most of this progress has been confined to the private sector and not to governmentfinanced health care programs and the populations they serve. This is a serious concern. Reimbursement is also a concern. In Table 2, we've seen that the Medicaid rate of reimbursement for screening mammography is less than the Medicare reimbursement rate in over half of the states. This is noteworthy, but not surprising, because Medicaid reimbursement rates have been found to be significantly lower generally than Medicare rates for the same services. 12 Low reimbursement has also been documented as an impediment to physician participation in the Medicaid program and, hence, to patient access to services. ~2.13 Finally, there are concerns with appropriate screening. For the majority of states, where no ages or frequencies were reported, there is a concern whether or not women are being screened according to the nationally recommended guidelines. We have learned from this survey that several states are not providing coverage for screening mammography and Pap smear consistent with medical guidelines. All state Medicaid agencies are urged to cover these services and to pay for them for poor women at the ages and frequencies recommended. Medicaid agencies may soon discover that they have no choice in the matter if Congress has its way. Legislation has been introduced to require coverage of mammography and Pap smear screening by all state Medicaid programs, at specified ages and frequencies, and with full funding by the federal government even in those states that currently cover these services. ~4
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REFERENCES 1. Title XIX, Social Security Act, 42 U.S.C. 1936. 2. American Cancer Society. Cancer in the economically disadvantaged: A special report prepared by the Subcommittee on Cancer in the Economically Disadvantaged. New York: American Cancer Society, 1986. 3. Romans MC, Marchant DJ, Pearse WH. Utilization of screening mammography-1990. Women's Health Issues 1991;1:68-73. 4. Harlan LC, Bernstein AB, Kessler LG. Cervical cancer screening: Who is not covered and why? Am J Public Health 1991;81:885-90. 5. American Cancer Society. Cancer facts & figures, Atlanta: ACS, 1991. 6. Marchant DJ. Use of mammography--United States, 1990. MMWR 1990;36:621. 7. Feig SA. Decreased breast cancer mortality through mammographic screening: Results of clinical trials. Radiology 1988;167z:659-65. 8. American College of Obstetricians and Gynecologists. Report of Task Force on Routine Cancer Screening. ACOG Committee Opinion 68, Washington DC: ACOG, 1989. 9. Romans MC. Jacobs Institute Workshop on Screening Mammography. Women's Health Issues 1991;1:63-7. 10. Consensus guidelines for mammography screening adopted by the American Cancer Society and 11 other medical specialty societies on June 27, 1989. 11. Makuc DM, Fried VM, Kleinman JC. National trends in the use of preventive health care by women. Am J Public Health 1989;79:21-6. 12. Physician Payment Review Commission. Physician payment under Medicaid, No. 91-4:34. Washington DC, 1991. 13. Committee on Health Care for Underserved Women, American College of Obstetricians and Gynecologists. Ob/Gyn services for indigent women: Issues raised by an ACOG survey. Washington DC: ACOG, 1988. 14. HR 1393, Medicaid breast and cervical cancer amendments of 1991. 102D Congress 1st Session.
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Abstract In the winter of 1990, we surveyed all states and the District of Columbia to ascertain Medicaid policies on screening mammography and Pap smear--two critical preventive cancer screens for women. Forty-four state Medicaid programs cover screening mammography and all 51 jurisdictions cover Pap smear services. However, the extent of coverage and reimbursement rates vary widely across states. Only a small minority of states reported age or frequency limits for screening; five of these are in conflict with nationally recommended guidelines.
ince its creation in 1965, Medicaid has been the primary source of health insurance for the poor in this country, particularly for poor w o m e n . The states and federal g o v e r n m e n t share the cost of the Medicaid program, and the states administer it within broad federal guidelines. All states are required to cover certain general categories of services---including inpatient and outpatient hospital services, physician and nurse practitioner services, nurse-midwife services, family planning services, and laboratory and x-ray services---and may elect to provide an array of optional services.~ But within these guidelines, each state has wide latitude in deciding which medical and ancillary services it will cover u n d e r its Medicaid program, the duration and scope of services, and the rate of reimbursement. The services that are covered and r e i m b u r s e m e n t rates vary widely, therefore, from state to state. Breast and cervical cancer screening are especially critical services for low-income and minority w o m e n . The poor and minorities have a low cancer survival rate as c o m p a r e d with other populations, primarily because of socioeconomic factors. 2 We k n o w that with m a m m o g r a p h y , higher income and education levels correlate with getting m a m m o g r a m s . 3 Nearly half (43%) of w o m e n over age 40 with h o u s e h o l d incomes u n d e r $15,000 per year and w h o have less than a high school degree have never had a mammograrn. In contrast, less than a quarter (24%) of w o m e n w h o have h o u s e h o l d incomes over $50,000 and hold a high school degree have n e v e r had the test. 3 Similarly, w o m e n with family incomes below the poverty level and with less than a high school education are m u c h less likely to have had a Pap smear in the
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MOORE:STATE COVERAGEOF MAMMOGRAPHYAND PAP SMEARS
© 1992 by The Jacobs Institute of Women's Health 1049-3867/92/$5.00
WHI Vol. 2, No. t Spring 1992
past 3 years or to have h e a r d of the Pap smear than w o m e n w h o are not p o o r and those w h o have completed high school. 4 Breast cancer accounts for 32% of all cancers in w o m e n in the United States, and one in nine w o m e n - - 1 7 5 , 0 0 0 this year--will get the disease. 5 Although the n u m b e r of w o m e n getting m a m m o g r a m s has risen sharply over the past few years, too few w o m e n are getting t h e m as often as necessary. 6 It has been estimated that if w o m e n had m a m m o g r a m s regularly, the national breast cancer d e a t h rate w o u l d d r o p by 40-50% .7 At the present time, m a m m o g r a p h y is the only screening m e t h o d available to detect subclinical or occult breast cancer, the stage least likely to have spread to regional n o d e s and b e y o n d , and the time w h e n curability is over 90%. M a m m o g r a p h y can also be the most costly of all cancer screens, s This is n o t e w o r t h y because cost is k n o w n to be a deterrent to regular screening. 9 Guidelines on the frequency with which w o m e n should have m a m m o grams, as r e c o m m e n d e d by national medical organizations including the American Cancer Society, the National Cancer Institute, and the American College of Obstetricians and Gynecologists are as follows: W o m e n age 40-49 should have m a m m o g r a m s every 1-2 years and yearly breast exams by their physician. W o m e n age 50 and over should have annual m a m m o g r a m s and breast exams. 10 Invasive cervical cancer accounts for 2.3% of all cancers in w o m e n in the United States. s In 1991, it was estimated that 13,000 w o m e n w o u l d develop invasive cancer of the cervix and some 4,500 would die from their disease, s Deaths from cervical cancer have decreased by more than 70% over the last 40 years, a decrease that has been widely attributed to the use of the Pap smear, s Recent studies have s h o w n that 72% of w o m e n have had a Pap smear within the last year. 4 Although utilization has been g o o d - with black w o m e n in particular making substantial gains in recent years 4--significant n u m b e r s of w o m e n today are not being screened. Hispanic, Spanish-speaking w o m e n , for example, have the poorest utilization rates of all w o m e n for the Pap smear. 4 The Pap smear remains the single most important test for the detection and prevention of cervical cancer. It is a simple, low-cost test that is p e r f o r m e d in a physician's office as part of a w o m a n ' s regular gynecologic or family planning exam. Guidelines on the frequency with which w o m e n should have a Pap smear, as r e c o m m e n d e d by national medical organizations, including the American Cancer Society, the National Cancer Institute, and the American College of Obstetricians and Gynecologists, are as follows: All w o m e n w h o are or w h o have been sexually active or w h o have reached age 18 should have an annual Pap test and pelvic examination. After a w o m a n has had three or more consecutive, satisfactory, normal annual examinations, the Pap test may be p e r f o r m e d less frequently at the discretion of her physician, s Despite w i d e s p r e a d public attention to the value of screening m a m m o g raphy and the Pap smear and concerns about access to these critical preventive cancer screens, information has been unavailable nationally on coverage of screening m a m m o g r a p h y and Pap smear by Medicaid programs and on utilization by Medicaid recipients. The s u r v e y reported here delineates state-bystate Medicaid policies for coverage of screening m a m m o g r a p h y and Pap smear.
METHODS A two-part questionnaire was mailed to the director of the Medicaid program in each state and the District of Columbia that asked about Medicaid coverage
Will Vol. 2, No. 1 Spring 1992
MOORE: STATE COVERAGE OF M A M M O G R A P H Y AND PAP SMEARS
41
and reimbursement for screening mammography and Pap smear. We asked about Medicaid coverage for mammography and Pap smear for specific indications to allow for variation in state policies. Respondents were asked to check either yes or no for coverage, to list reimbursement rates, and to check any requirements for coverage and reimbursement that were identified on the questionnaire. The standard Current Procedural Terminology (CPT) codes for each procedure were provided. Completed questionnaires were obtained from all 51 jurisdictions during the period December 1990 through April 1991. Responses reflect Medicaid policies as of, roughly, the latter part of 1990. (Where legislation that affects a state's coverage policy was enacted after the time all questionnaires were received and before the date of this report, it has been noted; see Table 1.)
Table 1.
MEDICAID COVERAGE OF SCREENING MAMMOGRAPHY BY STATES AND DISTRICT OF COLUMBIA AS OF DECEMBER 1990
State
Screening Mammography
Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia
O X1 X X X X X X X X X
Hawaii
X2
Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico
X X X X X X
Age Limits ,/* ,/*
Frequency Limits
Medical Necessity
By Physician Order
Nurse May Order
,/* ,/* ~/
,/
~/~"
v/~
,/* ,/
,/* ~/
0 3
X X X O X X X Xs X O X X6 X
,/
,/ ~/* ,/*
,/* ,/*
J J J
,/ (Continued)
42
MOORE: STATE COVERAGE OF MAMMOGRAPHY AND PAP SMEARS
WHI Vol. 2, No. 1 Spring 1992
Table 1. MEDICAID COVERAGE OF SCREENING MAMMOGRAPHY BY STATES AND DISTRICT OF COLUMBIA AS OF DECEMBER 1990 (Continued)
Screening Mammography
Age Limits
New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
X O X X O X X X X X X X X X O X X X X
,/
Totals Covered Not covered
44 7
State
Frequency Limits
Medical Necessity
,/
By Physician Order
Nurse May Order
,/
,/
,/ ,/
,/ ~/* ,/ ,/*
~/ ,/*
,/ ,/ ,/ ,/
,/*
,/*
,/
,/ ,/ ,/ J
Symbols: X = covered; O = not covered; ,/ = state has this particular requirement for coverage; * = comparable to nationally r e c o m m e n d e d guidelines for age/frequency of m a m m o g r a p h y screening. 1Authorizing legislation was enacted June 1991. 2Coverage began February 1, 1991. 3Authorizing legislation was enacted July 1991. 4Will cover for a "suspected condition." SAuthorizing legislation was enacted April 1991. 6Coverage was to have b e g u n in 1991 and follow nationally r e c o m m e n d e d guidelines for age/frequency.
RESULTS
Screening Mammography Each state's coverage of screening mammography is shown in Table 1. The majority (44) of states provide coverage for this procedure; seven states do not. Fourteen states reported age limits for screening mammography and 13 states reported frequency limits. In nine of these states, the ages for screening and the frequency of screening are comparable with the nationally recommended guidelines; in five states they are contradictory. Two states cover screening mammography only if it's medically necessary based on prior or family history of breast cancer. Thirty-one states cover this procedure only if it is ordered by a physician; in three of these states, a certified nurse-midwife or registered nurse may also order a screening mammogram. Table 2 lists each state's reimbursement rate for screening mammography (CPT Code 76092). Reimbursement rates vary widely across states, ranging from a low of $6 to a high of $150. In more than half of the states, the rate is less than the maximum Medicare payment of $55. WHl Vol. 2, No. 1 Spring 1992
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Table 2.
MEDICAID REIMBURSEMENT RATES FOR SCREENING MAMMOGRAPHY BY STATES AND DISTRICT OF COLUMBIA AS OF DECEMBER 1990 State
Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia
Reimbursement Rate*
0 0 $ 69.39 $ 46.44 $ 50.42 $ 28.28 X $ 35.00 $ 53.36 $ 90.001 $ 44.00 X $ 40.61 $ 70.65 $ 88.90 $ 85.401 $115.00 $ 22.00 inpatient/S28.60 outpatient 0 $ 30.00 $ 30.00 $ 49.00 0 $ 82.50
$ 56.00 $ 33.00 $ 96.70 $ 75.00 0 $ 50.0O X $ 7.48 $ 30.00 0 $ 75.OO $ 20.00 0 $ 41.92 $ 6.00 $ 35.00 $ 64.00 X2 $ 48.37 $150.003 approximately $ 30.77 $ 51.00 0
(Continued)
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WHI Vol. 2, No. 1 Spring 1992
Table 2.
MEDICAID REIMBURSEMENT RATES FOR SCREENING MAMMOGRAPHY BY STATES AND DISTRICT OF COLUMBIA AS OF DECEMBER 1990 (Continued) State
Reimbursement Rate*
Washington West Virginia Wisconsin Wyoming
X2
$ 31.50 $ 63.99 $ 66.84
Symbols: O = state does not reimburse for this procedure; X = no rate reported. IRate reported is for CPT code 76091, diagnostic mammography, bilateral. 2State reimburses a percentage of physician's usual and customary fee. 3State reimburses physicians on a profile system. *CPT Code 76092, screening mammography, bilateral (two film study of each breast).
Pap Smear Each state's coverage of Pap smear is shown in Table 3. All 51 jurisdictions cover both the Pap smear and follow-up services for an abnormal Pap smear. Five states reported age limits for coverage and 12 states reported frequency limits. In all but one of these states, however, the ages for screening and the frequency of screening contradict nationally recommended guidelines. In 14 states, the Pap smear is covered only when medically necessary, usually as certified by an attending physician. In the majority of states, the Pap smear is covered by physician order only (36 states); however, in four of these, a nurse may also order a Pap smear. Table 4 shows how the Pap smear is reimbursed--whether it is paid for as part of an annual, preventive gynecologic exam, as a separate lab service, or is reimbursed in both cases. The Pap smear is reimbursed as a laboratory service in all 51 jurisdictions. In 39 states, the Pap smear is considered a part of an annual gynecologic or family-planning exam and may also be billed using any of several standard office visit codes or a local family-planning code. In 12 states the Pap smear is not reimbursed as a part of the annual gynecologic or family-planning exam.
Table 3.
MEDICAID COVERAGE OF PAP SMEAR BY STATES AND DISTRICT OF COLUMBIA AS OF DECEMBER 1990
State
Pap Smear
Follow-Up: Abnormal Pap Smear
Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia
X X X X X X X X X X X
X X X X X X X X X X X
Age Limits
Frequency Limits
Medical Necessity
By Physician Order
Nurse May Order
J
J J J J J
J J (Continued)
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Table 3.
MEDICAID COVERAGE OF PAP SMEAR BY STATES AND DISTRICT OF COLUMBIA AS OF DECEMBER 1990 (Continued)
Pap Smear
Follow-Up: Abnormal Pap Smear
Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X
X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X
Totals Covered Not covered
51 0
51 0
State
Age Limits
Frequency Limits
J
J
J
J
Medical Necessity
J
By Physician Order
Nurse May Order
,/
,/
J J ,/ J J J
~
J
,/
J
Symbols: X = covered; ,/ = state h a s this particular r e q u i r e m e n t for coverage; * = comparable with nationally r e c o m m e n d e d g u i d e l i n e s for age/frequency of Pap smear.
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DISCUSSION Poor wo men are less likely to use preventive health services than are other women and have lower cancer screening and survival rates than the nonpoor. u Consequently, Medicaid coverage policies for screening mammography and Pap smear can have a tremendous impact on the health status of poor women. By covering these preventive cancer screens, each state acknowledges their importance for women's health and their commitment to providing access to them for poor women.
TABLE 4.
MEDICAID REIMBURSEMENT METHODOLOGY FOR PAP SMEAR BY STATES AND DISTRICT OF COLUMBIA AS OF DECEMBER 1990
State
Reimburses Pap Smear as Part of Annual Preventive Gynecologic Exam
Reimburses Pap Smear as Separate Lab Service
Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina
No
Yes
Yes Yes No Yes No Yes Yes Yes Yes Yes Yes No No No Yes Yes Yes No Yes Yes Yes Yes Yes Yes Yes Yes Yes No Yes Yes Yes Yes Yes
Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes (Continued)
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TABLE 4.
MEDICAID REIMBURSEMENT METHODOLOGY FOR PAP SMEAR BY STATES AND DISTRICT OF COLUMBIA AS OF DECEMBER 1990 (Continued)
State
North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Reimburses Pap Smear as Part of Annual Preventive Gynecologic Exam
Reimburses Pap Smear as Separate Lab Service
Yes Yes Yes No Yes Yes Yes Yes No No Yes Yes No Yes Yes Yes Yes
Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes
The access issue is especially relevant to this discussion because we've seen remarkable headway made in the last few years with coverage of cancer screening and other preventive health services by insurers. But most of this progress has been confined to the private sector and not to governmentfinanced health care programs and the populations they serve. This is a serious concern. Reimbursement is also a concern. In Table 2, we've seen that the Medicaid rate of reimbursement for screening mammography is less than the Medicare reimbursement rate in over half of the states. This is noteworthy, but not surprising, because Medicaid reimbursement rates have been found to be significantly lower generally than Medicare rates for the same services. 12 Low reimbursement has also been documented as an impediment to physician participation in the Medicaid program and, hence, to patient access to services. ~2.13 Finally, there are concerns with appropriate screening. For the majority of states, where no ages or frequencies were reported, there is a concern whether or not women are being screened according to the nationally recommended guidelines. We have learned from this survey that several states are not providing coverage for screening mammography and Pap smear consistent with medical guidelines. All state Medicaid agencies are urged to cover these services and to pay for them for poor women at the ages and frequencies recommended. Medicaid agencies may soon discover that they have no choice in the matter if Congress has its way. Legislation has been introduced to require coverage of mammography and Pap smear screening by all state Medicaid programs, at specified ages and frequencies, and with full funding by the federal government even in those states that currently cover these services. ~4
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REFERENCES 1. Title XIX, Social Security Act, 42 U.S.C. 1936. 2. American Cancer Society. Cancer in the economically disadvantaged: A special report prepared by the Subcommittee on Cancer in the Economically Disadvantaged. New York: American Cancer Society, 1986. 3. Romans MC, Marchant DJ, Pearse WH. Utilization of screening mammography-1990. Women's Health Issues 1991;1:68-73. 4. Harlan LC, Bernstein AB, Kessler LG. Cervical cancer screening: Who is not covered and why? Am J Public Health 1991;81:885-90. 5. American Cancer Society. Cancer facts & figures, Atlanta: ACS, 1991. 6. Marchant DJ. Use of mammography--United States, 1990. MMWR 1990;36:621. 7. Feig SA. Decreased breast cancer mortality through mammographic screening: Results of clinical trials. Radiology 1988;167z:659-65. 8. American College of Obstetricians and Gynecologists. Report of Task Force on Routine Cancer Screening. ACOG Committee Opinion 68, Washington DC: ACOG, 1989. 9. Romans MC. Jacobs Institute Workshop on Screening Mammography. Women's Health Issues 1991;1:63-7. 10. Consensus guidelines for mammography screening adopted by the American Cancer Society and 11 other medical specialty societies on June 27, 1989. 11. Makuc DM, Fried VM, Kleinman JC. National trends in the use of preventive health care by women. Am J Public Health 1989;79:21-6. 12. Physician Payment Review Commission. Physician payment under Medicaid, No. 91-4:34. Washington DC, 1991. 13. Committee on Health Care for Underserved Women, American College of Obstetricians and Gynecologists. Ob/Gyn services for indigent women: Issues raised by an ACOG survey. Washington DC: ACOG, 1988. 14. HR 1393, Medicaid breast and cervical cancer amendments of 1991. 102D Congress 1st Session.
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