Variability in Supplemental Breast Imaging Coverage and Cost-Sharing in the Northeastern United States Following 2024-2025 Legislative Actions: A Policy and Payer Implementation Analysis

Purpose: Following 2024–25 state legislation targeting access to supplemental and diagnostic breast imaging, we assessed variability in coverage and cost-sharing protections across the Northeast and evaluated whether payer implementation translated statutory mandates into real-world access across commercial, Medicaid, and federal plans.

Methods/Materials: Policy changes in nine states (CT, MA, ME, NH, NJ, NY, PA, RI, VT) were analyzed using statutes, legislative databases, and insurance bulletins. Payer implementation in 2025 was reviewed using commercial, Medicaid, Medicare, and employer policies to determine coverage, out-of-pocket costs, prior authorization, and eligibility. Cost-sharing elimination for screening and diagnostic mammography, supplemental ultrasound, and supplemental MRI was scored on a 0–4 scale.

Results: By 2025, all states eliminated out-of-pocket costs for screening and diagnostic mammography for fully insured plans (Figure 1). Supplemental ultrasound mandates were implemented in eight states and supplemental MRI mandates in five, typically limited to high-risk populations. Across 69 payer policies, mean parity scores were highest in PA (4.0), followed by NY, MA, RI, and VT (3.0), intermediate in CT and ME (2.0), lowest in NJ (1.3) and NH (1.0). Medicaid achieved higher parity than commercial insurers in all states except PA, where full parity occurred across payers, supported by administrative bulletins. Medicare uniformly scored 1.0 due to retained 20% coinsurance, and self-funded ERISA plans (NJ, VT) scored 1.0 and were mandate-exempt. Supplemental MRI remained the primary gap, with PA as the only state achieving full elimination of MRI cost-sharing. When cost-sharing was reduced, insurers frequently substituted prior authorization and clinical eligibility requirements, particularly for MRI.

Conclusions: Overall, state mandates in the Northeast improved protections for supplemental and diagnostic breast imaging, but implementation remained uneven, limiting equitable access. Persistent gaps affecting MRI, Medicare beneficiaries, and ERISA plans disproportionately impact patients with dense breasts and older adults who face higher risk of delayed diagnosis.