Starting on January 1, 2026, all state-regulated individual and group insurance plans will be prohibited from imposing cost-sharing requirements for diagnostic and supplemental breast examinations. Patients who are insured under Virginia law cannot be charged coinsurance, copayments, or deductible for:
- diagnostic mammograms
- breast ultrasounds
- breast magnetic resonance imaging (MRI)
The new law applies only to fully-insured health care plans that the Commonwealth of Virginia regulates. Federal, out-of-state, and employer insurance plans set up as “self-insured,” do not have to comply with Virginia state insurance laws. Contact your insurer or health benefits administrator if you are unsure of what type of plan you have.
Frequently Asked Questions
What costs does the law prohibit?
The law prohibits state-regulated health insurance plans from charging coinsurance, copayment, or a deductible for diagnostic and supplemental breast examinations.
What kinds of breast imaging services are included in the new cost-sharing prohibitions?
Diagnostic and supplemental breast imaging: diagnostic mammograms, breast ultrasounds, and breast MRIs.
- Diagnostic or “follow-up” breast imaging is used when an abnormality is seen or suspected from a screening mammogram or if an individual or physician feels something.
- Supplemental breast imaging is used when there is no abnormality but it is needed due to an individual’s personal or family medical history or other factors that may increase their risk of breast cancer. For example, women with a previous breast cancer diagnosis are automatically given a diagnostic mammogram, at least for the first 5 years post-diagnosis. Women with dense breast tissue are often recommended to receive additional imaging, like an ultrasound.
Am I covered by this law?
The law applies only to fully-insured health care plans that the Commonwealth of Virginia regulates. This includes:
- Individual Plans: purchased through Virginia’s Insurance Marketplace for an individual or family. (for themselves or their family)
- Small Group Plans: commercial insurance coverage purchased by an employer with 50 employees or fewer. (VA SHOP program)
- Large Group Plans: commercial insurance coverage purchased by an employer with greater than 50 employees
- Virginia’s State Employee Health Care Plans
Health insurance plans that are not impacted by this law:
Federal, out-of-state, and employer insurance plans set up as “self-insured” do not have to comply with Virginia state insurance laws. This includes:
- Self-Insured Plans: Self-insured health plans are not subject to Virginia’s state insurance regulations. They are regulated at the federal level. If you have employer-sponsored health insurance, that coverage is likely self-insured. Large employers often self-insure and take on the risk of providing coverage for their employees by paying for enrollees medical care directly and contract with a health insurance company to administer the health care plan.
- Medicare, Medicaid; Tricare/Military Health Insurance
- Short-term plans
Know Before You Go!
Contact your insurance company or your benefits administrator if you do not know which type of insurance plan you have.
Need Help Paying for Screening & Diagnostic Services?
If you do not have insurance, or if your plan is not covered by Virginia’s new law, financial help may be available. Click here to learn about VBCF’s Screening & Diagnostic Services Fund and other options.
