Since you asked: Can HDHPs cover breast MRIs and ultrasounds at no cost to patients?

Question

Can a high-deductible health plan (HDHP) that is qualified to pair with a health savings account (HSA) cover breast MRIs, ultrasounds and similar breast cancer screening services as preventive care (e.g., with no cost sharing or cost sharing that occurs before the HDHP minimum annual deductible is met) without putting participants’ ability to contribute to the HSA at risk?

Answer

Yes, according to recent IRS guidance.

Background

Under Internal Revenue Code section 223, to be eligible to contribute to an HSA, an individual must be covered by an HDHP and have no disqualifying health coverage. To qualify as an HDHP, a group health plan may not pay for or reimburse healthcare expenses before the minimum annual deductible is met — with the exception of preventive care.

The IRS is the government agency tasked with defining “preventive care” for HSA-qualified HDHPs under existing laws and regulations. Note: While other services (and drugs) may be preventive in nature (and even included on drug formularies), only those encompassed in IRS guidance will be allowed to be covered prior to the deductible being met for an HDHP to remain HSA-qualifying.

An HDHP can choose to provide any or all of the IRS-approved preventive care services prior to the HDHP minimum annual deductible being satisfied. The plan document for the HDHP needs to address what coverage will be considered “preventive” and be available without a deductible (or with a deductible below the applicable minimum deductible — self-only or family).

Preventive care does not generally include any service or benefit intended to treat an existing illness, injury or condition. Under the HDHP/HSA rules, a benefit must be described as preventive care either for purposes of section 1861 of the Social Security Act or in guidance issued by the IRS.

The IRS has issued various notices regarding what is considered preventive care for HDHP/HSA purposes, including (1) a “safe harbor” definition, (2) the addition of coverage for treatment “incidental” to other preventive care, (3) the extension of the definition of preventive care to coordinate with the ACA’s preventive services mandate, and (4) the treatment of specific chronic conditions.

Breast cancer screenings as preventive care

In a recent article published in HR Executive, “Why employers may need to reconsider breast cancer screening coverage," WTW’s Dr. Patricia Toro and Dr. Jeff Levin-Scherz note that employers are increasing their efforts to meet women’s health needs and promoting breast cancer screening. A result is that more employees are requesting that cost sharing be waived for breast ultrasounds or MRIs, which are clinically recommended for women who have dense breast tissue or a higher risk of cancer.

The U.S. Preventive Services Task Force (USPSTF) recently expanded its breast cancer recommendation for all women to start routine screening at age 40. However, younger women have denser breasts, and mammograms are less reliable to exclude breast cancer in this group. For these individuals, providers may be inclined to recommend an ultrasound or MRI as a second imaging test, after a mammogram.

IRS preventive care guidance on breast cancer screenings

In 2004, the IRS provided a safe harbor definition of “preventive care” for HDHP/HSA purposes, which includes preventive screenings for “Breast Cancer (e.g., Mammogram).” It was unclear whether breast cancer screenings other than mammograms, not prompted by symptoms of breast cancer, were also considered preventive care for HDHP/HSA purposes.

This issue was clarified recently in IRS Notice 2024-75, which states that all types of breast cancer screening for individuals who have not been diagnosed with breast cancer are treated as preventive care. Because breast cancer screening may include imaging other than mammograms, the reference in the 2004 definition of breast cancer screening as mammograms only is changed to “Breast Cancer (e.g., Mammograms, Magnetic Resonance Imaging (MRIs), Ultrasounds, and similar breast cancer screening services).”

Takeaways

• The IRS has issued general and specific guidance on what is considered preventive care for purposes of HDHPs/HSAs.
• Preventive care for purposes of HDHPs/HSAs is not limited to what is considered preventive care under the ACA.
• MRI, ultrasound, and other breast cancer screenings are considered preventive care for purposes of the HDHP/HSA rules under Notice 2024-75.
• Employer-sponsored group health plans currently must cover mammograms without cost sharing in accordance with the ACA preventive care rules but also may choose to cover other breast cancer screenings as preventive care for HDHP/HSA purposes following the requirements of Notice 2024-75.