MedicaidCoverageMedium impact
New York State Medicaid Coverage of Breast Cancer Screening, Imaging, and Testing for Management and Treatment
NY Medicaid·NY · Radiology, Oncology, General Surgery +4 more·Specialty Services
We identified it
Jun 30, 2026
Summary
New York State Medicaid now covers comprehensive breast cancer screening, imaging, and genetic testing with zero patient cost-sharing for all covered services. This includes mammography (baseline, annual, and high-risk), tomosynthesis, ultrasound, MRI, biopsies, and BRCA1/BRCA2 genetic testing for high-risk individuals, with specific coverage guidelines for transgender and gender-diverse patients.
Action Required
Billing team must immediately update NYS Medicaid fee-for-service and Medicaid Managed Care billing workflows to eliminate all patient cost-sharing (copays, coinsurance, deductibles) for all affected breast cancer screening and diagnostic codes (77063-77067, 10004-10012, 10021, 19081-19101, 76641-76642, 77046-77049). Verify in billing system that tomosynthesis (CPT 77063) is only billed in conjunction with 2D digital mammography. Train front-desk and verification staff to ensure no out-of-pocket cost collection occurs for these services. Update patient financial counseling materials to communicate zero cost-sharing for NYS Medicaid members. Ensure providers document medical necessity according to guidelines for ultrasound (dense breasts, palpable masses, high-risk status), MRI (20%+ lifetime risk, BRCA mutation status, prior chest radiation, genetic syndromes), and BRCA genetic testing. Claims submitted with patient cost-sharing will likely be denied or subject to recoupment.