Mammography

What is a mammography?

Mammography is an X-ray examination of the breast. It makes changes in the breast tissue visible before they can be felt and is used above all for the early detection of breast cancer. For health insurance, three situations must be distinguished because each is paid for differently:

1. Screening mammography within a programme: a mass screening for women aged 50 and over without symptoms, organised by a cantonal early detection programme.
2. Monitoring with increased risk: regular mammography or breast MRI for women with a moderately or highly increased familial or comparable individual risk.
3. Diagnostic mammography: an examination to clarify an urgent clinical suspicion of a breast disease.

The first two cases are part of prevention. Basic health insurance only pays for preventive examinations if the Health Care Benefits Ordinance (KLV) expressly lists them. The third case is a normal benefit in the event of illness.

Screening mammography is one of the few benefits on which no deductible is charged. The law allows the Federal Council to exempt individual services from national or cantonal prevention programmes from the deductible. Besides mammography, this applies for example to the early detection of bowel cancer in cantonal programmes, where a colonoscopy is possible every ten years.

How it works

Screening within a programme: If there is an early detection programme in your canton, you take part through it from the age of 50; the programme decides how it invites and registers participants. The examination takes place at a centre that meets the programme’s quality requirements. Basic health insurance pays for it every two years. No deductible is charged on the invoice; you pay the 10% retention fee, up to the annual maximum of CHF 700.

Monitoring with increased risk: Stricter requirements apply here. The risk is classified using a risk model. For the category “highly increased risk”, genetic counselling is required beforehand. Before the first examination there is a comprehensive, documented information and counselling session. Indication, counselling and monitoring are handled by a certified breast centre; frequency and method depend on risk and age. If the examination is to take place at another centre, the insurer’s cost approval is required beforehand. The deductible and retention fee apply as normal.

Diagnostic mammography: If there is an urgent clinical suspicion of a breast disease, your doctor can order a mammography. This is an examination to clarify a possible illness. Basic health insurance pays for it at any age, with deductible and retention fee; under KLV Annex 1 no. 9.1 the requirement is an urgent clinical suspicion, not any uncertainty.

Legal basis

• Art. 26 KVG: Basic health insurance covers certain examinations for the early detection of diseases and preventive measures for insured persons who are particularly at risk. Which ones is set by the Federal Department of Home Affairs in the KLV.
• Art. 12e let. c KLV: Screening mammography from the age of 50 every two years, within a programme under the Ordinance of 23.06.1999 on Quality Assurance in Programmes for the Early Detection of Breast Cancer by Mammography. No deductible is charged on this benefit.
• Art. 12d let. d KLV: Digital mammography and breast MRI with a moderately or highly increased familial breast cancer risk or a comparable individual risk, adapted to risk and age, through a certified breast centre.
• Art. 64 para. 6 let. d KVG: The Federal Council can exempt services from national or cantonal prevention programmes from the deductible. The provision does not mention an exemption from the retention fee.
• Art. 25 KVG and KLV Annex 1 no. 9.1: Diagnostic mammography falls under the general benefits in the event of illness; Annex 1 KLV requires an urgent clinical suspicion of a breast disease.
• Art. 103 KVV: Maximum retention fee of CHF 700 per year for adults.

Example: three mammographies, three bills

We compare three women who have a mammography in the same year. For the example we assume costs of CHF 200; the actual amount depends on the tariff. All three have a deductible of CHF 2,500 and no other healthcare costs in the year. The calculation uses the statutory values.

What this means for you

If you are 50 or older, it is worth asking about an early detection programme in your canton. Only there is the mammography exempt from the deductible. The two-year interval is important: basic health insurance does not pay for screening more often.

If breast cancer runs in your family, talk to your doctor about a risk assessment. With increased risk, monitoring is possible before the age of 50. These examinations count towards your deductible; with a high deductible you often pay for them yourself. If you need regular examinations, you are better off calculating with a lower deductible. The premium calculator shows the premiums for every deductible; you must request a lower deductible by 30 November, see deadlines.

Some supplementary insurance policies contribute to preventive examinations that basic health insurance does not pay for. What an insurer offers in its supplementary insurance is shown in the profiles of the health insurers. Keep your invoices and statements of benefits, for example in your account; this way you can see when your last screening mammography was.

Common mistakes

• Believing screening is completely free. The deductible does not apply, but the 10% retention fee does.
• Going for screening outside the programme. Without symptoms and without a programme, basic health insurance does not pay.
• Not keeping to the interval. Basic health insurance does not cover screening before two years have passed.
• Confusing diagnosis and screening. If your doctor orders a mammography because of an urgent clinical suspicion, it is a covered examination in the event of illness with deductible, not screening.
• Not mentioning familial risk. With increased risk there is a separate monitoring programme that starts earlier.

We explain how we calculate our examples under How we calculate.