Mammograms are essential preventive services for early detection of breast cancer, and women over 40 should have one each year. We’ll help you understand Medicare coverage for this important screening and diagnostic tool.
Breast cancer is the second most common cancer in women in the United States; only some skin cancers are more prevalent. Around 85 percent of breast cancer diagnoses are in women with no family history of the disease. Men can get breast cancer, too, though it’s much less common.
What Are Mammograms?
Mammograms are a cancer screening test that can find a lump up to three years before you or your doctor can feel it. Breast cancer is most treatable (and therefore survivable) when it’s found early, which is why mammograms are so important. Annual mammogram screenings are recommended for women as young as 40 (some even younger depending on their risk factors), so talk to your healthcare provider about what’s right for you.
The good news is that Medicare Part B fully covers annual screening mammograms for women over 40, and sometimes more frequently if medically necessary. (Screening mammograms for men, however, aren’t covered.) But diagnostic mammograms are only covered at 80 percent by Original Medicare.
If you need a mammogram but haven’t been approved for Medicare yet, you may be eligible for free or low-cost breast cancer screenings. The Centers for Disease Control and Prevention (CDC) has a tool to help you find one.
What’s the Difference Between Screening and Diagnostic Mammograms?
This distinction is important, both for your understanding of your healthcare and for your anticipated costs as a Medicare beneficiary.
Screening mammograms are annual preventive tests that are important for the early detection of lumps, abnormalities, and other breast health issues. You don’t have to have any signs or symptoms of abnormality to get your annual breast cancer screening. These screenings are recommended for women as young as 40 (and sometimes younger, if they are at high risk).
Diagnostic mammograms, by contrast, are used to make a diagnosis if your screening has revealed an abnormality or if you’ve found one yourself. Diagnostic mammograms might use extra compression or magnification or be shot from different angles.
What Type of Mammograms Does Medicare Cover?
Medicare Part B covers:
- One baseline mammogram for women ages 35–39
- Screening mammograms once every 12 months if you’re a woman age 40 or older
- Diagnostic mammograms more frequently than once a year, if medically necessary
Furthermore, there are three main types of mammograms:
- Conventional mammography takes 2-D black-and-white X-ray images of the breast, allowing the doctor to look for any lumps, deposits, or other areas of concern.
- Digital mammograms, like the conventional type, take 2-D black-and-white images of the breast. The difference is that digital mammogram images are entered directly into a computer, allowing the doctor to zoom, enhance, and otherwise inspect the images with more accuracy.
- 3-D mammograms take multiple pictures during the test to produce a comprehensive 3-D view of the breast tissue. This type of mammogram, also known as 3-D tomosynthesis mammography, has been shown to improve the diagnosis of cancer in people with dense breast tissue.
Medicare covers both conventional and 3-D mammograms, but not all providers offer 3-D mammography yet. You can talk with your doctor about what type of mammogram test is available and right for you.
What Will I Pay for My Mammogram?
For Medicare beneficiaries, it depends largely on the type of mammogram you’re getting.
Medicare Part B (which is included in Part C/Medicare Advantage plans) covers the full cost of the annual screening mammograms for people who meet the criteria above, in which case you’ll pay nothing out of pocket.
Diagnostic mammograms, though, are covered at 80 percent, meaning you’ll be left with the remaining 20 percent coinsurance, as well as any Part B deductible you have left to pay.
If you have a Medigap insurance plan, your out-of-pocket costs may be lower. Medigap plans are sold by private insurance companies and help you pay for the “gaps” in coverage left by Original Medicare plans.
FAQ: Medicare and Mammograms
What happens if I get called back after a screening mammogram?
According to the American Cancer Society, if you get called back, it's usually to take new pictures or get other tests. Fewer than 1 in 10 women called back for more tests are found to have cancer. If something in your screening results causes suspicion, you may have to get further imaging, such as a diagnostic mammogram, ultrasound, or MRI. You may need a biopsy of the breast tissue in question. The American Cancer Society has resources to support you while you’re waiting for results or if you’ve been diagnosed with breast cancer.
How often does Medicare cover a screening mammogram?
Medicare Part B, which covers outpatient care, will pay the full cost of a woman’s screening mammogram once every 12 months.
Does Medicare pay for mammograms after age 65?
Medicare covers annual breast cancer screening for women up to age 74.
Does Medicare Part C help with mammogram coverage or cost?
Medicare Part C, also called Medicare Advantage, automatically includes Medicare Part B, which covers mammograms. So Part C doesn’t change anything in terms of cost of coverage.
How did the Affordable Care Act affect mammogram coverage?
The Affordable Care Act (ACA) required most insurers and the Medicare program to eliminate cost-sharing for screening mammography (as well as many other preventive measures), which meant that free breast cancer screening became available to many more people. The result was an increase in screening mammograms among older women, for whom they’re recommended.
Conclusion: Medically Required Mammograms Are Always Covered
While Medicare does cover mammograms, your cost will depend on the type of service you’re getting.
For women, getting your annual mammogram breast cancer screenings could save your life—so don’t let a year pass without this important service!
The good news is that Medicare fully covers screenings for women who require preventive mammography, while diagnostic mammograms for anyone are covered at 80 percent.
If you need further information, you can get answers in your area by visiting Medicare.gov and using the “Find Someone to Talk To” tool on the right side of the page. You can also call 1 (800) MEDICARE, or 1 (800) 633-4227.TTY users can call 1 (877) 486-2048.
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