At What Age Does Medicare Stop Paying for Mammograms?

Mammograms are a crucial tool in the early detection of breast cancer. Understanding how Medicare covers these procedures is important for beneficiaries, as Medicare provides healthcare coverage for older adults.

Understanding Medicare Coverage for Screening Mammograms

Medicare Part B provides comprehensive coverage for screening mammograms, which are routine checks performed when there are no symptoms of breast disease. A significant aspect of this coverage is that Medicare does not impose an upper age limit for screening mammograms. As long as an individual is eligible for Medicare Part B, these vital screenings remain covered regardless of age.

Coverage details include one baseline mammogram for women aged 35 to 39. Following this, Medicare Part B covers one annual screening mammogram for women aged 40 and older. For these screening services, beneficiaries typically pay $0 out-of-pocket, provided the healthcare provider accepts Medicare assignment. This means the service is covered at 100% of the Medicare-approved amount.

Understanding Medicare Coverage for Diagnostic Mammograms

Diagnostic mammograms differ from screening mammograms as they are performed when a person exhibits symptoms, has an abnormal result from a screening mammogram, or has a history of breast cancer requiring closer monitoring. These are not routine preventive checks but rather targeted investigations. Medicare Part B also covers diagnostic mammograms, recognizing their necessity in addressing specific health concerns.

For diagnostic mammograms, the cost-sharing structure is different from screening mammograms. Beneficiaries are generally responsible for 20% of the Medicare-approved amount after they have met their Medicare Part B deductible. Similar to screening mammograms, there is no age limit for Medicare coverage of medically necessary diagnostic mammograms. A doctor’s order or referral is typically required to deem a diagnostic mammogram medically necessary for coverage.

Important Considerations for Medicare Mammogram Coverage

To ensure maximum coverage and avoid unexpected costs, it is important to confirm that your healthcare provider accepts Medicare assignment. When a provider accepts assignment, they agree to accept the Medicare-approved amount as full payment, limiting your out-of-pocket expenses to coinsurance and deductibles, if applicable. All mammograms, whether for screening or diagnostic purposes, must be deemed medically necessary by a healthcare professional for Medicare to cover them.

If a beneficiary is enrolled in a Medicare Advantage (Part C) plan, the plan is required to cover at least all the benefits that Original Medicare (Parts A and B) covers, including mammograms. However, Medicare Advantage plans may have different rules regarding network providers, referrals, or prior authorizations. While screening mammograms typically remain cost-free with in-network providers, diagnostic mammograms under these plans may have varying copayments or coinsurance.