Does Medicare Cover Annual Breast Exams?

Medicare provides health coverage for millions of Americans, helping beneficiaries manage their healthcare needs, including preventive care. Understanding how Medicare covers specific services like breast exams helps individuals plan for their health and finances. This article clarifies Medicare’s provisions for both preventive and diagnostic breast examinations.

Coverage for Screening Breast Exams

Medicare Part B covers preventive breast cancer screenings. For women aged 35 to 39, Medicare covers one baseline screening mammogram. This initial screening establishes a reference point for future examinations.

For women aged 40 and older, Medicare Part B covers annual screening mammograms. These screenings are covered once every 12 months.

A clinical breast exam, a physical examination by a healthcare provider, is also covered by Medicare. This exam is included as part of the “Welcome to Medicare” preventive visit, available within the first 12 months of enrolling in Part B. It is also covered as part of the annual “Medicare wellness visit,” which helps develop or update a personalized prevention plan. These screening services are covered at 100% of the Medicare-approved amount if the provider accepts assignment.

Coverage for Diagnostic Breast Exams

Diagnostic breast exams differ from screening exams because they are performed when there is a specific medical reason. This reason could be a new symptom, such as a lump or pain, a suspicious finding from a prior screening mammogram, or a personal history of breast cancer.

Medicare Part B covers various diagnostic services as medically necessary. These services can include diagnostic mammograms, which provide more detailed images than screening mammograms, and breast ultrasounds, often used to determine if a lump is solid or fluid-filled. In some cases, a breast MRI may also be covered if medically necessary.

Unlike screening exams, these diagnostic services are subject to standard Medicare Part B cost-sharing rules. Beneficiaries typically contribute through deductibles and coinsurance. The specific financial details for these exams are outlined in the following section.

Understanding Your Costs

For Medicare Part B beneficiaries, the cost structure for breast exams depends on whether the service is preventive or diagnostic. Screening mammograms and clinical breast exams, when performed as part of a “Welcome to Medicare” or annual “Medicare wellness visit,” are covered at no out-of-pocket cost, provided the healthcare provider accepts Medicare assignment.

For diagnostic breast exams, such as diagnostic mammograms, breast ultrasounds, or breast MRIs, the financial responsibilities are different. Beneficiaries must first meet the Medicare Part B deductible. After the deductible is satisfied, Medicare typically pays 80% of the Medicare-approved amount for the service. The beneficiary is then responsible for the remaining 20% coinsurance.

Beneficiaries enrolled in a Medicare Advantage (Part C) plan should be aware that their costs and coverage rules may vary from Original Medicare. These private plans must cover at least the same services as Original Medicare, but they can have different cost-sharing amounts, such as varying copayments, coinsurance, or deductibles. Individuals with a Medicare Advantage plan should review their specific plan’s benefits documentation or contact their plan administrator to understand their financial obligations for both screening and diagnostic breast exams.