Does Medicare Cover Mammograms? A Breakdown of Coverage

Mammograms are a widely recognized tool for detecting breast cancer early, often before symptoms appear. This proactive approach to health can significantly improve outcomes. Understanding how your health insurance covers these screenings helps ensure you receive timely care. Medicare, the federal health insurance program, generally provides coverage for mammograms.

Medicare Part B Coverage

Medicare Part B, which covers medical services and outpatient care, provides specific coverage for mammograms. It differentiates between screening mammograms, which are preventive, and diagnostic mammograms, which are used to investigate a suspicious finding. For women aged 35 to 39, Medicare Part B covers one baseline mammogram in their lifetime. This initial mammogram serves as a point of comparison for future screenings.

For women aged 40 and older, Medicare Part B covers one annual screening mammogram. These yearly screenings are covered at 100% of the Medicare-approved amount, meaning you pay no Part B deductible or coinsurance, as long as your healthcare provider accepts Medicare assignment. Medicare assignment is an agreement where the provider accepts Medicare’s approved amount as full payment.

Diagnostic mammograms are covered differently under Part B. These are performed when a doctor suspects an abnormality, such as a lump, or to follow up on an irregular screening mammogram. For these services, the Part B deductible applies, and beneficiaries are responsible for 20% of the Medicare-approved amount after meeting their deductible. Medicare covers as many diagnostic mammograms as are medically necessary.

Medicare Advantage Plan Coverage

Medicare Advantage Plans, also known as Medicare Part C, are offered by private insurance companies approved by Medicare. These plans are legally required to cover at least all the services that Original Medicare (Part A and Part B) covers. This means that Medicare Advantage plans must provide coverage for both screening and diagnostic mammograms.

While Medicare Advantage plans must offer the same baseline coverage, their specific cost-sharing rules can differ from Original Medicare. Plans may have different copayments, coinsurance amounts, and deductibles for services, including diagnostic mammograms. Check with your specific Medicare Advantage plan for details on out-of-pocket costs and any network requirements to ensure coverage.

Receiving Your Covered Mammogram

To ensure your mammogram is covered by Medicare, follow specific steps. A doctor’s order or referral is generally required for both screening and diagnostic mammograms. However, for screening mammograms, a referral may not be needed if the facility meets certain certification requirements. The facility performing the mammogram must be certified by the Food and Drug Administration (FDA) and accept Medicare.

Confirm that your healthcare provider and the mammography facility accept Medicare assignment. This ensures that for screening mammograms, you will not incur out-of-pocket costs. For diagnostic mammograms, accepting assignment helps ensure predictable costs, as the provider agrees to the Medicare-approved amount.