Does Medicare Part A Cover Mammograms?

Mammograms are an important tool in the early detection of breast cancer, offering a way to identify changes in breast tissue that might otherwise go unnoticed. Regular screenings contribute to overall women’s health by allowing for timely intervention if concerns arise. For eligible individuals, Medicare serves as a primary healthcare provider, helping to ensure access to these important services.

Medicare Coverage for Mammograms

Medicare Part A, which primarily covers inpatient hospital stays, does not cover outpatient services such as mammograms. These diagnostic screenings fall under Medicare Part B, which is medical insurance. Part B covers medically necessary services and preventive services.

Medicare Part B provides coverage for both screening and diagnostic mammograms. Screening mammograms are preventive checks conducted when a person does not have symptoms of breast disease, aiming for early detection of breast cancer.

Diagnostic mammograms are performed when a person has symptoms, a suspicious finding from a physical exam, or an abnormal result from a screening mammogram. These are considered medically necessary follow-up services to further investigate a potential health concern. Medicare Part B covers these procedures when a doctor orders them based on specific medical need.

Frequency and Associated Costs

Medicare Part B outlines specific frequencies for covered mammograms. A baseline mammogram is covered once in a person’s lifetime for those between 35 and 39 years of age. For individuals aged 40 and older, Medicare covers one screening mammogram every 12 months. This annual screening is a preventive benefit.

Diagnostic mammograms do not have a strict frequency limit and are covered as often as deemed medically necessary by a healthcare provider. The coverage for these tests is based on the medical necessity to diagnose or treat an illness.

Screening mammograms are covered at 100% under Medicare Part B. Beneficiaries pay nothing out-of-pocket for the test, provided the healthcare provider accepts Medicare assignment. Accepting assignment indicates that the provider agrees to accept the Medicare-approved amount as full payment for the service.

For diagnostic mammograms, the financial responsibility is different. The Medicare Part B annual deductible applies before coverage begins. For 2025, this deductible is $257. After the deductible has been met, the beneficiary is responsible for 20% of the Medicare-approved amount for the service, known as coinsurance.

Steps to Obtain Your Mammogram

For screening mammograms, a referral or doctor’s order is not required. They are considered a preventive service.

For diagnostic mammograms, a doctor’s order is necessary, as these are performed to investigate specific symptoms or abnormal findings. Your healthcare provider will assess your condition and provide the necessary order if a diagnostic mammogram is warranted. This order ensures the service is medically necessary for coverage.

To find a facility that accepts Medicare, you can ask your doctor for recommendations or use resources available through Medicare.gov, such as the Physician Compare tool. Confirm that the facility and the healthcare provider accept Medicare assignment to minimize your out-of-pocket costs.