Does Medicare Pay for Diagnostic Mammograms?
Unravel Medicare's intricate coverage for diagnostic mammograms, detailing eligibility, patient costs, and plan variations.
Mammograms are used for early detection of breast conditions, identifying concerns before symptoms appear. Medicare, the federal health insurance program, covers mammography services, helping beneficiaries access this diagnostic tool.
Screening Versus Diagnostic Mammograms
Understanding the distinction between screening and diagnostic mammograms is important for Medicare coverage. A screening mammogram is a routine examination for individuals without symptoms of breast disease. This preventive measure is typically conducted annually for women aged 40 and older, and includes a baseline mammogram for women between 35 and 39 years old.
In contrast, a diagnostic mammogram is performed for a specific medical reason. This includes following up on an abnormal screening finding, evaluating new symptoms like a palpable lump, nipple discharge, unusual breast pain, or skin changes, or when there is a personal history of breast cancer. Diagnostic mammograms investigate a potential issue. This article focuses on Medicare’s coverage for these diagnostic studies.
Medicare Part B Coverage
Medicare Part B, which covers outpatient medical services, provides coverage for diagnostic mammograms. For coverage to apply, the diagnostic mammogram must be medically necessary. A doctor or other healthcare provider must order the test due to specific symptoms, an abnormal finding from a prior screening, or other factors warranting further investigation.
Medicare Part B covers the technical and professional components of the service, including the performance of the mammogram and the interpretation of results by a radiologist. There is no limit to how many diagnostic mammograms Medicare will cover in a given year, provided each is medically necessary. Facilities performing mammograms that bill Medicare must be certified by the Food and Drug Administration (FDA).
Patient Cost Sharing
Beneficiaries with Original Medicare Part B should anticipate out-of-pocket costs for diagnostic mammograms. The Medicare Part B deductible must be met before coverage begins. For 2025, this annual deductible is $257.
After the deductible is met, beneficiaries are typically responsible for a 20% coinsurance of the Medicare-approved amount for the diagnostic mammogram. This cost-sharing applies when the service is received from a provider who accepts Medicare assignment. Accepting assignment means the provider agrees to accept the Medicare-approved amount as full payment, limiting the patient’s financial responsibility to the deductible and coinsurance.
Medicare Advantage Plan Coverage
Medicare Advantage Plans, also known as Part C, are offered by private insurance companies approved by Medicare. These plans must cover at least the same services as Original Medicare, including medically necessary diagnostic mammograms.
However, Medicare Advantage plans may have different cost-sharing structures than Original Medicare. This can include varying deductible amounts, copayments instead of coinsurance, or a combination. These plans often operate with network restrictions, meaning beneficiaries may need to use in-network providers for the highest level of coverage. Individuals enrolled in a Medicare Advantage plan should review their specific plan documents for details regarding coverage and out-of-pocket costs for diagnostic mammograms.