Does Medicare Pay for Mammograms Every Year?

Medicare plays a significant role in providing healthcare coverage for millions of Americans, primarily seniors and individuals with certain disabilities. Understanding how Medicare covers preventive services, such as mammograms, is important for beneficiaries. Mammograms are a recognized tool for the early detection of breast changes, which can lead to better health outcomes. Medicare’s commitment to preventive care includes provisions for these important screenings.

Medicare Coverage for Screening Mammograms

Medicare Part B covers screening mammograms. These screenings are a preventive service designed to detect breast cancer early, even before any symptoms appear.

For women aged 40 and older, Medicare covers one annual screening mammogram. Additionally, Medicare covers one baseline mammogram for women who are between the ages of 35 and 39. These preventive services are covered at 100% of the Medicare-approved amount, meaning beneficiaries typically have no out-of-pocket costs if their provider accepts Medicare assignment. A screening mammogram is a routine check-up performed when there are no existing symptoms or concerns.

Medicare Coverage for Diagnostic Mammograms

Diagnostic mammograms differ from screening mammograms because they are performed when there is a specific medical indication or concern. They are ordered when symptoms like a new lump, pain, or nipple discharge are present, or as a follow-up to a suspicious screening finding.

Medicare Part B also provides coverage for diagnostic mammograms. However, the cost-sharing differs from screening mammograms. For a diagnostic mammogram, the Part B deductible applies first. After the deductible is met, Medicare typically pays 80% of the Medicare-approved amount for the service. The beneficiary is then responsible for the remaining 20% coinsurance.

For example, if a patient has an abnormal screening result, their doctor may order a diagnostic mammogram to evaluate the area more closely. This approach allows for targeted investigation when a potential issue is identified or when a patient’s medical history warrants more frequent monitoring.

Navigating Costs and Accessing Your Mammogram

Understanding practical considerations ensures your mammogram is covered by Medicare. Confirm that your healthcare provider and facility accept Medicare assignment. Providers who accept Medicare assignment agree to accept the Medicare-approved amount as full payment, which helps to minimize your out-of-pocket expenses.

A doctor’s order is typically required for both screening and diagnostic mammograms to ensure coverage. This order validates the medical necessity of the procedure, whether it is for routine prevention or to investigate a specific concern. Without a valid order, Medicare may not cover the service, leaving the beneficiary responsible for the full cost.

Medicare Advantage Plans (Part C) also cover mammograms. These plans are required to offer at least the same benefits as Original Medicare, which includes both screening and diagnostic mammograms. However, Medicare Advantage Plans may have different cost-sharing rules, network requirements, or prior authorization processes.

Contact your Medicare plan or provider before your appointment to confirm coverage details and clarify potential out-of-pocket costs like coinsurance or deductibles. If you have supplemental insurance, such as Medigap, it may cover some or all of the remaining coinsurance or deductible amounts not paid by Original Medicare.