How Often Does Medicare Pay for Mammograms After Age 70?
Understand Medicare's coverage for mammograms after age 70. Learn about screening frequency, costs, and how Original Medicare and Advantage plans pay.
Mammograms are an important tool for early breast cancer detection, identifying changes before symptoms appear. This proactive approach can significantly impact treatment outcomes, allowing for less aggressive and more effective interventions. For seniors in the United States, Medicare offers various levels of coverage to support their health needs, including these preventative screenings.
Medicare Part B Rules for Mammograms
Medicare Part B provides comprehensive coverage for mammograms, with specific rules depending on the service type. For screening mammograms, routine examinations performed when there are no symptoms, Medicare Part B covers one every 12 months. This coverage applies to all women aged 40 and older, with no age limit for continued coverage. These annual screenings are covered at 100% of the Medicare-approved amount, meaning beneficiaries typically pay nothing out-of-pocket if the provider accepts Medicare assignment.
In contrast, diagnostic mammograms are performed when a medical concern exists, such as an abnormal finding or symptoms like a lump or pain. Medicare Part B covers these medically necessary diagnostic mammograms. Cost-sharing differs from screening mammograms: beneficiaries are generally responsible for the Part B deductible first. After the deductible is met, 20% coinsurance of the Medicare-approved amount applies. Medicare covers diagnostic mammograms as often as deemed medically necessary by a physician, without a frequency limit.
Understanding Medicare Advantage Coverage
Medicare Advantage Plans, also known as Part C, offer an alternative way for individuals to receive Medicare benefits through private insurance companies. By law, these plans must provide at least the same level of coverage as Original Medicare Part A and Part B. This includes coverage for annual screening mammograms, ensuring beneficiaries enrolled in a Medicare Advantage plan have access to this preventative service.
While Medicare Advantage plans must cover the same services, specific costs and rules can vary significantly from Original Medicare. Differences might include varying copayments, deductibles, coinsurance, provider networks, and prior authorization requirements. It is important for beneficiaries to review their specific plan’s Evidence of Coverage (EOC) or contact their plan directly. This helps them understand the exact details regarding costs, network providers, and any specific procedures for obtaining covered services.
What to Know About Mammogram Costs
Screening mammograms are covered at no direct cost under both Original Medicare Part B and Medicare Advantage plans, provided the provider accepts Medicare assignment or is in the plan’s network. This full coverage for preventative screenings underscores their importance in maintaining health without posing a financial barrier.
For diagnostic mammograms, which address specific medical concerns, costs are incurred. Under Original Medicare Part B, beneficiaries must first meet their annual deductible ($257 in 2025), then a 20% coinsurance of the Medicare-approved amount applies. Medicare Advantage plans may structure their cost-sharing differently, potentially through fixed copayments or varying coinsurance percentages. These costs contribute towards the plan’s annual out-of-pocket maximum, providing a limit on beneficiary spending. To avoid unexpected charges, patients should confirm coverage details with their provider’s billing department and their Medicare or Medicare Advantage plan prior to receiving services, ensuring the provider is Medicare-approved.