How Often Will Medicare Pay for a Mammogram?

Medicare covers various preventive services. Among these, mammograms are an important tool for the early detection of breast cancer. Timely screenings can greatly improve health outcomes.

Screening Mammogram Coverage

A screening mammogram is a routine preventive examination performed when no specific symptoms are present. This type of mammogram aims to detect potential issues before they become apparent. Medicare Part B covers these routine screenings for eligible beneficiaries.

Medicare Part B covers one baseline mammogram for women between the ages of 35 and 39. For women aged 40 and older, Medicare Part B covers one screening mammogram every 12 months.

When a healthcare provider accepts Medicare assignment, beneficiaries pay nothing for screening mammograms. This means there is no deductible or coinsurance required for these preventive services. The entire Medicare-approved amount for the screening is covered.

Diagnostic Mammogram Coverage

In contrast to screening mammograms, a diagnostic mammogram is performed when a healthcare professional identifies specific symptoms, an abnormal finding from a screening mammogram, or another medical reason to investigate further. This examination is used to assess an area of concern more closely. The purpose is to determine the nature of a breast abnormality, such as a lump or suspicious mass.

Medicare Part B also covers diagnostic mammograms, provided they are deemed medically necessary by a healthcare provider. There is no specific frequency limit for diagnostic mammograms; coverage is based on the medical need for further evaluation.

However, the cost-sharing for diagnostic mammograms differs from screening mammograms. Beneficiaries are responsible for the Medicare Part B deductible before coverage begins. After meeting the deductible, individuals typically pay 20% of the Medicare-approved amount for the diagnostic service. This 20% coinsurance also applies to the associated doctor’s services.

Understanding Your Costs

For screening mammograms, beneficiaries generally incur no out-of-pocket costs if their healthcare provider accepts Medicare assignment. It is important to confirm that the provider accepts Medicare assignment to ensure this no-cost benefit.

For diagnostic mammograms, costs involve both the Medicare Part B deductible and a 20% coinsurance. This means beneficiaries pay the full deductible amount first, and then 20% of the Medicare-approved cost for the service. The specific amount of the deductible can vary annually, so it is advisable to check current Medicare figures.

Medicare Advantage Plans, also known as Part C, must cover at least the same services as Original Medicare, including both types of mammograms. However, these plans are offered by private insurance companies and may have different cost-sharing structures, such as varying copayments or deductibles. Beneficiaries enrolled in a Medicare Advantage Plan should consult their specific plan documents for details on coverage and any associated out-of-pocket costs.