Medicare Part B covers both screening and diagnostic mammograms as preventive and treatment services for breast cancer.
Medicare covers one baseline screening mammogram for beneficiaries 35-39 years of age, and one annual mammogram for beneficiaries 40 and older.
While screening mammograms are covered once every 12 months at no cost, you will owe a deductible and coinsurance for diagnostic mammograms.
Does Medicare cover mammograms after age 65?
A mammogram is a diagnostic test that takes an X-ray picture of the breast to examine for changes in the breast tissue. Medicare Part B covers both screening and diagnostic mammograms as a preventive service for breast cancer. Coverage for annual screening mammograms begins at age 40 and continues for as long as your doctor finds them medically necessary. [i]
Medicare coverage differs between screening mammograms and diagnostic mammograms, and includes:
- an initial mammogram for beneficiaries aged 35-39, at no cost.
- a screening mammogram once every 12 months for beneficiaries aged 40 and up, at no cost.
- additional diagnostic mammograms as often as medically necessary, at a cost.
Annual screening mammograms are considered a preventive service and are completely covered under Medicare Part B, which means that you don’t owe any out-of-pocket costs for this service. However, diagnostic mammograms are not fully covered by Medicare, so you will owe out-of-pocket costs, which may include copayments, coinsurance or deductibles.
Screening vs. Diagnostic Mammograms
What is the difference between a screening mammogram and a diagnostic mammogram?
Both screening and diagnostic mammograms are essential tools for the diagnosis and treatment of breast cancer. A screening mammogram is a preventive tool in which both breasts are imaged and examined to determine any suspicious lumps or abnormalities. A diagnostic mammogram is a diagnostic tool for people with breast cancer in which suspicious lumps or abnormalities are analyzed in more detail.
Generally, a screening mammogram is performed in women with no outward symptoms of breast cancer, while a diagnostic mammogram can analyze or diagnose breast cancer. When a screening mammogram doesn’t show enough information, the provider can use a diagnostic mammogram.
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Medicare covers both screening and diagnostic mammograms, but coverage varies depending on the type of mammogram you are receiving. Starting at age 35, your Medicare Part B plan will pay the entirety of the cost for either an initial baseline mammogram or a yearly screening mammogram.
- If you are age 35-39 and enrolled into Medicare because of a disability, Medicare will cover one baseline mammogram after enrollment.
- Once you turn 40 years of age, Medicare will cover one screening mammogram every 12 months until you and your doctor choose to discontinue them.
Although Medicare pays for screening mammograms, it does not fully cover the cost of diagnostic mammograms, no matter how infrequently you may need them. If you have been diagnosed with breast cancer and require diagnostic mammograms during treatment, you will be required to pay out-of-pocket for any coinsurance, copayments or deductibles for your mammograms.
How Much Does Medicare Pay?
Does Medicare pay 100% for mammograms?
As long as you receive your screening mammogram from a provider that accepts Medicare assignment, Medicare Part B will cover 100% of your mammogram costs – even if you have not met your Part B deductible for the year. However, Medicare will only provide full coverage of this service once every 12 months, so it’s important to make sure that you are scheduling your mammograms 12 months apart.
Medicare covers ongoing diagnostic mammograms as part of your treatment-related services for breast cancer. However, unlike yearly screening mammograms, Medicare does not cover the full cost of diagnostic mammograms. Instead, you will be required to pay the remainder of your Part B deductible, if applicable, and a 20% coinsurance of the Medicare-approved amount for the mammogram.
Speak with your doctor to learn more about your out-of-pocket costs for diagnostic mammograms.
Do I need a referral for a screening mammogram with Medicare?
You do not need a referral or a physician’s prescription for a screening mammogram under your Medicare plan, even if you are enrolled in a Medicare Advantage plan. This is because Medicare considers screening mammograms a preventive service, which means that it is available to you at no additional cost and without needing a referral.
Do I need a mammogram after 65?
According to the Centers for Disease Control and Prevention, breast cancer is the second most common type of cancer affecting women in the United States. [i] Screening mammograms are among the most important tools that we can use to catch and diagnose breast cancer early.
Breast cancer statistics reveal that breast cancer diagnosis rates increase after 60 years of age. [i] Given the increased risk of breast cancer with age, women are recommended to undergo a screening mammogram once every year until at least 54 years of age. Starting at 55, you should continue to receive screening mammograms once every 1-2 years, for as long as you have a life expectancy of 10 years or longer. [i]
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Medicare Advantage plans offer the same coverage as Original Medicare Parts A and B, which means that all Medicare Advantage plans must cover both screening and diagnostic mammograms. However, while annual screening mammograms are fully covered by Medicare Advantage plans, the costs for diagnostic mammograms may differ from Original Medicare, depending on your plan.
A breast exam is another diagnostic breast cancer tool that can be used to detect lumps or other abnormalities within the breasts. Medicare Part B covers annual breast exams, separately from screening and diagnostic mammograms, as part of your pelvic exam. Medicare will cover a pelvic and breast exam once every 12-24 months, depending on your cervical and vaginal cancer risk.
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