When Does Medicare Cover Mammograms?

If you have Medicare Part B or Medicare Advantage (Part C), you may want to know how often Medicare pays for mammograms. With Medicare, you’re covered for:

• one mammogram as a baseline test if you’re a woman between the ages of 35 and 49
• one screening mammogram every 12 months if you’re a woman who’s 40 years or older
• one or more diagnostic mammograms, if necessary, to diagnose a medical condition, such as breast cancer

If you’re reaching the recommended age for a mammogram, you can check whether you have coverage this important test. Let’s look at the parts of Medicare that offer mammogram coverage.

Part A

Medicare Part A, also known as hospital insurance, covers any services or treatments needed when you’re admitted to the hospital as an inpatient. Part A also covers hospice care and limited home healthcare and skilled nursing facility care. Mammogram costs typically aren’t included under Part A.

Part B

Medicare Part B covers medically necessary outpatient diagnostic and treatment services. Both screening and diagnostic mammograms are covered by Medicare Part B, which makes this a necessary Medicare option if you want to have this test covered.

Part C

Medicare Part C, also known as Medicare Advantage, is a private insurance plan that replaces original Medicare. A Medicare Advantage plan will automatically provide Medicare Part B coverage, meaning that your mammogram costs will be covered the same as if you had Medicare Part B.

Some Part C plans also cover medical transportation costs, which may be helpful if you need help getting to your mammogram appointment.

Part D

Medicare Part D is prescription drug coverage, which is an add-on to original Medicare. Part D doesn’t cover mammogram costs, but it may help cover the costs associated with breast cancer medications.

Medigap

Medigap is a supplemental insurance option if you have original Medicare. This type of plan can help lower your out-of-pocket Medicare plan costs. If you have original Medicare and are looking for help with mammogram costs, such as deductibles and coinsurance, Medigap may be an option to consider.

One recent study found that roughly 23 percent of women report having to pay some out-of-pocket costs for a mammogram. If you have Medicare and want to know how much a mammogram will cost, you should first understand what Medicare will cover.

If you have Medicare Part B or Medicare Advantage, coverage for mammograms includes:

• 100 percent of yearly screening mammogram costs
• 80 percent of necessary diagnostic mammogram costs

Medicare beneficiaries pay nothing for yearly mammogram screenings. However, there may be some out-of-pocket costs for diagnostic mammograms. These costs generally include any premiums and deductibles owed, plus a coinsurance of 20 percent of the Medicare-approved costs for this test.

Having to pay out-of-pocket medical costs can greatly affect the likelihood someone will seek medical care.

One study found that when the Affordable Care Act eliminated cost sharing for mammogram screenings, more women received mammograms during their recommended screening periods.

If you’re in need of a mammogram but haven’t been approved for Medicare yet, you may be eligible for free or low-cost breast cancer screenings while you wait.

If you’re due for a mammogram, there are three main types of mammography to choose from:

• Conventional mammogram. A conventional mammogram takes 2-D black and white film images of the breast. During this test, the doctor can view the images as they are produced to look for any lumps, deposits, or other areas of concern.
• Digital mammogram. Like a conventional mammogram, a digital mammogram takes 2-D black and white images of the breast. However, digital mammogram images are entered directly into a computer, allowing the doctor to zoom, enhance, and otherwise inspect the images with more accuracy.
• 3-D mammogram. A 3-D mammogram takes multiple pictures during the test to produce a comprehensive 3-D view of the breast tissue. This type of mammogram, also known as 3-D tomosynthesis mammography, has been shown to improve the diagnosis of cancer in dense breast tissues.

With your Medicare coverage, both conventional and 3-D mammogram costs are covered. However, not every provider offers 3-D mammograms yet. You can talk with your doctor about what type of mammogram test is available and right for your situation.

A mammogram, otherwise known as a mammography, is a type of X-ray that’s used to detect or diagnose breast cancer. Mammograms are generally scheduled yearly for women ages 50 and older to help with the early detection of this disease.

During a mammogram, you’ll be asked to undress from the waist up to allow the machine full access to the breasts. Each breast will be placed between two specialized camera plates on the mammography machine and compressed for imaging.

While the compression lasts no longer than a few seconds each time, you may notice some pressure, discomfort, or pain. Mammograms generally take no longer than 20 minutes to perform.

If you’re a Medicare beneficiary and have an upcoming mammogram, this test may be covered under your plan. Medicare Part B and Medicare Advantage plans both cover 100 percent of yearly screening mammogram costs, and 20 percent of diagnostic mammogram costs.

If you have other costs associated with your plan, such as a deductible, you may have to pay this amount out-of-pocket before Medicare will cover your diagnostic mammogram testing.

Breast cancer screening recommendations begin as early as 40, depending on your breast cancer risk. Speak with your doctor today to determine when to schedule your first or next mammogram.