Mammograms can detect abnormal tissue and breast cancer.
Eligibility
If you do not have symptoms or a prior history of breast cancer, Medicare Part B Part B, also known as medical insurance, is the part of Medicare that covers most medically necessary doctors’ services, preventive care, hospital outpatient care, durable medical equipment (DME), laboratory tests, x-rays, mental health services, and some home health care and ambulance services. covers preventive mammograms, as follows:
- One baseline mammogram for women age 35-39
- One annual screening mammogram for women age 40+
Medicare does not cover preventive mammograms for men. However, Medicare does cover diagnostic mammograms for everyone. Your provider may recommend a diagnostic mammogram if your screening shows an abnormality or if a physical exam reveals a lump. Medicare covers as many diagnostic mammograms as necessary.
Costs
If you qualify, Original Medicare Original Medicare, also known as Traditional Medicare, is the fee-for-service health insurance program offered through the federal government, which pays providers directly for the services you receive. Almost all doctors and hospitals in the U.S. accept Original Medicare. covers mammogram screenings at 100% of the Medicare-approved amount when you receive the service from a participating provider. This means you pay nothing (no deductible or coinsurance). Medicare Advantage Medicare Advantage, also known as Part C, Medicare Private Health Plan, or Medicare Managed Care Plan, allows you to get Medicare coverage from a private health plan that contracts with the federal government. All Medicare Advantage Plans must offer at least the same benefits as Original Medicare (Part A and Part B), but can do so with different rules, costs, and coverage restrictions. Plans typically offer Part D drug coverage as part of Medicare Advantage benefits. Medicare Advantage Plans include Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), Private Fee-for-Service (PFFS) plans, Special Needs Plans (SNPs), and Medicare Medical Savings Accounts (MSAs). Plans are required to cover mammogram screenings without applying deductibles, copayments, or coinsurance when you see an in-network In-network means part of a private health plan’s network of providers. If you use doctors, hospitals, pharmacies, home health agencies, skilled nursing facilities, and durable medical equipment suppliers that are in your Medicare Advantage Plan or Part D plan’s network, you will generally pay less than if you go to out-of-network providers. provider and meet Medicare’s eligibility requirements for the service.
Diagnostic mammograms are covered at 80% of the Medicare-approved amount. When you receive the service from a participating provider, you pay a 20% coinsurance after you meet your Part B deductible. If you are enrolled in a Medicare Advantage Plan, your plan’s cost-sharing may apply when seeing in-network providers.
During the course of your mammogram screening, your provider may discover and need to investigate or treat a new or existing problem. This additional care is considered diagnostic, meaning your provider is treating you because of certain symptoms or risk factors. Medicare may bill you for any diagnostic care you receive during a preventive visit.
Note: Some cancer screenings and other services are associated with specific genders in Medicare materials and rules but are covered regardless of the gender marker in your Social Security record, as long as the screening is clinically appropriate for you. Medicare has specific billing modifiers that your provider should use when submitting claims for services when the gender marker on your Social Security record could cause an incorrect coverage denial.