Mammograms can detect abnormal tissue and breast cancer.
If you do not have symptoms or a prior history of breast cancer, Medicare Part B 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.
If you qualify, 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 Plans are required to cover mammogram screenings without applying deductibles, copayments, or coinsurance when you see an in-network 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.