How Does Medicare Cover Mammograms: Diagnostic Mammograms After Age 65, Medicare Coverage for Breast Cancer Screenings
Medicare is an insurance program that helps cover the cost of certain medical expenses. It offers coverage for hospital stays and some outpatient services, such as doctor visits or medication costs.
This article provides a comprehensive list of what Medicare covers and doesn’t cover related to mammograms, which can help you understand how your plan may work if you have questions about it.
Table of Contents
How Does Medicare Cover Mammograms?
Medicare Part B covers cancer prevention and early detection yearly screenings. Screening mammograms for women eligible for Medicare is a vital healthcare benefit for women aged 40 and beyond.
Just because you turn 65 does not mean your yearly mammograms should stop being covered, which is why Original Medicare does cover screening tests for early detection of breast cancer.
If you are enrolled on Original Medicare you’ll pay your annual Part B deductible and then 20 percent of the costs for diagnostic mammograms. If you go to a doctor or qualified health care provider that accepts Medicare assignment, you will not have to pay anything for a screening mammogram.
If your screening mammogram shows an abnormality or if a physical exam reveals a lump, your doctor may recommend a diagnostic mammogram, which diagnostic mammograms are covered by Medicare more often than once a year.
How often does Medicare Pay for Mammogram Coverage for Breast Cancer Screening?
Medicare pays for one annual mammogram screening every 12 months.
If your screening shows a lump your doctor may recommend a diagnostic mammogram on a regular basis due to a medically necessary condition, and medicare will approve the additional treatments.
What types of Mammogram Services does Medicare Cover?
There are two types of mammogram services that may be covered by Medicare. These include:
- Screening mammograms are covered by Medicare as part of your preventive health benefits. This test must include at least a two-view exposure of each breast.
- Diagnostic mammography is a radiologic procedure for patients with signs and symptoms of breast disease, a family history of breast cancer, or a personal history of benign breast disease. Medicare will cover diagnostic mammography as long as your doctor accepts Medicare.
There are three types of outpatient imaging options: conventional, digital, and 3D.
How much does Medicare pay for Screening Mammography?
For women between the ages of 35 and 39 years old and covered by Medicare due to receiving SSDI disability benefits, Medicare will pay for one baseline mammogram. Once you reach 40, Medicare will cover the cost of a screening mammogram every year.
Medicare will pay 100 percent of the Medicare-approved amount for your annual screening. Medicare will also pay 20 percent of the Medicare-approved amount for diagnostic mammograms if medically necessary.
Does my Medicare Supplement Plan Cover Mammograms?
Medicare supplement plans aka Medigap plans are secondary insurance plans that help fill in the coverage gap left behind by Original Medicare. One of the things that Medicare supplement plans can help with is the cost of diagnostic mammograms.
With the Medigap Plan F, Medicare Beneficiaries will pay nothing towards the cost of each diagnostic mammogram test. This can add up to a significant amount depending on the frequency of testing.
If you have the Medigap Plan G, once you have satisfied your Medicare Part B annual deductible, all diagnostic mammogram tests will be covered at 100 percent.
Medicare coverage for cancer prevention is an important tool in detecting breast cancer early. Early detection is key to successful treatment and survival rates.
Medicare Advantage plans also cover mammograms, but each company can cover them in a different way.
Does my Medicare Advantage Plan (Medicare Part C) Cover Mammograms?
Medicare Beneficiaries enrolled in a Medicare Advantage plan are covered for mammogram screenings.
Medicare Part B and Medicare Advantage plan both cover 100 percent of the cost of a screening mammogram once per year and 20 percent of the cost of a diagnostic mammogram.
Your Medicare Advantage plan may also charge an annual deductible and copay in addition to the 20% coinsurance. Medicare covers 80 percent of the costs of the test.
How Medicare Covers Screening and Diagnostic Mammograms?
Screenings are fully covered by Medicare Part B every 12 months. You may need a diagnostic mammogram if your screening reveals something suspicious like a lump.
Medicare Part B also covers your diagnostic mammogram which is a special X-ray of the breast that is used to take a closer look for signs of cancer.
Medicare will cover the cost of a diagnostic mammogram if your doctor recommends it and you meet one of the following conditions:
- You have a history of breast cancer.
- You have signs and symptoms that indicate breast disease.
- Your doctor recommends a mammogram be performed.
Does Medicare Cover 3D Mammograms?
A 3D mammogram is a type of breast cancer screening that uses low-dose X-rays to create images of the breasts. Medicare covers 3D mammograms for women who are at high risk for breast cancer or who have a family history of the disease.
Are Mammograms Free with Original Medicare?
Medicare covers one screening mammogram every 12 months for women who are enrolled in Original Medicare or a Medicare Advantage plan.
However, diagnostic mammograms – which are used to assess abnormal findings from a screening mammogram or to evaluate symptoms such as a lump or nipple discharge – may require copayments, deductibles, and coinsurance.
It’s important to check with your plan about coverage for diagnostic mammograms.
Medicare Beneficiaries enrolled in a Medigap Plan G may have to pay their annual Part B deductible if it has not already been satisfied.
Having health insurance is important for people with cancer so that they can access the care they need. Government programs like Medicare, Medicaid, and SCHIP can help cover the costs of cancer treatment.
You may also want to buy a cancer policy to cover additional expenses not covered by a health insurance policy such as hotel costs, gas, and airfare.
For more Medicare information reach out to one of our independent Medicare insurance agents.
Does Medicare Cover Screening Mammograms After Age 65?
Yes, Medicare covers mammograms for women eligible for Medicare.
Do I need a Referral from my General Practitioner to have a Mammogram covered by Medicare?
If you’re a woman covered by Medicare, you’re probably wondering if you need a referral from your GP in order to have a mammogram. The answer is: it depends.
If your mammogram is for screening purposes (i.e. to check for signs of breast cancer), then you do not need a referral from your GP.
However, if your mammogram is for diagnostic purposes (i.e. to investigate a suspicious lump or other symptoms), then you will need a referral from your GP in order to have the procedure covered by Medicare.
It’s important to be aware of the difference between screening and diagnostic mammograms, as the type of mammogram will affect whether or not you’re required to pay a Medicare coinsurance or copayment.
Screening mammograms are generally covered by Medicare with no out-of-pocket costs, while diagnostic mammograms may require a coinsurance or copayment depending on your particular plan.
Additionally, some Medicare Advantage plans may offer additional coverage for Mammograms beyond what is offered by Original Medicare, so it’s worth checking with your insurer to see what they cover.
And finally, if you have a Medicare Supplement plan, this can help pay for some of the costs associated with diagnostic Mammograms, as these are covered by Medicare Part B.
So in summary: if you’re a woman covered by Medicare, you may need a referral from your GP for a diagnostic mammogram, but not for a screening mammogram. And depending on your particular plan, you may have additional coverage for Mammograms beyond what is offered by Original Medicare.
Does Medicare also Cover Breast Ultrasound?
Breast ultrasound is a diagnostic procedure that uses sound waves to create images of breast tissue. It can be used to help evaluate lumps or masses that are found during a physical exam, mammogram, or breast MRI.
Ultrasound is often used to determine if a mass is solid or filled with fluid. If the mass is solid, further testing may be needed to determine if it is benign (non-cancerous) or malignant (cancerous).
What if a Medicare Beneficiary Needs More Information about Mammogram Screenings?
Ways to find out what items are covered by Medicare?
One way to find out what items are covered by Medicare is to visit the website of the Centers for Medicare and Medicaid Services (CMS).
CMS is responsible for administering the Medicare program. The website provides a searchable database of covered items, as well as a list of frequently asked questions about coverage.
Another way to learn about Medicare coverage is to speak with a customer service representative at 1-800-MEDICARE (1-800-633-4227). Representatives can answer general questions about coverage and direct you to resources where you can find more detailed information.
You can also talk with one of our licensed Medicare insurance agents at Integrity Now Insurance Brokers. Our agents are here to help answer all of your questions.
How to Get Extra Help with Your Mammogram Costs with Medicare
Extra Help is a government program that helps people with limited incomes and resources pay for their prescription drugs. If you qualify for Extra Help, you may be able to get help paying for some or all of your mammogram costs.
To qualify for Extra Help, you must meet certain income and resource requirements.
If you think you might qualify for Extra Help, contact your local Social Security office or visit www.socialsecurity.gov/extrahelp to learn more and to apply online.
Additional Cancer Screening Questions:
Is Cervical & Vaginal Cancer Screenings Covered by Medicare?
Cervical and vaginal cancer screenings are covered by Medicare. However, there are some conditions and limitations that apply. For example, Medicare will only cover one screening per lifetime for women who have had a hysterectomy. Other screenings may be covered if they are deemed medically necessary.
Where Can I find more information about Regular Mammogram Screenings?
The American Cancer Society provides additional resources related to regular mammogram screenings.
My mammogram Doctor Recommends More Frequent Tests am I covered by Medicare?
Yes, if your treating physician has a medically necessary reason for the additional test Medicare will provide coverage.
How Can We Help you with your Medicare Coverage?
Our goal is to help you get the most out of your Medicare coverage so that you can live a healthy and happy life.
We look forward to hearing from you soon. Call us at 562-735-3553 or fill out our online Medicare quote form.