Does Medicare Cover Mammograms?
Yes, Medicare does cover mammograms. Women can expect one fully covered screening every 12 months starting at age 40, while insured through Medicare. Patients pay nothing for these annual preventative examinations if performed by a Medicare-approved doctor. Medicare Part B also provides medically necessary and diagnostic mammograms within the same year, covering 80% of the cost.
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Staying Ahead of Breast Cancer
According to the American Cancer Society, 12% of women will experience breast cancer in their lifetime. Experts estimate 287,850 new cases in women each year, with 43,250 accompanying deaths. Breast cancer cases do occasionally occur in men, though much less commonly.
Doctors can best treat breast cancer early in its development before it spreads to other parts of the body. Mammograms, X-rays that scan the entire breast for signs of cancer, can detect abnormalities in the chest up to three years before a patient might feel them. Further, these examinations are effective in saving lives; studies have proven that regular mammogram screenings can reduce death rates in women over 40.
What Mammogram Services Does Medicare Cover?
Luckily, women enrolled in Original Medicare receive full coverage for annual mammograms. Medicare Part B kicks in to cover the total cost of any preventative mammogram performed at least eleven full months since your last screening. Part B will cover 80% of the Medicare-approved amount for repeat screenings within the same year prescribed as necessary by your doctor.
Mammograms can serve either as screening, diagnostic, or surveillance procedures. Medicare mammogram coverage includes preventative testing for all individuals, regardless of gender starting at age 40. Those who qualify for Medicare between the ages of 35 and 39 may receive one baseline mammogram during that time.
Screening mammograms attempt to catch cancer early in its development before patients experience any symptoms. Discovering cancerous cells before they grow into tumors or metastasize increases the odds of successful treatment, making preventative screenings crucial in the battle against cancer. The American Cancer Society recommends women schedule annual screening mammograms beginning at age 45.
Medicare Part B fully covers annual screening mammograms through the rest of their lives, as long as their cancer specialist orders the test, agrees to the Medicare fee schedule, and they are over the age of 55.
Doctors utilize diagnostic mammograms to examine patients currently experiencing symptoms of breast cancer, including lumps in the breast, nipple discharge, localized skin pigment changes, or pain. Sometimes, concerning results from screening mammograms also lead to follow-up diagnostic tests.
Medicare Part B covers 80% of the Medicare-approved cost of any diagnostic mammogram, leaving patients to pay the remaining 20% and their annual Part B deductible. However, Medicare imposes no limit on the number of diagnostic tests one patient can receive. Underlying cancer requires urgent treatment, and delaying testing could prove fatal.
Surveillance mammograms monitor progress and regression in women who have previously undergone breast cancer treatment. Cancer has a way of rearing its ugly head months or years after successful treatment, even in patients who have received mastectomies. Staying vigilant with continual scans can help catch recurrences before they cause severe damage.
Medicare coverage for surveillance mammograms depends entirely on your healthcare provider. Some doctors consider post-eradication recurrences as new cancer, qualifying retroactive tests as screening mammograms. Others view surveillance mammograms as diagnostic procedures since cancer has previously inhabited the area. The way your surveillance mammograms get classified directly affects how Medicare Part B will pay for them.
How Often Can You Get a Mammogram With Medicare?
Medicare allows enrollees one free screening mammogram every year for the rest of their lives, starting at age 40. Part B covers 80% of the Medicare-approved cost of any additional screenings deemed medically necessary by a doctor.
Medicare sets no frequency limits for the amount of medically necessary diagnostic mammograms, covering 80% of all tests prescribed by a doctor.
The Cost of a Mammogram With Medicare
Medicare Part B will cover 100% of annual screening mammograms and 80% of medically necessary diagnostic X-rays. Mammogram costs vary widely by state but average about $290 nationally for conventional tests. In this example, patients enrolled in Medicare would have to pay the remaining 20%, $58, in addition to their Part B deductible ($226 in 2023).
Patients must also pay 20% of the Part B coinsurance for repeat screening mammograms prescribed by a doctor within the same 12-month window. Doctors typically charge less for screening mammograms than diagnostic procedures, occasionally dropping prices by more than half.
Medicare cost-sharing refers to the fees you must pay out-of-pocket under Medicare, including deductibles, copays, and coinsurances. If you need more than one screening per year or a diagnostic mammogram, you must pay 20% of the Medicare coinsurance on top of your annual deductible. These out-of-pocket costs often deter women at risk from seeking medically necessary examinations.
How Do Other Medicare Options Cover Mammograms?
Original Medicare offers federally subsidized, fee-for-service health care in two parts: Part A (hospital insurance) and Part B (medical insurance). Diagnostic and screening mammograms typically see coverage under Part B, which pays for medically necessary outpatient treatment services. Medigap plans can also help cover some of the costs of mammograms, specifically the 20% left over after coinsurance. Medicare Advantage, which replaces Original Medicare, may also offer some extended benefits when it comes to mammogram coverage.
Private insurance companies offer Medicare Advantage plans as an alternative to Original Medicare. At a minimum, Medicare Advantage plans must provide all the same benefits as Original Medicare, therefore covering mammograms identically to Part B. Medicare Advantage plans often include additional perks, like covered transportation to mammogram appointments or discounted cancer medications.
Medicare Supplement, or Medigap
An optional supplement to your Original Medicare plan, Medigap helps absorb out-of-pocket treatment costs like Medicare coinsurances, copays, and deductibles. Patients who require frequent mammograms can use Medigap to help cover the 20% coinsurance and Part B deductibles that come with every diagnostic test.
Getting a Mammogram with Medicare
For Medicare to pay for your mammogram, you must receive care from a Medicare-approved doctor. “Participating providers” welcome Medicare recipients and always take assignment, meaning they accept the Medicare-approved amount for service as full payment. “Non-participating providers” take assignment on a case-by-case basis and often charge patients an additional limiting fee of up to 15% of the Medicare-approved amount for care.
Thoroughly research your healthcare options and speak with your doctor before scheduling a mammogram to confirm your financial obligation to the procedure. Low-income or uninsured individuals can also check the CDCs program database for free or low-cost screenings in their area.
How Are Mammograms Performed?
Patients must undress above the waist during a standard mammogram to receive X-rays. A technician will compress their breasts one at a time between two steel plates, spreading the tissue for a comprehensive scan. The resulting image will highlight any cellular abnormalities beneath the skin, making it easy for a doctor to spot early signs of cancer or active tumors.
Patients can expect results for screening mammograms within two weeks, while diagnostic tests often yield a same-day turnaround. Ask your provider how long the results should take and follow up if necessary. Wait times may also vary depending on the type of mammogram you receive.
Different Types of Mammograms
Medicare offers three different varieties of mammograms: conventional, digital, and 3D. Determining which one you will receive depends on your specific health situation, which form of Medicare you have, and what facilities are available where you live. Keep in mind that 3D is the best variety but is not available at all Medicare facilities.
Typically the least expensive of the three methods, conventional mammograms utilize black and white X-ray film to produce 2-D images. Doctors can scrutinize these pictures live during the test to identify any lumps or deposits. Conventional mammograms successfully detect breast cancer 79% of the time, though they occasionally result in false positives, especially among younger women with dense breasts. Nearly half of the women who receive mammograms through a ten-year window will live through at least one false positive, only to see it debunked by further testing.
Medicare offers standard coverage for conventional mammography through all Medicare-approved providers, though digital methods have largely replaced conventional film procedures.
While both digital and conventional mammograms follow the same procedure, digital techniques store the resulting X-rays as electronic files on a computer. This feature allows doctors to magnify, enhance, and further manipulate images for in-depth assessment. Additionally, doctors can share digital files online, making it easier to consult with radiologists and breast surgeons remotely.
Digital mammography has proven more effective than conventional film X-rays for premenopausal women and those with dense breasts. Medicare Part B covers digital mammograms prescribed by a doctor.
3-D mammography, also referred to as digital breast tomosynthesis, takes multiple layered X-rays of the breasts from different angles, synthesizing them to create a comprehensive three-dimensional image of the tissue. 3-D mammograms have 51% greater success detecting invasive cancer cells in the breast than 2-D digital mammography.
As with 2-D conventional and digital methods, Medicare Part B would cover preventative screening and diagnostic 3-D mammograms ordered by a Medicare-approved physician. However, not all healthcare providers offer 3-D mammograms yet, as the technology costs more to maintain and install. Other downsides to 3-D mammography include higher coinsurance, greater exposure to radiation, and longer wait times for results.
Importance of Regular Mammograms
Scheduling regular mammograms can reduce the risk of dying from breast cancer. Nothing outweighs early detection in the fight against cancer, and mammograms remain the best discovery method for women within the standard screening age.
The benefits of routine mammograms increase as you get older. Studies by the United States Preventative Services Task Force found that regular screenings reduced breast cancer deaths by up to 14% for women over 50 and 33% for women over 60. Annual mammograms also provide doctors with detailed records of your breasts comparable against each other later when attempting to spot minor changes in the tissue.
Putting It All Together
The longer it takes to find cancer in the body, the more intense, invasive, and occasionally futile the treatment. Annual examinations can help many women avoid the adverse outcomes of lingering breast cancer, including chemotherapy, radiation, mastectomies, and death.
You can get screened for breast cancer at a clinic, hospital, or doctor’s office. Medicare fully covers annual preventative mammograms for no out-of-pocket cost as long as a compliant doctor performs the procedure. Speak with a licensed Medicare agent for more information on mammogram coverage, and consult your doctor to confirm their Medicare status before setting up an appointment.