Mammograms and Medicare: What You Need to Know

October is Breast Cancer Awareness Month. With that in mind, we wanted to write an article uncovering some mysteries about Medicare and mammograms. Mammograms are vital in the detection of breast cancer.  

We’re going to look at mammogram recommendations by age, types of mammograms, and Medicare coverage for mammograms.  

If you have more generalized questions about breast cancer and Medicare, check out our previous blog here.

What is a mammogram?

Mammograms are highly effective diagnostic tools that can help identify cancer in nearly 90% of cases. Mammograms are used to look for suspicious tissue in the breast.

You might need a mammogram if you found something during your breast self-exam, which should be conducted once a month. Otherwise, you should get a mammogram annually, or as directed by your doctor.

When should I start getting mammograms?

Most doctors suggest annual mammograms to women in their 40s, depending on their breast cancer risk.

‍Breast cancer risk increases with age, with women in their Medicare years at higher risk than younger women. 70% of breast cancer diagnoses are women over the age of 55.

What are the different types of mammograms?

There are two types of mammograms: screening mammograms and diagnostic mammograms.

Screening mammograms

Screening mammograms can be conventional film or digital. During a screening mammogram, you will be asked to remove your clothing from the waist up so the machine can access each breast. You will place each breast between two camera plates on the mammography machine.  

The machine compresses on the breasts for less than a minute per picture. While this is not painful, you may experience some discomfort. Mammograms usually take about 20 minutes from start to finish.

Diagnostic mammograms

Diagnostic mammograms are needed if your screen shows any abnormalities or dense breast tissue. There are a few options your doctor might choose.

Ultrasounds and 3D diagnostic mammograms are the most used options, but a breast MRI might also be ordered if your doctor sees it necessary.

What types of mammograms does Medicare pay for?

Medicare will pay for all screening mammograms, both conventional and digital. Diagnostic mammograms are covered as well but will have a 20% coinsurance.

Are mammograms free with Medicare?

Original Medicare: You are entitled to one free screening mammogram every 12 months through your Medicare Part B coverage. Medicare will cover 80% of diagnostic mammograms.  

Medicare Supplement: With Original Medicare and a supplemental policy, you will not pay the 20% coinsurance for a diagnostic mammogram. You would only be subject to your small annual deductible.

Medicare Advantage: MA plans are required to offer the same care as Original Medicare. HMO/PPO plans cover the same as Part B in most cases, although coverage for diagnostic mammograms may vary slightly depending on the plan. Medicare MSA enrollees can use their deposit to pay for mammograms if they have not hit their deductible.  

Does Medicare cover diagnostic mammograms?

Medicare will cover 80% of diagnostic mammograms, leaving you with 20% of the bill. If you have a Medicare Supplement, your plan will cover that 20% coinsurance. You would only be responsible for your small annual deductible.

Diagnostic mammograms are only ordered if screenings come back with abnormalities or inconclusive information. These tests are more in-depth.  

Does Medicare cover mammograms after age 65?

Once you are enrolled in Medicare, you will receive coverage for an annual mammogram. Medicare covers 100% of the cost for one screening mammogram every 12 months.

‍Research suggests that women in their 60s who receive annual mammograms are 33% less likely to die from a breast cancer diagnosis.  

Does Medicare cover mammograms after age 75?  

There is no age limit to mammograms, so Medicare will cover mammograms for those older than 75. If you are in good health, you should still be getting an annual mammogram.

Those with declining health should work with their doctors to determine their own mammogram schedule.

How often will Medicare cover mammograms?

For screening mammograms, Medicare covers one test per 12-month period for all women on Medicare over age 40. This is in line with the recommended annual mammogram recommendations by the American Cancer Society.

Part B will cover 80% of additional mammograms done during the 12-month period if they are deemed medically necessary. If you have a supplement, it will pick up the remaining 20% coinsurance.

Conclusion

Mammograms and early detection play a big part in fighting breast cancer. But we’re not done yet. If you want to learn more about breast cancer or donate to breast cancer research, please visit the National Breast Cancer Foundation.  

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