A woman’s lifetime risk of breast cancer is 12%; over an 80-year lifespan, 1 in 8 women will develop breast cancer. The risk increases significantly the older you get. A woman of 40 has a 1.5% chance of developing cancer in the next 10 years, but a woman of 60 has a nearly 4% risk.
Fortunately, regular breast examinations and routine screening mammograms can help detect breast cancer at its earliest stages when treatment is most effective. That’s good news for Medicare beneficiaries because Medicare pays 100% of your costs for screening mammograms.
When should I have a mammogram?
Different health organizations have different recommendations. For example, the American Cancer Society recommends annual screening mammograms beginning at age 45 for women of average risk. The U.S. Preventive Services Task Force, on the other hand, recommends mammogram screening beginning at age 50. Many providers, including the Mayo Clinic, follow a more conservative schedule and recommend annual mammography beginning at age 40.
If you are at high risk for developing breast cancer, your doctor may recommend screening mammograms even earlier. Women with a family history of breast cancer and those with gene mutations that put them at high risk may start mammographic screening much earlier.
Talk to your doctor about your family history and lifestyle risks, and follow his or her advice about breast cancer screening with mammography.
When does Medicare cover screening mammograms?
If you are between the ages of 35 and 39, Medicare pays for one baseline mammogram. If your provider accepts assignment, you pay nothing for the test and your deductible doesn’t apply.
Starting at age 40, Medicare covers one screening mammogram for women every 12 months. Some doctors recommend screening mammograms only every other year, while others stick with a yearly schedule. As long as you get just one screening mammogram in any 12-month period, Medicare covers it at 100%.
Currently, Medicare doesn’t cover any breast screening exams for men. However, if you are a man and your doctor finds something suspicious in your breast tissue, Medicare will pay for diagnostic mammograms and other breast studies your doctor orders. You pay 20% of the allowable charges and your Part B deductible applies.
Does Medicare cover additional mammogram tests?
Sometimes, a woman has a routine screening mammogram and the radiologist sees something potentially abnormal. In this case, the doctor will usually order another mammogram using different views to get a better image of the suspicious area.
These additional views are considered a diagnostic mammogram, and Medicare covers diagnostic mammograms differently than screening mammograms. A diagnostic mammogram is like any other diagnostic test for Medicare purposes. Part B covers diagnostic mammograms, breast ultrasounds, and other diagnostic breast studies at 80% after you meet your deductible.
If you have Medicare Advantage, you may pay a copayment instead of 20% coinsurance for the test. You may also need a referral for diagnostic mammograms and breast studies. Depending on your plan, you may also need to see a network provider for the exam to be covered.
Does Medicare cover 3D mammograms?
3D mammograms combine multiple images of your breasts to give the radiologist a complete picture of your entire breast. They are becoming more popular as a screening tool because the 3D picture makes it easier for the radiologist to spot abnormalities. Some studies suggest that 3D mammograms eliminate the need for additional images if a suspicious area is present, and they may detect more abnormalities than normal mammography.
Original Medicare does not cover 3D mammograms as part of your free annual routine screening. If you have a 3D mammogram, Medicare considers it a diagnostic test and covers it at 80% after you meet your deductible.
Note, however, that if Medicare doesn’t cover your 3D mammogram as part of a screening study, your Medigap plan won’t cover it, either.
If you have Medicare Advantage, your plan may cover 3D mammography differently than Original Medicare, so check your plan benefits brochure for details.
Why did I get two bills for my mammogram?
There are two parts to your mammogram bill. The first part is called the technical component, and it covers the cost of the mammogram itself—the use of the mammography machine, the technologist who performed it, and any supplies used during the study.
The second part is the professional component. This charge is for the services of the radiologist who reviews the mammogram images and reports the findings to your doctor.
Some imaging facilities bundle both of those charges into one bill, but others bill these costs separately. Both bills are treated the same by Medicare. If the study was a screening mammogram, Medicare covers both parts at 100%. Medicare pays 80% of both bills if the mammogram is a diagnostic study.
Breast cancer is the second most common cancer in the U.S. With early detection and treatment, the five-year survival rate is 99%. Medicare’s commitment to preventive care and screening mammograms means you don’t need to leave your health to chance.