Mammogram plays an important role in the early detection and diagnosis of breast cancer in women.

Sadly, it isn’t an affordable procedure.

You should expect to pay an average of $150 for a screening mammogram and $500 for a diagnostic mammogram without insurance. That’s a lot of money, considering women may need more than one session in a year.

The good news is Medicare covers mammograms!

Does Medicare cover mammograms?

Mammograms are not covered by Original Medicare Part A. This is because Part A is limited to inpatient care. And since mammograms don’t require hospitalization, they will be covered by Original Medicare Part B. 

Your Part B insurance will cover the following types of mammograms:

1. Baseline mammograms

Baseline mammograms refer to the initial mammogram taken as a reference point for future comparisons. It helps detect any changes in the breast tissue over time. 

Typically, it is performed for women who have no previous breast cancer history and are within a certain age range. This means they haven’t been diagnosed with breast cancer but are at risk of developing it. 

Medicare will cover a baseline mammogram once in your lifetime (when you’re between 35 to 39 years old).

2. Screening mammograms

Screening mammograms are routine X-ray exams used to check for breast cancer in women with no apparent symptoms. They aim to detect potential issues early, even before noticeable signs or lumps. 

If you’re a woman above 40 years old, you will need regular screening mammograms for early detection and better chances of recovery (in case breast cancer is detected). Medicare will offer coverage once every 12 months. 

Women, who have had their Medicare screening mammogram but feel the need for another one in the same year, will have to pay for it out of their pocket. Or they can opt for a diagnostic mammogram. 

3. Diagnostic mammograms 

Most women question – does Medicare cover diagnostic mammograms in the same year as screening mammograms. The short answer is yes.

It’s because the purpose of both mammograms is different. While screening mammograms just detect unusual changes in breast tissue, a diagnostic mammogram confirms the presence of cancer. 

If medically necessary, Medicare will cover diagnostic mammograms more than once a year. 

Does Medicare cover 3D mammograms?

Previously, Medicare coverage for mammograms was limited to baseline, screening, and diagnostic tests. But, in 2015, it realized the benefits of 3D mammograms and started covering its expense in Part B.

3D mammograms, also known as digital breast tomosynthesis, are advanced breast imaging procedures. They use a series of X-ray images taken from multiple angles to create a 3D representation of the breast tissue. 

This technology allows for a more detailed and comprehensive view, which helps doctors detect breast cancer more accurately. It also helps reduce false positives.

However, since this is an advanced mammogram type, your doctor must first recommend it as a medically-necessary test. Otherwise, Medicare will not offer its coverage. 

Are mammograms free with Medicare?

If you’re getting a baseline or screening mammogram covered by Medicare, it will be completely free. You won’t have to pay anything. The only condition is that your doctor must accept the assignment. 

However, if you want a diagnostic or 3D mammogram, Medicare will cover 80% of the expenses after you have paid the deductible for the benefit period ($240 in 2024). The remaining 20% amount will be your out-of-pocket cost. 

For example, if the Medicare-approved amount for a 3D mammogram is $500 and you have already paid the deductible, Medicare will pay $400. You’ll have to pay the remaining $100. 

That said, the bill can even be zero for people with supplemental insurance (Medigap or Medicaid). This is because their supplemental insurance will cover the out-of-pocket cost!

Please note Medicare Advantage plans (Part C) are also required to cover all types of mammograms. You won’t have to pay any deductibles, coinsurance, or copayments. But the eligibility criteria and requirements may vary. 

So, consult with your insurance provider to learn about Part C Medicare mammogram coverage. 

At a glance: Medicare guidelines for diagnostic mammograms

If you want to get a diagnostic mammogram, follow these guidelines:

• Should be 40 years or above.
• Should have a doctor’s referral for a diagnostic mammogram.
• Should have paid the deductible for the benefit year. 

Medicare beneficiaries below 40 years old or without a referral won’t qualify for the coverage. If they meet these criteria but haven’t paid the complete deductible or some portion of it, they’ll have to first pay the amount. This can make the mammogram expensive. 

How often does Medicare pay for mammograms?

Medicare will pay once for a baseline mammogram when you’re between 35 to 39 years old. If you’re 40 years old or above, you will qualify for routine screening mammograms. Medicare will cover these at 100% once every year. 

Women won’t get coverage for another screening in the same year. But there’s a Medicare mammogram 11 months rule that you should know. 

If 11 months have passed since your last screening and your doctor has recommended another one, Medicare will offer 100% coverage for it. 

As for the diagnostic and 3D mammograms, you can get as many as medically necessary in a year. Medicare will cover each of them at 80% after you have paid the deductible for the benefit period.

Do I need a referral for a mammogram with Medicare?

You don’t need a referral for a baseline or screening mammogram with Medicare. If you suspect breast cancer and want peace of mind, you can refer yourself for a mammogram. Medicare will cover the expenses. 

But if you’re going for a diagnostic or 3D mammogram, a referral will be necessary for Medicare to cover it. 

At what age does Medicare stop paying for mammograms?

There’s no age limit for mammogram coverage. Medicare will continue paying for your screening and diagnostic mammograms once you’re 40 years or above!