Your Medicare Coverage for Annual Mammograms Explained
Turning 65 marks a new chapter, but some health habits should continue, and regular breast cancer screening is one of the most critical. Many beneficiaries wonder if their benefits change as they age. This guide clarifies exactly what you can expect from your Medicare plan regarding mammogram coverage.
The Role of Medicare Part B in Preventive Screenings
Original Medicare is divided into several parts, but Part B is your primary source for outpatient medical services, including preventive care. This is where your mammogram coverage is found. The Centers for Medicare & Medicaid Services (CMS) have clear guidelines to ensure beneficiaries have access to these screenings.
- Screening Mammograms: These are routine, preventative tests used to check for breast cancer in women who show no signs or symptoms. Medicare Part B covers one screening mammogram every 12 months for all women age 40 and older. This coverage has no deductible or coinsurance, meaning it is provided at no cost to you as long as your provider accepts Medicare assignment.
- Baseline Mammogram: Medicare Part B also covers one baseline mammogram for women between the ages of 35 and 39.
The fact that Medicare Part B continues to cover these screenings well past the age of 65 is a key detail that reassures many seniors. It emphasizes that preventive care should not end as you get older.
Understanding Screening vs. Diagnostic Mammograms
It's important to distinguish between two types of mammograms, as their coverage and potential costs differ under Medicare.
- Screening Mammogram: A yearly check-up with no out-of-pocket costs, as described above. If a radiologist reads your screening mammogram and finds something suspicious, it may lead to a diagnostic test.
- Diagnostic Mammogram: A more detailed, focused mammogram ordered when a doctor suspects breast cancer due to an abnormality found in a screening, a lump felt during an exam, or other symptoms. In this case, the test is no longer classified as preventive. Medicare Part B will cover 80% of the Medicare-approved amount for a diagnostic mammogram. You will typically be responsible for a 20% coinsurance payment after you have met your annual Part B deductible.
How Medicare Advantage (Part C) Covers Mammograms
If you have a Medicare Advantage plan, your coverage must be at least as good as Original Medicare (Part A and B). This means your plan will also cover annual screening mammograms at no cost. However, Medicare Advantage plans are offered by private insurance companies, so the rules for diagnostic mammograms and other services can differ.
- Varying Costs: Unlike Original Medicare, your Medicare Advantage plan may have different costs for diagnostic mammograms. You could have a copayment or coinsurance, and you may need to ensure your doctor is in your plan's network to avoid higher costs.
- Network Restrictions: Many Advantage plans operate within specific networks of doctors and hospitals. Always confirm with your plan or provider that they are in-network to receive the full benefit coverage.
Navigating Your Costs: A Comparison Table
| Feature | Original Medicare (Part B) | Medicare Advantage (Part C) |
|---|---|---|
| Annual Screening Mammogram | $0 (if provider accepts assignment) | $0 (must use plan's network) |
| Diagnostic Mammogram | 20% coinsurance (after Part B deductible) | Varies by plan (may be copay or coinsurance) |
| Provider Network | Any provider who accepts Medicare | Limited to plan's network (typically) |
| Referral Needed | No referral required | May require a referral (depends on plan) |
The Importance of Continued Screening for Seniors
As women age, their risk of developing breast cancer increases. The Centers for Disease Control and Prevention provides comprehensive information on risk factors. Continuing with regular mammograms after 65, even if you feel healthy, is a crucial step in early detection. Early detection significantly increases the chances of successful treatment and positive outcomes. Medicare's robust coverage for annual screening mammograms is a reflection of the importance of this ongoing care.
Finding a Covered Mammogram Provider
For those on Original Medicare, finding a provider is straightforward. You can use the Medicare.gov website to locate providers who accept Medicare in your area. For those with a Medicare Advantage plan, it is essential to use your plan's provider directory to find an in-network facility. Your doctor's office or the imaging center itself can also help you verify coverage before your appointment.
Conclusion
For seniors, managing healthcare and understanding coverage can be complex, but fortunately, the answer to Does Medicare cover mammograms after age 65? is a clear and resounding yes. Both Original Medicare Part B and Medicare Advantage plans are mandated to cover an annual screening mammogram at no cost. By staying informed about the distinction between screening and diagnostic services and understanding your specific plan's rules, you can ensure you continue to receive this vital preventative care without financial barriers. Regular screening is a powerful tool for your health, and Medicare is there to support you in using it throughout your later years.
