Traditional Medicare and Medicare Advantage plans cover mammograms for both screening and diagnostic purposes. Levels of cover may vary, however.
Both traditional Medicare, which includes parts A and B, and Medicare Advantage cover screening mammograms at 100%. They also cover diagnostic mammograms, but a person may need to pay any deductibles, coinsurances, and copayments that apply.
Read on to learn more about mammogram coverage under traditional Medicare and Medicare Advantage plans. This article will also look at who may need a mammogram, the types of mammogram available, and what to expect during the procedure.
We may use a few terms in this piece that can be helpful to understand when selecting the best insurance plan:
- Deductible: This is an annual amount that a person must spend out of pocket within a certain time period before an insurer starts to fund their treatments.
- Coinsurance: This is a percentage of a treatment cost that a person will need to self-fund. For Medicare Part B, this comes to 20%.
- Copayment: This is a fixed dollar amount that an insured person pays when receiving certain treatments. For Medicare, this usually applies to prescription drugs.
Traditional Medicare covers screening mammograms for females but not for males.
This plan also covers as many diagnostic mammograms a doctor considers necessary, and these are available for both males and females.
Medicare covers diagnostic mammograms if:
- a person has a history of breast cancer
- they have signs and symptoms that indicate breast disease
- a person’s doctor believes that a mammogram is necessary
Medicare Part B coverage
Medicare Part B provides baseline mammograms for females aged 35–39 and annual screening mammograms for females aged 40 and over.
If they visit a provider who accepts Medicare, the screenings will be free of charge.
Medicare Part B also covers diagnostic mammograms and will cover more than one per year if a doctor decides that it is medically necessary.
A person will usually need to pay a coinsurance of 20%, as well as any deductible included in the policy.
Medicare Advantage coverage
If someone meets the Medicare eligibility requirements, Advantage plans will cover the cost of screenings. To receive the screening at no charge, however, a person must use an in-network provider.
Medicare Advantage plans also cover diagnostic mammograms, but they do not pay the entire cost. If a person visits an in-network provider, the plan pays part of the cost, but deductibles, copayments, and coinsurances will apply.
Screening mammograms are X-rays of the breast. Females who do not have symptoms or signs of breast disease usually undergo screening mammograms. The purpose of the X-rays is for the early detection of cancer.
Below are the American Cancer Society (ACS) guidelines for screening mammograms:
- Females aged 40–44 should get one per year, if they choose to.
- Females aged 45–54 should get one per year.
- Females aged 55 and older should get one every 2 years.
- Screenings should continue for as long as a female is in good health and expects to live for at least 10 more years.
A person should talk to their doctor about when it is best to start screening mammograms. The doctor will base their recommendation on a person’s individual risk factors and family history.
Although there is a difference between screening and diagnostic mammograms, a doctor can use the same machines for both.
The sections below will look at the similarities and differences in more detail.
Screenings usually consist of taking two or more X-ray images of each breast.
These images can show tumors a person may not be able to feel. They can also reveal tiny calcium deposits that can sometimes indicate the presence of cancer.
Diagnostic mammograms involve taking a higher number of images, with different views of the breast from various angles.
Doctors use diagnostic X-rays to assess changes that may have been apparent in a screening mammogram. They also use these images to view breast tissue when a screening mammogram is hard to obtain, such as in a person with a breast implant.
There are two main types of mammogram: film screen and digital.
Film screen mammograms, or conventional X-rays, record images on large sheets of film. Digital mammograms record images into a computer. A doctor who notices an irregularity on a digital image can enlarge it to take a closer look.
Standard digital mammograms are called 2D digital mammograms. A new option is 3D digital mammograms, which take images of thin slices of the breast.
The ACS are conducting a study comparing the outcomes of 2D and 3D digital mammograms.
Doctors do not tend to advise regular self-exams of the breasts for cancer detection, say the National Cancer Institute. Clinical trials show that self-exams alone do not lower the death rate from the condition.
Instead, the medical community recommends mammograms and clinical exams for screening.
A person who performs self-exams should be mindful of several factors that can cause changes in the breasts. These include:
- the monthly menstrual cycle
It is typical for breasts to feel a little lumpy, but if a person detects any unusual changes, they may wish to consider seeking medical advice.
The procedure for a mammogram is simple, but many people find it uncomfortable. Some people also experience some pain.
During a mammogram, a person will stand in front of an X-ray machine. A technologist will place the individual’s breast on a plastic plate. Another plate, above, will press down on the breast to flatten it. The plates hold the breast still while the technologist takes the X-ray. They will then repeat these steps to obtain a side view of the breast.
The Centers for Disease Control and Prevention (CDC) provide the following tips for undergoing a mammogram:
- On the day, avoid wearing perfume, deodorant, or powder, all of which can appear as white spots on the X-ray.
- Avoid undergoing a mammogram the week before or during menstruation, as the breasts may be swollen during this time.
- To avoid having to undress from the waist down, a person may wish to wear a top with pants or a skirt rather than a dress.
Most people get a report on their mammogram results within a few weeks of the procedure. A person who does not receive the report within 30 days may wish to contact their healthcare provider.
If a mammogram report shows an irregularity, it is important to remember that this does not necessarily indicate cancer.
A person with an abnormal result may need to undergo additional tests, and a doctor may also refer them to a breast specialist.
Traditional Medicare and Medicare Advantage will pay for 100% of the cost of a screening mammogram for people who meet the age criteria.
To get screening mammograms for free, a person enrolled in a Medicare Advantage plan must meet the additional requirement of using an in-network provider.
Both plans also cover diagnostic mammograms, but deductibles, copayments, and coinsurance may apply. Coverage includes as many diagnostic mammograms as a doctor deems necessary.
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