Does Medicare Pay for 3D Mammograms?
- Does Medicare pay for 3D mammograms? Find out how you can get a mammogram covered under your Medicare plan, and why you might need the more detailed 3D scan.
Basic diagnostic tests are generally included in your Original Medicare (Part A and Part B) coverage. The reason for your mammogram (screening vs. diagnostic) can affect whether you're required to pay a Medicare coinsurance or copayment and deductible for your 3D mammogram.
Medicare coverage for extra testing and more expensive exams might be limited. Women with Medicare can typically use their benefits to pay for a medically necessary 3D mammogram, but a private Medicare plan such as a Medicare Supplement or Medicare Advantage plan could help cover additional costs or services.
- A Medicare Advantage (Medicare Part C) plan will cover your 3D mammogram the same as Original Medicare would, and some Medicare Advantage plans may include additional mammogram coverage and/or lower coinsurance or copayment requirements than Original Medicare. Some plans may also offer additional women's health benefits, cancer treatment options or other benefits that Original Medicare doesn't cover.
- A Medicare Supplement (also called Medigap) plan can help pay your Medicare Part B coinsurance, if your diagnostic mammogram requires you to pay the typical 20% of the Medicare-approved amount for your mammogram.
It's important to note Medicare Advantage plans and Medicare Supplement plans are very different types of Medicare coverage, and you can't have each type of plan at the same time.
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When Does Medicare Cover Diagnostic Tests?
Medicare pays for many routine tests through its Part A and Part B coverage. Tests done at a doctor’s request in the hospital are typically paid for by Part A coverage, while outpatient testing, which includes regular screenings, most often fall under Part B.
If you get your Medicare coverage through a Medicare Advantage plan, often called Part C, you have all the same benefits you would have gotten from Original Medicare Parts A and B, including mammograms as part of your annual health exam.
Medicare does not always pay for diagnostic tests. Some tests are not included on the list of annual screening exams you automatically get with regular coverage. You could also be denied coverage for tests that are taken more often than the usual annual limit.
As a rule, Medicare will pay for medically necessary screenings, though these are usually the basic version of whichever screening test your doctor has requested, including mammograms. 3D mammograms are not automatically a covered benefit.
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When Does Medicare Cover 3D Mammograms?
Medicare does include mammograms as a covered test with no out-of-pocket expense to you if:
- You are getting a 2D mammogram as part of your annual screening
- Your doctor has authorized a 3D mammogram as part of the annual screening
- It is your first mammogram, or you have not had a mammogram for at least 11 months
Medicare Part B pays for 80% of the price of a diagnostic mammogram, which may leave you out of pocket for the remaining cost. This is billed to you at the Medicare-approved price, which is generally lower than the market price for diagnostic tests.
Be aware that a 3D mammogram is typically more expensive than a conventional 2D test, and so your total cost could be higher if you get this kind of mammogram.
Medicare does not pay for screening mammograms for women under age 35, even if they have Medicare for disability-related reasons. Medicare also does not pay any of the costs of a screening mammogram for male beneficiaries, even if they have the BRCA1/2 mutations associated with male breast cancer.
Conventional Medicare benefits do pay up to 80% of the cost of a diagnostic screening for men who may have developed breast cancer, but it is not included as part of their regular annual health screening.
When Should You Get a Mammogram?
According to the American Cancer Society, women in the United States are encouraged to get their first mammogram between the ages of 35 and 39, to use as a baseline for comparison with later tests. Women aged 40 and over should get a mammogram as part of their annual physical.
Your doctor might encourage you to get your first mammogram done earlier, or to get them more often than once a year, if you are at higher risk of breast cancer. This may be because of your family history, genetics or because you have early signs of breast cancer that the doctor wants to monitor closely.
3D vs. Regular Mammograms
During a regular mammogram, which is technically called a conventional digital mammography, the scanner takes two pictures of your breast, one from the top and one from the side. The images can be stored in your medical history and compared with later scans to spot any suspicious changes to your breast tissue over the years, which is sometimes a sign of breast cancer.
The more advanced 3D mammogram uses similar equipment, and the process is broadly the same while the images are being taken. The difference is that a 3D scan takes multiple images of the breast from multiple angles. These images are then combined into a single 3Dimensional picture that provides much more detail about the breast tissue than a 2D scan does.
This kind of scan can, under certain circumstances, identify cancer at an earlier stage than conventional digital mammography. It's also helpful to monitor post-cancer breast tissue for early signs of recurrence and to develop a detailed picture of small changes in breast tissue that could be problematic.
Doctors sometimes ask for a 3D mammogram when you have an unusually high risk of breast cancer or when you have already had it, and they want to monitor your treatment and recovery.
Other Options for Getting a 3D Mammogram
If you are a female Medicare beneficiary under age 35, if you are male, or if you have had a screening mammogram sometime in the last 11 months, you may not be able to get Medicare to pay for your mammogram.
If Medicare will pay for your conventional mammogram, but your doctor has not authorized a 3D scan, you may have to pay out of pocket for the total cost of the test. Fortunately, there are alternatives to Medicare that might help you pay for some or all of the cost of a 3D mammogram.
Private insurance policies often include coverage options that Medicare lacks. Ask your insurance company about how your mammogram would be paid for. Be sure to ask about the differences between 2D and 3D scans, as well as the difference, if any, between annual screening and diagnostic mammograms.
If you have limited income and assets, you may be eligible for Medicaid. If you carry Medicaid as a supplemental policy to your Medicare benefits, you are likely to have full coverage for most screening and diagnostic tests, which may include a 3D mammogram. Medicaid may also pick up the 20% co-payment Medicare imposes for diagnostic mammograms.
FAQ
What does a 3D mammogram cost out of pocket?
The price of 3D mammograms varies with location, the circumstances of your health condition and even the specific provider. Some testing providers offer a 3D upgrade at no extra charge, while others may charge hundreds of dollars more for the 3D test.
Who should get a 3D mammogram?
3D mammograms can provide finer detail than conventional imaging, so they work somewhat better for women with denser than average breast tissue. This includes younger women, women with a family history of breast cancer and women who have previously had breast cancer.
Can you get a 3D mammogram without Medicare authorization?
You always have the option to pay for medical tests and treatments without billing Medicare. If you feel you need a 3D mammogram and are able to pay out of pocket, your Medicare will not be affected.
