Medicare covers one screening mammogram per year at no cost to you
Medicare Part B pays for one mammogram every 12 months for women age 40 and older with no out-of-pocket cost — no deductible, no copay. If your doctor orders more than one screening mammogram in a 12-month period, Medicare will not pay for the additional ones. A screening mammogram is an X-ray of the breast to look for cancer in someone with no symptoms.
If you have symptoms — pain, a lump, or discharge — your doctor may order a diagnostic mammogram instead. Medicare covers diagnostic mammograms separately and does not count them against your annual screening limit. You will owe your Part B deductible and 20% coinsurance for a diagnostic mammogram.
The timing of your mammogram matters. Medicare counts the 12-month period from the date of your last screening mammogram, not from January 1. If you had a mammogram on March 15, your next covered screening is March 15 of the following year or later.
Key Takeaways
- Medicare covers one screening mammogram every 12 months at no cost if you are age 40 or older and enrolled in Part B.
- Diagnostic mammograms (ordered because of symptoms) are covered separately and do not use up your annual screening benefit.
- The 12-month period runs from your last mammogram date, not from the calendar year.
- You must go to a Medicare-approved facility; mammograms at non-approved providers are not covered.
Screening versus diagnostic mammograms and what each costs
A screening mammogram is routine imaging when you have no breast symptoms. Medicare covers the full cost of one per year. You pay nothing at the time of service if the facility is in the Medicare network.
A diagnostic mammogram is ordered when you report a symptom or when a screening mammogram found something that needs closer look. Because it is diagnostic rather than preventive, you owe your Part B deductible (currently $240 per year) and 20% of the Medicare-approved amount for the procedure. If you have already met your deductible for the year, you pay only the 20% coinsurance.
Some women need both in the same year. For example, your annual screening mammogram might show a finding that requires a diagnostic mammogram the same week. The screening is free; the diagnostic one is subject to your deductible and coinsurance.
What happens if you need more than one mammogram per year
If your doctor orders a second screening mammogram within 12 months of your last one, Medicare will deny payment for the second one. Your doctor can appeal the denial if they believe the second screening was medically necessary, but this process takes time and is not always successful.
Diagnostic mammograms do not count toward your annual limit. If you need three diagnostic mammograms in one year because of a medical concern, Medicare will cover all three (subject to your deductible and coinsurance). The limit applies only to screening mammograms ordered for routine cancer prevention.
If you are unsure whether your mammogram is being ordered as screening or diagnostic, ask your doctor before the appointment. The facility will bill it according to how your doctor codes the order, and that coding determines whether it counts against your annual benefit.
Where to get a covered mammogram
Your mammogram must be performed at a facility that is enrolled in Medicare and certified by the FDA. Most hospitals, imaging centers, and breast clinics meet this requirement. Before you schedule, ask the facility if they accept Medicare and are FDA-certified for mammography.
If you go to a non-Medicare facility or a facility that is not FDA-certified, Medicare will not pay, and you will owe the full cost. Some facilities that perform mammograms for cash or through private insurance networks are not set up to bill Medicare, even if they are otherwise may have access to.
You can search for Medicare-approved mammography facilities on the Centers for Medicare & Medicaid Services (CMS) website or call 1-800-MEDICARE to ask for a list in your area.
How the 12-month period works and when your next mammogram is covered
Medicare measures the 12 months from the date of your last covered screening mammogram, not from January 1 or any other calendar date. If you had a screening mammogram on June 10, 2024, your next covered screening is June 10, 2025 or later. A mammogram on June 9, 2025 would not be covered.
The facility or your doctor's office should keep a record of your last screening date. If you move or change providers, ask for a copy of your mammogram report or a letter stating the date of your last screening. This prevents confusion if a new provider orders a mammogram and is unsure of your history.
If you are turning 40 and have never had a screening mammogram, your first one is covered when ready. There is no waiting period or prior authorization required.
What to do if Medicare denies your mammogram claim
If you receive a denial notice, check the reason. Common reasons are: the mammogram was ordered within 12 months of your last screening, the facility was not Medicare-approved, or the claim was coded incorrectly.
If you believe the denial is wrong, you can file an appeal. The notice will include instructions on how to appeal and a important date (usually 120 days from the date of the notice). You can appeal on your own or ask your doctor's office to help.
If the denial is because the facility was not Medicare-approved, you may owe the full bill. Contact the facility to ask if they will adjust the charge or work out a payment plan. Some facilities will write off the bill if they were not properly enrolled in Medicare at the time of service.
Supplemental insurance and mammogram coverage
If you have a Medigap (supplemental) policy, it will cover your Part B coinsurance and deductible for diagnostic mammograms. This means if you owe 20% coinsurance for a diagnostic mammogram, your Medigap plan pays that 20%. You still pay nothing for your annual screening mammogram because Medicare covers it in full.
If you have a Medicare Advantage plan (Part C) instead of Original Medicare, your mammogram coverage may differ. Some Advantage plans cover more than one screening mammogram per year or waive the deductible for diagnostic mammograms. Check your plan documents or call the plan to confirm what you pay.
Frequently Asked Questions
Can I get a mammogram before 12 months if my doctor thinks I need one?
If your doctor orders it because of a symptom or finding, yes — that is a diagnostic mammogram and is covered separately. If your doctor wants another screening mammogram for routine prevention before 12 months have passed, Medicare will not pay. Your doctor can request an exception, but approval is not may provide.
Do I need a referral from my primary care doctor to get a mammogram?
No. You can schedule a screening mammogram directly at any Medicare-approved facility without a referral. If your doctor orders a diagnostic mammogram, you do not need a referral either, though some facilities may ask for the doctor's order.
What if I had a mammogram at a private facility before I turned 65 and enrolled in Medicare?
That mammogram does not count toward your Medicare annual limit. Your 12-month period starts from your first Medicare-covered screening mammogram. If you turn 65 in March and had a private mammogram in January, you can have a Medicare-covered screening mammogram in March with no waiting.
Does Medicare cover 3D mammograms?
Yes. 3D mammography (tomosynthesis) is covered the same way as standard 2D mammography — one screening per year at no cost, or diagnostic mammograms subject to your deductible and coinsurance. The facility bills it the same way and Medicare pays the same benefit.
What if I turn 40 this year — when can I get my first covered mammogram?
You can have a screening mammogram covered when ready once you turn 40 and are enrolled in Medicare Part B. There is no waiting period. Schedule it at any Medicare-approved facility.