Dear Marci,

My friend recently got a mammogram and did not have to pay anything for it. When I got a mammogram, though, my provider billed me for part of the cost. We both have Original Medicare with no supplemental insurance. Why were our costs different?

-Lilly (Spokane, WA)

Dear Lilly,

There are several reasons that you and your friend might have had different costs for your mammogram. Mammograms can be covered by Medicare as preventive or diagnostic services:

• A service is considered preventive if you have no symptoms of the disease the service is meant to address. Medicare Part B covers many preventive services at 100% of the Medicare-approved amount. These services, which are recommended by the U.S. Preventive Services Task Force and can be found here, are covered with no cost sharing (no deductible or coinsurance) as long as you meet the coverage rules and get the services from the right kind of provider. A mammogram is one of the preventive services that Part B covers at 100% of the Medicare-approved rate. For women 35-39 years old, Part B covers one baseline mammogram, and for women over age 40, Medicare covers one mammogram every 12 months.
• A diagnostic service addresses symptoms that already exist. A person might get a diagnostic mammogram if they have a history of breast cancer or if they showed symptoms during another exam. Medically necessary outpatient diagnostic services are covered at 80% of the Medicare-approved amount. If you get a diagnostic mammogram from a doctor who accepts assignment, you will be responsible for 20% of the Medicare-approved amount after you meet your Part B deductible.

If your friend received a preventive mammogram and you received a diagnostic mammogram, this might explain why you were responsible for cost sharing while she was not. If, however, your mammogram was a preventive service (you had no prior symptoms and you meet all the coverage criteria for the service), there are a few other reasons you might have had costs when your friend did not:

• You might have seen a provider who did not accept Medicare assignment. A provider who accepts assignment agrees to take Medicare’s approved amount as full payment, and not to bill you for anything more than the Part B deductible or coinsurance charge. If you saw a provider who did not accept assignment, they may have billed you for more.
• Depending on where you received your mammogram, you might be responsible for a separate facility fee.
• Your provider may have made a diagnosis during the visit or conducted additional tests or procedures. If you were receiving a preventive mammogram, but your doctor provided diagnostic services at the same time, you are responsible for cost sharing related to those services.

If, after reviewing this information, you think you have been inappropriately charged for this service, you should contact your health care provider. Some providers are not familiar with the full list of Medicare-covered preventive services, and they may have made a simple mistake due to their lack of knowledge about the benefits. If you are unable to resolve the problem by contacting your provider, contact your local State Health Insurance Program (SHIP) and a counselor will help you. Visit www.shiptacenter.org or call 877-839-2675 to contact your SHIP.

-Marci