Here are two situations I reviewed recently.
A 74-year-old man got a bill for his colonoscopy. He thought this was supposed to be a free procedure.
A 71-year-old woman has never paid for a mammogram since she has been on Medicare. But she discovered she has to pay for the last one.
These individuals received diagnostic, not screening, tests and the differences can be significant. Here’s what Medicare beneficiaries need to know.
Screenings
A screening is a medical test performed on asymptomatic individuals to assess the likelihood that they have a particular disease, with the goal of preventing illness or death from that disease.
Medicare covers over 20 screenings as part of preventive services. Some of the more common tests screen for:
- breast cancer
- cardiovascular disease
- cervical cancer
- colorectal cancer
- diabetes
- glaucoma
- lung cancer
- prostate cancer.
Each screening test has its own coverage criteria. For example, prostate cancer screening is done once every 12 months for men who are at least 50 years old. It consists of a digital rectal examination and prostate specific antigen (PSA) blood test. Medicare covers an annual lung cancer screening for asymptomatic individuals who smoked at least one pack a day for 20 years and may or may not have quit.
There is no charge for most screenings if they meet the specific criteria. However, those with Original Medicare must see healthcare providers who accept Medicare assignment. Medicare Advantage members need to see in-network providers.
Diagnostic Tests
A diagnostic test is a medical procedure used when symptoms suggest an individual may have some underlying medical condition. This test can help plan and evaluate treatment and determine a prognosis. A high PSA or a spot on the lung identified during a screening can prompt further testing to determine a diagnosis.
Diagnostic tests can result in a bill. For Original Medicare beneficiaries, most tests are subject to the annual Part B deductible ($537 in 2025) and a 20% coinsurance. The Medicare Advantage plan determines the charge, usually a copayment. In some situations, the plan may require prior authorization.
Back to the two situations that started this post.
The man’s colonoscopy started off as a screening test; however, the physician likely found something that appeared abnormal, removed some polyps and took a biopsy to determine whether there is an underlying condition. That turned the screening procedure into a diagnostic test. He’s responsible for the designated cost sharing.
The woman had to pay for the mammogram because her physician found a palpable lump. A diagnostic mammogram takes more pictures to make an accurate diagnosis.
Quick Points
Screening: No signs or symptoms.
Diagnostic test: Signs and symptoms are present, even if not apparent to the individual.
Screening: To detect a potential health issue.
Diagnostic test: To confirm a diagnosis.
Screening: Generally no cost to the beneficiary but there are exceptions. One example is prostate screening. There is no cost for the PSA test but the digital rectal exam is subject to Part B cost sharing.
Diagnostic test: For Original Medicare, the Part B deductible and 20% coinsurance apply. A Medigap policy (Medicare supplement insurance) can help with these costs. Medicare Advantage members will pay what the plan charges. There can also be exceptions, as for a colonoscopy. The Part B deductible does not apply and the coinsurance is 15%.
Find out what Medicare covers here and talk with your physician or plan, as necessary. A few simple questions asked before such procedures will keep you from feeling scammed afterward.
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