Under the Affordable Care Act, a mammogram is considered preventive care when it is a routine screening for a woman with no symptoms, and most private health plans must cover it with no copay, no coinsurance, and no deductible. That protection comes from the U.S. Preventive Services Task Force giving screening mammography a Grade B rating for women aged 40 through 74, which federal law then translates into a zero-cost-sharing requirement for non-grandfathered plans.1Office of the Law Revision Counsel. 42 USC 300gg-13 – Coverage of Preventive Health Services2United States Preventive Services Taskforce. Recommendation: Breast Cancer: Screening Whether you actually walk out owing nothing depends on your plan type, whether the facility and the radiologist are in your network, and whether the exam stays classified as a screening.
Screening vs. Diagnostic: The Distinction That Decides Your Bill
The ACA’s free-mammogram rule only covers screening mammograms. A screening is routine monitoring with no specific area of concern. You have no lump, no breast pain, no nipple discharge, no unusual skin changes, and no abnormal result on a previous exam that needs a closer look.3Centers for Disease Control and Prevention. Screening for Breast Cancer The imaging takes standard views of each breast to catch early changes before you or your doctor can see or feel them.
A diagnostic mammogram investigates a specific problem. It uses additional or magnified views focused on a particular area, gets billed under different codes, and does not fall under the ACA’s zero-cost-sharing requirement. Your normal deductible, copay, or coinsurance applies.
About 10% of screening mammograms result in a callback for more imaging. That follow-up is billed as diagnostic even though a routine screening triggered it. The original screening stays free; the follow-up views do not.
Who Qualifies and How Often
The current USPSTF recommendation, updated in April 2024, is biennial screening mammography for all women aged 40 to 74.2United States Preventive Services Taskforce. Recommendation: Breast Cancer: Screening That is a change from the previous guideline, which had left screening in your 40s as an individual decision and started routine biennial screening at 50. Now biennial screening from age 40 is the universal recommendation, and it is the standard your plan must follow at no cost.
The USPSTF finds both traditional 2D digital mammography and 3D breast tomosynthesis effective as screening tools, but it has not issued a separate Grade B rating for 3D alone. Because the ACA’s zero-cost rule is tied to those ratings, federal law does not specifically require plans to cover 3D mammograms without cost-sharing. Many insurers include 3D in their standard mammogram benefit at no extra charge, but some apply cost-sharing or a surcharge to the 3D component. A handful of states require full coverage of tomosynthesis; elsewhere, ask your insurer before scheduling. A standard 2D screening is always available to you at zero cost under the federal rule.
When You Can Still Get a Bill
Several common situations knock a mammogram out of the free-preventive category.
Grandfathered Plans
Health plans that existed on or before March 23, 2010, and have not made certain significant changes since then are “grandfathered.” They are exempt from the ACA’s preventive services mandate and are not required to cover screening mammograms at no cost.4HealthCare.gov. Marketplace Options for Grandfathered Health Insurance Plans Their numbers have shrunk since 2010, but some remain. Your plan documents or the insurer’s customer service line will tell you whether yours is grandfathered.
Out-of-Network Providers
The zero-cost-sharing rule generally applies only when you use an in-network provider.5HealthCare.gov. Preventive Health Services If the imaging facility is out-of-network, your plan may make you pay part or all of the cost. Confirm that both the facility and the radiologist reading your images participate in your network before you schedule.
A Screening That Converts Mid-Visit
If the radiologist sees something concerning during your routine screening and takes additional views during the same visit, those extra images are usually billed as diagnostic. The screening portion is still free; the diagnostic portion is billed separately with normal cost-sharing. This surprises a lot of patients who expected one free visit.
Follow-Up Imaging and Procedures
When a screening leads to a callback, whatever comes next, a diagnostic mammogram, a breast ultrasound, an MRI, or a biopsy, is treated as diagnostic care. Your deductible, copay, and coinsurance apply. Costs vary widely by procedure, location, and whether the facility is hospital-based or freestanding. Diagnostic mammograms can run roughly $250 to $1,000, breast ultrasounds roughly $100 to $330, and biopsies add more on top. No federal law currently requires plans to cover diagnostic follow-ups without cost-sharing, though some states have moved to close that gap.
A Separate Office Visit
If the screening mammogram is the primary reason for your visit, your plan cannot tack on a separate charge for the visit itself as long as the preventive service is not billed separately from it.6Centers for Medicare and Medicaid Services. Background: The Affordable Care Acts New Rules on Preventive Care But if your provider addresses other health concerns during the same appointment and bills a separate office visit, you may owe cost-sharing on that.
If You Have Medicare or Medicaid
The ACA rules described above govern private plans. Medicare and Medicaid handle mammograms under their own frameworks.
Medicare Part B covers a screening mammogram once every 12 months at no cost for women 40 and older, plus one baseline mammogram for women aged 35 to 39, provided the doctor accepts Medicare assignment.7Medicare. Medicare and You Handbook 2026 Diagnostic mammograms are not free under Medicare. You pay 20% of the Medicare-approved amount after meeting the Part B annual deductible, which is $283 in 2026.8Centers for Medicare and Medicaid Services. 2026 Medicare Parts A and B Premiums and Deductibles
Medicaid coverage depends on your state. In states that expanded Medicaid under the ACA, expansion enrollees in alternative benefit plans receive USPSTF-recommended preventive services, including screening mammograms, with no cost-sharing.9U.S. Department of Health and Human Services, ASPE. Access to Preventive Services Without Cost-Sharing: Evidence from the Affordable Care Act Traditional Medicaid programs may cover mammograms but are not required to waive cost-sharing. Contact your state Medicaid program or managed care plan to confirm what applies to you.
Surprise Bills from Out-of-Network Radiologists
You can pick an in-network imaging facility and still find out that the radiologist who read your images is out-of-network. The No Surprises Act blocks that provider from balance billing you. They cannot charge you more than your normal in-network cost-sharing, calculated using the median in-network rate for similar services in your area. The protection applies automatically when you receive scheduled care at an in-network facility and were not told in advance that an out-of-network provider would be involved. If you receive a bill that looks like balance billing after an in-network mammogram, that is your basis for disputing it.