The good news is that early detection–especially through regular mammograms—can dramatically improve survival rates and lead to better treatment outcomes. In fact, mammograms can often spot cancer years before physical symptoms appear, giving individuals more options and more time to act.

Mammograms are one of the most important preventative tools we have.

They’re quick, safe and effective—and getting them regularly is a vital part of staying proactive about your health. But knowing when to schedule a mammogram, and how your health insurance covers it, is just as important as showing up for the appointment.

Understanding your Marketplace plan’s preventive care benefits can help ensure you get the screenings you need—without unexpected costs standing in the way. Here’s what you need to know about mammogram coverage, so you can feel confident about using your benefits to protect your health.

Understanding Mammograms for Breast Cancer Screening

A mammogram is a specialized X-ray of the breast that helps detect early signs of breast cancer—sometimes as much as two to three years before a lump can be felt during a physical exam. By finding cancer early, mammograms give individuals more treatment options and improve the chances of successful outcomes.

Mammograms are quick, often less than 30 minutes. During the screening, a technician carefully positions each breast on a flat surface to capture detailed images from different angles. These images are then reviewed by a radiologist, who looks for unusual changes or early signs of cancer.

Who needs a mammogram?

Mammograms are typically recommended based on a combination of age, family history and personal risk factors. General guidelines from health experts such as the American Cancer Society suggest that women with average risk for breast cancer:

• Start routine screening mammograms between ages 40 and 44.
• Continue screenings every year between age 45 to 54.
• Switch to screening every other year, or continue yearly over the age of 55.

Your doctor will help you determine the best schedule for you, balancing early detection with your unique health needs and preferences.

When are mammograms recommended?

Preventive mammograms are part of routine care even if you feel perfectly healthy and don’t notice any symptoms. They are meant to catch cancer at the earliest, most treatable stage.

However, if you experience any changes in your breasts—such as a new lump, persistent pain, nipple discharge, or changes in the size, shape, or skin of the breast—your provider may order a diagnostic mammogram. Unlike routine screenings, diagnostic mammograms involve more detailed imaging and are used when there’s already a specific concern to investigate.

How are Mammograms Covered by Marketplace Insurance?

Thanks to the Affordable Care Act (ACA), most Marketplace insurance plans are required to cover preventive screening mammograms at no additional cost to you—as long as you visit an in-network provider. This means you typically won’t pay a copay, deductible or coinsurance for your routine breast cancer screenings.

Preventive care is a critical part of staying healthy, and this coverage ensures that important screenings like mammograms are accessible for more people, without financial barriers standing in the way.

However, there’s an important distinction to understand when it comes to how mammograms are billed:

• Preventive mammograms are routine screenings performed when you don’t have any symptoms. These are fully covered when recommended based on your age or risk factors and completed with an in-network provider.
• Diagnostic mammograms are performed when there is a specific concern—like a lump, unusual pain, or an abnormal result from a previous screening. Diagnostic mammograms are generally covered by Marketplace plans, but they may involve out-of-pocket costs such as copays, coinsurance, or your deductible.

How can you tell whether your mammogram will be considered preventive or diagnostic?

• If you’re getting a mammogram simply because it’s time for your scheduled screening (based on your age or risk factors), it’s classified as preventive.
• If you're having a mammogram because of symptoms, a physical finding, or follow-up from a previous mammogram, it’s considered diagnostic.

Understanding this difference is important because it can affect whether you owe anything after the appointment.

Always review your specific Marketplace plan documents and Summary of Benefits (SOB) to know exactly what’s covered—and don’t hesitate to contact you plan’s member services team if you have questions.

How Can I Learn More About No-Cost Preventive Care?

Preventive care—including screening mammograms—is a critical part of staying healthy and catching potential health concerns early. Marketplace health plans are designed to make these services more accessible, but it’s important to understand exactly what your plan covers before you schedule your appointment.

To find out exactly what’s included in your Marketplace health plan’s preventive care benefits:

• Review your plan documents and Summary of Benefits (SOB). Your plan materials will outline which preventive services are covered at no cost, any age-based guidelines, and whether there are specific requirements—like using in-network providers—to qualify for full coverage.
• Check the Healthcare.gov preventive care guidelines. These national standards explain what services are generally covered without cost-sharing, including breast cancer screenings.
• Contact your health insurance provider’s member services team. If you’re not sure whether your upcoming screening will be considered preventive or diagnostic, or you want to confirm provider networks, a quick call to your health plan’s customer service team can help you avoid unexpected costs.

Choosing a Marketplace health plan with strong preventive care benefits puts your health first—and makes it easier to stay proactive without worrying about surprise bills. Regular screenings like mammograms are simple steps that support long-term wellness, giving you peace of mind and empowering you to take charge of your health journey.

When you understand your preventive care coverage, you can make confident decisions about your care—and feel good knowing you’re taking important steps to protect your future.

Questions about Mammogram Coverage with Marketplace Health Insurance