Medicare Ob-Gyn: Does Medicare Cover Gynecological Exams?
- Better anticipate the costs of your medical care by learning the facts about Medicare and gynecological exams. Find out what's usually covered and what's not.
Reproductive health is a vital part of women's health at every stage of life. Even after menopause, most women still benefit from regular checkups with gynecologists. Understanding the rules regarding Medicare ob-gyn coverage helps you make informed decisions regarding your healthcare.
Does Medicare Cover Gynecologist Visits?
Whether Medicare covers gynecologist visits depends on what services you receive at your doctor's office. Typically, a routine gynecologist visit involves a pelvic exam, where the doctor checks your reproductive organs with a manual and visual exam to assess your reproductive health.
Medicare typically covers one pelvic exam every 24 months, provided you see a gynecologist who accepts Medicare. Women who are at high risk for cervical or vaginal cancer and premenopausal women who have had an abnormal Pap test during the previous 36 months can usually receive coverage for annual pelvic exams under Medicare rules.
Some other tests, examinations and procedures that your gynecologist performs in the office may not be covered. You can consult your Medicare plan provider to find out if a particular service is covered.
Does Medicare Pay for Pap Smears?
Cervical cancer is the fourth most common cancer among women in the world. A Pap test checks for abnormal cells in the cervix and vagina to help diagnose cervical cancer. Because outcomes for cancer treatment are better when the disease is caught early, doctors typically recommend regular Pap tests for screening purposes.
Medicare typically covers one Pap smear every 24 months. Women at high risk for cervical or vaginal cancer and women of child-bearing age who had at least one abnormal pap smear during the previous 3 years usually qualify for annual Pap smears under Medicare.
Does Medicare Pay for Pap Smears If You're Over 65?
Yes, Medicare covers one Pap smear per 24 months for all women, regardless of age. Medicare does treat women over the age of 65 differently when it comes to more frequent Pap smears. If you're at an increased risk of cervical or vaginal cancer, Medicare is likely to cover an annual Pap smear. However, if you aren't at an increased risk, Medicare usually won't cover yearly Pap smears — even if you had abnormal test results during the previous 36 months.
Risk factors for cervical cancer include:
- Having many sexual partners
- Having sex at an early age
- STIs like chlamydia, gonorrhea, syphilis and HIV/AIDS
- Compromised immune system
If your doctor believes you're at an increased risk, they will likely need to explain to Medicare why. Then, Medicare will determine whether to approve you for annual Pap smears.
Does Medicare Pay for an HPV Test After 65?
A sexually transmitted disease called the human papillomavirus (HPV) can cause some types of cervical cancer. Health experts generally recommend that women of child-bearing age be tested for HPV. Medicare pays for HPV tests once every 5 years for women who are between the ages of 30 and 65 and who don't have any symptoms of HPV. Normally, Medicare doesn't cover HPV tests for women over the age of 65.
Does Medicare Cover a Breast Exam?
During a breast exam, a doctor examines your breasts with their hands to feel for any lumps or abnormalities that may indicate breast cancer. Under rules regarding Medicare for gynecological exams, the breast exam is considered part of the pelvic exam. As a result, Medicare usually covers one breast exam every 24 months.
Does Medicare Pay for a Mammogram?
A mammogram is an imaging test that detects abnormalities in breast tissue. Doctors use the test to diagnose breast cancer. Medicare will usually pay for:
- One baseline mammogram for women ages 35 to 39
- Yearly mammograms for breast cancer screening for women age 40 and over
If your doctor believes you may have breast cancer, Medicare may cover more than one mammogram per year so that your doctor can diagnose the condition or monitor your health. This type of mammogram is called a diagnostic mammogram.
How Much Do You Pay With Medicare for Gynecological Exams?
How much you pay with Medicare for gynecological exams depends on what type of Medicare you have and what services are being performed.
Medicare Part B
If you have Original Medicare, Medicare Part B is the portion responsible for covering gynecological exams. The amount you can expect to pay for covered services is:
- Pelvic exam: Typically free
- Pap smear: Typically free
- HPV test: Typically free
- Breast exam: Typically free
- Screening mammogram: Typically free
- Diagnostic mammogram: Usually 20% of the cost with Medicare paying the remaining 80%
- Other covered gynecological services: Usually 20% of the cost with Medicare paying the remaining 80%
For this pricing to apply, you must choose a doctor who accepts Medicare and your care must fall under Medicare guidelines. For example, Medicare doesn't cover HPV tests for women over 65, so older adults would need to pay out of pocket for the testing.
Medicare Part C
Medicare Advantage or Medicare Part C plans must cover at least what Medicare Part B does. As a result, most plans will cover the services outlined above. However, you may need to pay a copay or coinsurance for a pelvic exam, Pap smear, breast exam or mammogram. Your plan may also cover more frequent gynecological exams than Original Medicare and provide coverage for services not usually covered under Medicare Part B. Because each Medicare Advantage plan has its own rules, check with your plan provider for more information regarding coverage for gynecological care.