This post is for all you baby boomers out there who are enrolling into Medicare after having seen your gyn every year since college for an annual exam, and for all you Medicare veterans coming to my practice for the first time since your previous doctor retired. There’s something you need to know –
Medicare only pays for routine breast and pelvic exams and pap smears every 2 years.
It’s true. Here it is, from Medicare’s web site –
Medicare helps pay for a Pap test, pelvic exam, and clinical breast exam once every 24 months.
Most women don’t need a routine pap smear every year. So I’m happy to have you forgo that testing on an annual basis. In fact, if your paps have always been normal, we can even go 3 years between paps.
But I still recommend you have a breast exam every year, and a pelvic if you still have all those parts.
What if I’m high risk?
If you are high risk for cervical cancer (see below for the definition of high risk), you get a pap every year.
But if your paps have always been normal, and you see me for only a routine check up less than 2 years since your last routine check up, Medicare just won’t pay.
What About Problem Visits?
Now, if you a medical problem, Medicare will almost always pay for your visit. So don’t be afraid to come in if, for example, you have a urinary tract infection. Or a yeast infection. Or have a pessary, osteoporosis, breast cancer, abnormal paps, abnormal bleeding or are on hormone replacement and you need to come in more often than once every two years. We have a diagnosis code to support the medical necessity of those visits, and we’ll all be fine.
In fact, if you come to see me for a “check-up”, but also have other problems that we deal with on that visit, I can “carve out” the portion of the visit that medicare will pay from the preventive part they won’t – so you won’t get stuck with the whole bill.
The ABN (Advance Beneficiary Notice)
If you’re here for preventive services, my staff will ask you to sign a form called an ABN, or Advanced Benificiary Notice. This is to prove to Medicare that we informed you which services were not covered and that you agreed to pay for them if Medicare won’t.
If we don’t have the signed ABN in your chart, we can’t bill you, so please understand when we ask you to fill one out. Every single year.
If, after reading the ABN, you decide to forgo the preventive services, that is absolutely your choice. We’ll happily see you next year for these services.
What about your secondary insurance?
Good question. You may have a secondary insurance that will pick up what Medicare pays. On the other hand, your secondary may not pick up the uncovered portion of your visit. Since everyone’s plan is different, that part is up to you to figure out.
Apologies
I’m really sorry about this, but there is absolutely nothing I can do. I can’t make up a code to get your visit covered if it is not.
And I really don’t know how your last doctor got Medicare to pay for you to see him every 6 months for the past 10 years when you don’t have any gyn problems.
I only know that these are the rules, and I have to play by them.
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Read Medicare’s Information Booklet for Women
High Risk Definition: You are at increased risk for cervical cancer, according to Medicare’s guidelines, if you have not had a pap for 7 years or have not had 3 normal paps in a row. Also, if you started having sex before age 16, have had more than 5 lifetime sexual partners or an STD, or are a DES-daughter, you get a pap every year.
So, finally, it will pay off to be a DES-daughter. Will I need to prove that I am a DES-daughter or is it enough that it is noted in my chart? Am I then eligible for a “complete” annual exam? Thanks for letting us know about this situation.
Anonymous-
As long as it is in your chart, that should be enought.
All new Medicare enrolles are eligible for a “welcome to Medicare” complete physical, which is separate from the pap.
All your DES gets you is a pap, pelvic and breast exam. It does not include the rest of a complete physical.
See the Booklet I referenced at the end of the post. It is a very good resource. I’d like to order some for my patients, but unfortunately, it’s only available on the web.
Thanks for visiting!
I think I’d be more worried about this if I thought Medicare and I would last long enough for me to get there.
But, a quick question: so Medicare doesn’t cover physicals, but focuses on problems (ongoing, I gather) and such? Does that mean there’s a level of self-diagnosis to getting care? (Say, for example, that a woman at the initial physical doesn’t have high blood pressure, but ten years later, she does. How’d she know? If at the gyn thing, then how would a man know?)
Bardiac- good question. How can one diagnose something that is without sympotms? I guess Medicare figures once every two years is good enough for that sort of tnhing. Or that we docs will pick up these things on the fly as we see patients for other problems.We do after all, try to look at the whole patient. Even if we’re not getting paid to do so. Which explains why I threw in a breast exam for free for my medicare patient who came today for abdominal pain on her “off year” for preventive services.
TBTAM, I am really confused. Medicare will pay for an annual screening MMG, but only a biannual clinical breast exam? This makes no sense since the MMG report states that this is done in conjunction with a breast exam. Considering that MMGs are not 100% accurate how is this permissable? Are there exceptions for high risk patients? Is there any linkage between this lack of coverage and the incidence of breast cancer? This seems very foolhardy.
I think you're all having too many pap smears.
That's a dangerous thing to do…it leads to over-detection and over-treatment.
I was reading an article on cervical screening and it mentioned the average number of smears for a US woman is 55+ in her lifetime. (55!!)
The countries with the lowest rates of cancer and biopsies are Finland and the Netherlands – they have an average of 5-7 tests in total over their lifetime.
Even the prostitutes in the famous Red Light District don't have more frequent smears – no point, it just leads to over-treatment and possible harm.
Pelvic exams are unnecessary in healthy women with no symptoms.
Thankfully, many US doctors are starting to question this very invasive practice….most women would find that exam very confronting.
I'm very pleased it's never even been mentioned to me by one of our doctors.
Women are entitled to live with dignity and bodily autonomy…this over-medicalized approach to women's health is a major negative in the lives of many women.
I hear my US colleagues talk about it…hear the anger, worry and distress it causes…
All of my US colleagues obtain their healthcare in Hong Kong to avoid the medical barriers in the States, preventing access to reliable birth control and treatment for other health problems.
The stories are shocking – being refused the Pill until you agree to full gyn exams (not even recommended in other countries so they can hardly be vitally important to your health)
One friend was refused anti-inflammatory cream for a skin condition until she agreed to a smear – her solicitor sorted out that one very promptly.
I think it's totally unacceptable to coerce women into optional cancer screening or gyn exams.
These tests have risks and are being offered to healthy women…that is why it MUST be the woman's decision to accept that risk. She must provide her informed consent or the Dr is breaking the law and should be held responsible for any negative outcome. (and there are many negative outcomes)
Few doctors would put their hands up for that one!
I think US women are over-examined, over-tested and over-treated to their detriment.
Womanhood is not a disease.