Does Medicare Cover Annual Gynecological Exams?

Medicare is a federal health insurance program for individuals aged 65 or older, younger people with certain disabilities, and those with End-Stage Renal Disease. Many individuals approaching or enrolled in Medicare inquire about coverage for annual gynecological exams. Unlike some private health insurance, Medicare covers preventive care, including gynecological services, through specific screenings and visits rather than a single annual physical.

Medicare Part B Coverage for Preventive Gynecological Services

Original Medicare (Part A and Part B) provides foundational coverage. Medicare Part B covers various outpatient medical services, including preventive care aimed at detecting health problems early. Instead, Part B covers specific preventive services that contribute to overall health, including gynecological well-being.

New Medicare Part B enrollees are eligible for a one-time “Welcome to Medicare” preventive visit within the first 12 months. This visit is not a physical exam but includes a review of medical and social history, a basic health assessment, and a personalized prevention plan, outlining necessary screenings and preventive services. After the first year, individuals can receive an Annual Wellness Visit (AWV) once every 12 months. The AWV updates the personalized prevention plan, conducts a health risk assessment, and reviews current health conditions and prescriptions; it also does not involve a full physical examination.

Medicare Part B specifically covers several key gynecological screenings. Pap tests and pelvic exams, including a clinical breast exam, are covered to screen for cervical and vaginal cancers. These screenings are covered once every 24 months for most individuals. However, annual coverage is provided for those at high risk for cervical or vaginal cancer, or if they are of child-bearing age and had an abnormal Pap test within the past 36 months. Medicare also covers Human Papillomavirus (HPV) tests as part of a Pap test once every five years for individuals aged 30-65 without symptoms.

Screening mammograms are also covered under Medicare Part B for early breast cancer detection. Women aged 40 and older are covered for one screening mammogram every 12 months. Additionally, a baseline mammogram is covered once in a lifetime for women between 35 and 39.

Costs and Coverage Specifics for Preventive Gynecological Services

Understanding cost implications for gynecological services under Medicare Part B requires distinguishing between preventive and diagnostic care. Many Medicare-covered preventive services, such as the “Welcome to Medicare” visit, Annual Wellness Visits, Pap tests, pelvic exams, clinical breast exams, and screening mammograms, are typically covered at 100% of the Medicare-approved amount. This means beneficiaries pay no deductible or coinsurance if the healthcare provider accepts Medicare assignment.

However, if a gynecological visit or test transitions from preventive to diagnostic, the cost-sharing structure changes. A service is diagnostic if it addresses existing symptoms, diagnoses a specific condition, or involves follow-up for an abnormality. For diagnostic services, the standard Medicare Part B deductible of $257 in 2025 applies. After meeting the deductible, beneficiaries are responsible for 20% of the Medicare-approved amount, with Medicare paying the remaining 80%.

For instance, if a screening mammogram reveals a suspicious finding and a diagnostic mammogram is needed, it would be subject to the Part B deductible and 20% coinsurance. Similarly, if a new gynecological symptom is discussed or treated during a preventive visit, that portion may be billed as a separate diagnostic service, incurring typical Part B cost-sharing. Adherence to frequency limitations is important; exceeding covered frequency without medical necessity may result in the service not being fully covered.

How Other Medicare Plans Impact Coverage

Beyond Original Medicare, other plan options can influence how gynecological services are covered and what out-of-pocket costs an individual might incur. Medicare Advantage Plans (Part C) are offered by private insurance companies approved by Medicare. These plans are required to cover at least all the services that Original Medicare Part A and Part B cover, including the preventive gynecological screenings previously discussed.

While Medicare Advantage Plans must provide the same level of coverage as Original Medicare for these preventive services, they often offer additional benefits not covered by Original Medicare, such as vision, dental, or hearing care. However, Medicare Advantage Plans may have different cost-sharing structures, such as copayments or deductibles, and may require beneficiaries to use a network of providers. Individuals with Medicare Advantage Plans should review their specific plan details to understand any potential out-of-pocket expenses or network restrictions.

Medicare Supplement Insurance, or Medigap plans, are designed to work with Original Medicare (Part A and Part B). These plans are sold by private companies and help cover some of the out-of-pocket costs that Original Medicare does not, such as deductibles, coinsurance, and copayments. If a diagnostic gynecological service or follow-up care results in Part B coinsurance or a deductible, a Medigap plan would typically cover part or all of these costs, depending on the specific plan purchased. Medigap plans do not offer additional benefits like routine vision or dental care; their primary purpose is to reduce the financial burden of Original Medicare’s cost-sharing.