Medicare Rules Letter

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MUST READ PRIOR TO YOUR VISIT – Annual Exam NOT covered by Medicare

Dear Medicare patient:

THIS NOTICE CONTAINS DETAILED INFORMATION REGARDING “YOUR PERSONAL FINANCIAL RESPONSIBILITY” TOWARD YOUR ANNUAL EXAM 2023 THOUGH YOU HAVE MEDICARE AND POSSIBLE SECONDARY INSURANCE COVERAGE

Medicare deductible for 2023 is $226.00

It is extremely important that you read and understand this notice before your visit and be prepared to meet your responsibility at the time of the visit.

At your “Comprehensive Preventative Medicine Visit” (annual exam) several things will be done. We ask you about your history and any problems that you may be experiencing. Your exam may include several items including blood pressure, examining your thyroid gland, breasts, abdomen, pelvic organs, Pap Smear, and rectal exam. The provider will then counsel you regarding any testing that may be advisable for you, as well as any preventative measures that may be advisable such as calcium supplements, exercise, etc. Annual exams are not covered by Medicare. Medicare covers certain portions of the exam that are categorized as screening services (pelvic exam, breast exam, and obtaining a Pap Smear) However, Medicare only pays for these screening services once every 2 years, unless you meet certain criteria that place you in a high-risk category.

These factors are listed below:

• Onset of sexual activity before the age of 16
• Have 5 or more sexual partners in your lifetime
• Have history of sexually transmitted disease
• Have not had 3 negative Pap Smears
• Are HIV positive
• Were exposed when your mother was pregnant to Diethylstilbestrol (DES)

Please let your Provider know if any of these factors exist so the screening services can be covered on an annual basis. In this case, the entire exam is still not covered.

Fees WILL be collected at the front desk on the date of your exam:

In the year that Medicare PAYS for screening services (pelvic exam and Pap Smear), it does not cover the cost of the remainder of the exam and consultation.

In the year Medicare DOES NOT PAY for the screening services, the cost of the Comprehensive Preventative Medicine Visit (Annual Gyn exam) one visit out of every two years is as follows:

Patient out-of-pocket responsibility with or without coinsurance:

Established patient $208.00 New Patient: $232.00

Please take note: Anything your insurance does not pay for, you are responsible to pay.

A Pap Smear can only be done in association with an annual exam (Comprehensive Preventative Medicine Visit). If you are only visiting the office for a problem, a Pap Smear cannot be done at the time of that visit. You will need to return for a well-woman visit (Comprehensive Preventative Medicine Visit) and Pap Smear.

Please note* Medicare does pay for an annual Mammogram once a year to the date.

As always, we are honored to have the privilege of caring for you. We must do this within the guidelines that are established by Medicare.  Changes can only be made by contacting your Legislator/Congressman. Please do not ask us to try and find a way for your visit to be covered by Medicare. Not following the rules is a violation of Federal Law. It is illegal and has severe penalties against your doctor/provider. Thank you again for trusting us with your care and please keep in mind that we do not make the rules.  We are obligated, however, to follow them.

Medicare began paying for special Annual Wellness Visits on January 1, 2011. These services are intended to help you develop a plan for addressing ongoing medical problems. In general, these services should be performed by your primary care provider. The services you normally receive in our office are not included in the Annual Wellness Visit. Specifically, the new Annual Wellness Visit does not include pelvic and breast examinations or the collections of Pap smears. The Medicare Annual Wellness Visit is geared to address your ongoing general medical needs and not specific gynecological problems or concerns.

The Medicare Annual Wellness Visits should be available to you through your Primary Care Provider. As always, we are happy to see you for any gynecologic problems you may have, including the ongoing management of menopausal symptoms, bladder problems, issues with pelvic pain, prolapse, osteoporosis, breast concerns, or other gynecological related conditions. Your normal deductible and co-insurance will apply to these problem-oriented services.

*For more information regarding the above you can visit the website for The American Congress of Obstetricians and Gynecologists at www.acog.org