WOMEN with

Visiting Your Doctor for a Pap Test, Pelvic Exam, 

and Clinical Breast Exam 

This booklet will help you understand: 

• What is covered in the Original Medicare Plan. 

• What Medicare pays. 

• What you pay. 

CENTERS FOR MEDICARE & MEDICAID SERVICES 

MEDICARE

Women with Medicare

Table of Contents 

Introduction ....................................................................................................2

Pap Test, Pelvic Exam, and Clinical Breast Exam ........................................3

What Medicare Pays ..................................................................3

What You Pay ............................................................................3

Summary of What’s Covered ....................................................4

Example #1......................................................................................................5

Example #2......................................................................................................6

Example #3......................................................................................................7

Keeping a Record ..........................................................................................8

Other Medicare Covered Preventive Services ..........................................9-10

For More Information ..................................................................................11

Words to Know (where words in red are defined) ................................12-13

Disclaimer: This booklet provides a summary of Medicare benefits. It is not a legal document. The 

official Medicare program provisions are contained in the relevant laws, regulations, and rulings. 

1

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Women with Medicare

Introduction 

Medicare covers many preventive services to keep you healthy. These 

services cover exams and tests that check for certain illnesses. This booklet 

will give you information on how the Original Medicare Plan helps pay for 

three preventive services for women: the Pap test, pelvic exam, and clinical 

breast exam. It also explains what you must pay. 

It is important to know that Medicare pays for much of your health care, 

but not all of it. In providing good care, your doctor/health care provider 

may do exams or tests that Medicare does not pay for. Your doctor/health 

care provider may also recommend that you have tests more often than 

Medicare covers them. If this happens, you may have to pay for some or 

all of the costs. Be sure to talk to your doctor/health care provider to find 

out how often you need these exams to stay healthy. 

You will usually get a Pap test, pelvic exam, and clinical breast exam 

during the same office visit. Your doctor/health care provider may give you 

other exams or tests on the same day. The Original Medicare Plan may or 

may not cover these other exams or tests. For example, the Original 

Medicare Plan does not pay for routine physical exams. If you have your 

Pap test, pelvic exam, and clinical breast exam on the same visit as your 

physical exam, Medicare will only cover part of this visit. 

If you are in a Medicare health plan like a Medicare managed care plan 

(HMO) or Private Fee-for-Service plan, you still get all the Medicare 

covered services, including preventive services. Your costs for these 

services will be different from those described in this booklet. Check your 

plan materials for more information. 

Note: In this booklet, you will see some words in red. These words are 

defined at the end of the booklet. 

2 

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Women with Medicare

Pap Test, Pelvic Exam, and Clinical Breast Exam 

What Medicare pays in the Original Medicare Plan: 

Medicare helps pay for a Pap test, pelvic exam, and clinical breast exam 

once every 24 months. 

For some women, Medicare helps pay for a Pap test, pelvic exam, and 

clinical breast exam once every 12 months. This includes women who: 

• Are of an age to have children and have had an abnormal Pap test 

within the past 36 months; or 

• Are at high risk for cervical or vaginal cancer, see box below. 

Medicare considers you at high risk for cervical or vaginal 

cancer if you: 

• 

• 

years; or 

• Are the daughter of a woman who took diethystilbestrol 

(DES) during pregnancy; or 

• 

• 

• 

Your doctor may think you are at high risk for cervical or 

vaginal cancer for other reasons. Medicare will only help 

groups listed above. 

pay for these exams every year if you are in one of the 

Have not had any Pap tests within the last 7 years; or 

Have had less than three normal Pap tests in the last 7 

Began having sexual intercourse before the age of 16; or 

Have had five or more sexual partners in your life; or 

Have had a sexually transmitted disease. 

What you pay: 

• 20% of the Medicare-approved amount for the pelvic exam, clinical breast 

exam, and the collection of the Pap test specimen. 

• Nothing for the laboratory to read your Pap test. 

• No Part B deductible. 

3

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Summary of What’s Covered in the Original Medicare Plan 

What Medicare Covers What You Pay 

Pap Test One Pap test every 24 

months. 

Exception: If you are in one 

of the high risk groups listed 

on page 3, Medicare will 

help pay for a Pap test once 

every 12 months. 

• 20% of the Medicareapproved amount for the 

part of the exam when your 

doctor/health care provider 

collects the specimen. 

• Nothing for the lab Pap test. 

• No Part B deductible for 

this service. 

Pelvic 

Exam/Clinical 

Breast Exam 

One pelvic/clinical breast 

exam every 24 months. 

Exception: If you are in 

one of the groups listed on 

page 3, Medicare will help 

pay for a pelvic exam and 

clinical breast exam once 

every 12 months. 

• 20% of the Medicareapproved amount. 

• No Part B deductible for 

this service. 

Service 

Remember, if you have other exams or tests done on the same day, you may 

have to pay out-of-pocket for some or all of those services. 

The following three examples will show you common situations in which you 

may get a Pap test, pelvic exam, and clinical breast exam. Each example will 

show you what Medicare pays and what you must pay. 

4 

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Women with Medicare

Example #1 

Mrs. Ramos is in the Original Medicare Plan. She feels healthy and is 

visiting her doctor who accepts assignment for a routine physical exam. 

It has been 25 months since her last Pap test, pelvic exam, and clinical 

breast exam. During her visit, the doctor talks with Mrs. Ramos about 

her health, listens to her heart and lungs, and examines her skin. This 

physical exam also includes a Pap test, pelvic exam, and breast exam. 

Mrs. Ramos’ Pap test is sent to a lab for testing. 

Note: This is only an example. Your actual charges, what you pay, and 

the services you get will be different. Also, if you have additional health 

coverage, it may pay some of the costs Medicare doesn’t cover. 

Amount Charged 

This is the amount Mrs. Ramos’ doctor charges for 

this physical exam, including the Pap test collection, 

pelvic exam, and breast exam. 

$125 

Medicare-Approved Amount 

This is the amount Medicare approves. Medicare 

approves a certain amount for covered services only. 

In this case, Mrs. Ramos’ Pap test, pelvic exam, and 

breast exam are covered services. The rest of her 

physical exam is not covered. 

$75 

Medicare Pays 

Medicare pays 80% of the Medicare-approved amount. 

(80% of $75 = $60) 

$60 

Mrs. Ramos Pays 

Mrs. Ramos must pay 20% of the Medicare-approved 

amount. (20% of $75 = $15) 

She must also pay for the part of her visit not covered 

by Medicare. ($125 - $75 = $50) 

($15 + $50 = $65) 

$65 

In this example, Mrs. Ramos does not have to pay the Part B deductible. 

She also does not have to pay the charge for the lab to read her Pap test. 

5 For more information, visit www.medicare.gov 
Women with Medicare 

Example #2 

Ms. Adams is in the Original Medicare Plan. She goes to see her 

doctor because she has back pain. Her doctor accepts assignment. 

It is also time for her to get a Pap test, pelvic exam, and clinical 

breast exam. During her visit, her doctor checks her back, 

examines her breasts, and does a Pap test and pelvic exam. Ms. 

Adams’ Pap test is sent to a lab for testing. 

Note: This is only an example. Your actual charges, what you 

pay, and the services you get will be different. Also, if you have 

additional health coverage, it may pay some of the costs Medicare 

doesn’t cover. 

Amount Charged $160

This is the total amount Ms. Adams’ doctor charges 

for this visit. Adams’ back exam, Pap test 

collection, pelvic exam, and breast exam are included 

in this charge. 

Medicare-Approved Amount 

This is the amount Medicare approves. 

approves a certain amount for covered services only. 

In this case, Ms. Adams’ back exam, Pap test, pelvic 

exam, and breast exam are covered services. 

$135 

Medicare Pays 

Medicare pays 80% of the Medicare-approved amount. 

(80% of $135 = $108) 

$108 

Ms. Adams Pays 

Ms. Adams has already paid her Part B deductible* 

($100 in 2001). 

She now must pay 20% of the Medicare-approved 

amount. 

$27 

Ms. 

Medicare 

(20% of $135 = $27) 

*The Part B deductible is not required for most preventive services like the 

Pap test. Part of Ms. Adams’ visit includes an exam of her back. This type of 

exam is not a preventive service and requires payment of the Part B 

deductible before Medicare will pay its share. 

Ms. Adams’ does not have to pay the charge for the lab to read her Pap test. 

6 

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Women with Medicare 

Example #3 

Ms. Lewis is in the Original Medicare Plan. She does not remember 

exactly when she had her last Pap test, pelvic exam, and clinical 

breast exam. She goes in to see her doctor who accepts assignment 

to get the tests done. When the bill is processed, Ms. Lewis’ records 

show that it has been less than 24 months since she last had these 

tests and Medicare will not cover the costs. Ms. Lewis is not in any 

of the high risk groups that would let Medicare cover these exams 

every 12 months. 

Note: This is only an example. Your actual charges, what you pay, 

and the services you get will be different. Also, if you have 

additional health coverage, it may pay some of the costs Medicare 

doesn’t cover. 

Amount Charged $150

Ms. Lewis’ doctor charges $100 for the office visit. 

The lab, where her Pap test is sent charges $50. 

($100 + $50 = $150) 

Medicare-Approved Amount 

This is the amount Medicare approves. 

approves a certain amount for covered services only. 

In this case, Ms. Lewis’ Pap test, pelvic exam, and 

breast exam are not covered because it has not been 

24 months since she last had them and she is not at 

high risk. 

$0 

Medicare Pays 

Medicare does not pay for any of the charges because 

it has already paid for these same services less than 

$150 

visit and lab test. 

24 months ago. 

$0 

Ms. Lewis Pays 

Ms. Lewis must pay the entire char

Medicare 

ge for her doctor’s 

7 

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Women with Medicare

Keeping a Record 

It can be hard to remember when you had your last Pap test, pelvic exam, 

and clinical breast exam. It can be even harder to remember the dates if 

you move or get care from more than one doctor/health care provider. If 

you get these exams more often than Medicare covers, you may have to pay 

for it even if it is only a couple of months early. 

You can help yourself by keeping a record of your exams. Use the space 

below. Make sure you write down the date of your visit, your 

doctor’s/health care provider’s name, and the services you had done. 

You may want to make a copy of this page in case you need more space. 

Date of Visit Doctor’s/Health Care 

Provider’s Name 

What was done at visit 

(Pap test, pelvic exam, 

clinical breast exam) 

Results 

8 

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Women with Medicare 

Other Medicare Covered Preventive Services 

Medicare covers other preventive services that are important for your health.

You may have to go to a different health care provider or somewhere other than your

doctor’s office to get these services.

Who is Covered What You Pay

Colorectal Cancer Screening: 

• Fecal Occult Blood Test -

Once every 12 months. 

• Flexible Sigmoidoscopy -

Once every 48 months. 

• Colonoscopy - Once every 24 

months if you are at high risk 

for colon cancer. If you are 

not at high risk for colon cancer, 

once every 10 years (or 48 

months after a screening flexible 

sigmoidoscopy). 

• Barium Enema - Doctor can 

use this instead of a flexible 

sigmoidoscopy or colonoscopy. 

All people with 

Medicare age 50 and 

older. , there 

is no minimum age 

for having a 

colonoscopy or a 

barium enema instead 

of a colonoscopy. 

Nothing for the fecal occult 

blood test. 

For all other tests, 20% of the 

Medicare-approved amount 

or a set copayment amount 

after you pay the yearly Part 

B deductible ($100 in 2002). 

For flexible sigmoidoscopy 

or colonoscopy you pay 25% 

of the Medicare-approved 

amount if the test is done in 

an ambulatory surgical center 

or hospital outpatient 

department. 

Mammogram Screening: 

Once every 12 months. 

Medicare also covers new 

digital technologies for 

mammogram screening. 

All women with 

Medicare age 40 

and older. 

Women between the 

ages of 35 and 39 

can get one baseline 

mammogram. 

20% of the Medicare-approved 

amount. 

You do not have to pay 

the Part B deductible for 

this service. 

Service 

However

9

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Women with Medicare

Other Medicare Covered Preventive Services (continued)

Shots (vaccinations): 

Flu Shot - Once a year in the fall 

or winter. 

Pneumoccocal Pneumonia Shot -

One shot may be all you ever 

need. Ask your doctor. 

Hepatitis B Shot 

Bone Mass Measurements: 

Varies with your health status. 

Certain people at risk 

for losing bone mass 

including women with 

low levels of the female 

hormone estrogen, and 

people who have had 

broken bones in the 

past, or who are already 

being treated for 

osteoporosis.* 

20% of the Medicareapproved amount or a set 

copayment amount after you 

pay the yearly Part B 

deductible ($100 in 2002). 

Glaucoma Screening: 

Once every 12 months, starting 

January 1, 2002. Must be done 

or supervised by an eye doctor 

who is legally allowed to do this 

service in your state. 

People at high risk for 

glaucoma, including 

people with diabetes 

or a family history of 

glaucoma. 

Nothing for flu and pneumonia 

shots if the health care provider 

accepts assignment. 

For Hepatitis B shots, 20% of 

the Medicare-approved amount 

or a copayment amount after 

you pay the yearly Part B 

deductible ($100 in 2002). 

All people with 

Medicare. 

All people with 

Medicare. 

People at medium to 

high risk for Hepatitis B. 

Service Who is Covered What You Pay

20% of the Medicareapproved amount after you 

pay the yearly Part B 

deductible ($100 in 2002). 

* For more information about bone mass measurements, look at www.medicare.gov on the 

web and select “Frequently Asked Questions.” Or, call 1-800-MEDICARE 

(1-800-633-4227). TTY users should call 1-877-486-2048. 

For more information, call 1-800-MEDICARE (1-800-633-4227)

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Women with Medicare

For More Information 

You can look at www.medicare.gov, on the web to read, print, or 

order booklets. 

You may find the following booklets helpful: 

Pap Tests for Older Women: A Healthy Habit for Life 

(CMS Pub. No. 99914) – This brochure answers commonly asked 

questions about Pap tests. 

Medicare Preventive Services...To Help Keep You Healthy 

(CMS Pub. No. 10110) – This brochure gives information on preventive 

services covered by Medicare. 

Medicare & You (CMS Pub. No. 10050) – This handbook gives basic 

information about Medicare coverage and benefits, health plan choices, 

rights and protections, and more. 

Medicare and Other Health Benefits: Your Guide to Who Pays First 

(CMS Pub. No. 02179) – This booklet explains how Medicare works 

with other types of health insurance, and who pays first. 

You can also call 1-800-MEDICARE (1-800-633-4227) to get a free 

copy of the booklet you want. Have the publication number ready when 

you call. TTY users should call 1-877-486-2048. 

11 For more information, visit www.medicare.gov 
Women with Medicare

Words To Know 

Assignment - In the Original Medicare Health Care Provider - A person who is 

Plan, this means a doctor agrees to trained and licensed to give health care. 

accept Medicare’s fee as full payment. Also, a place that is licensed to give 

If you are in the Original Medicare Plan, health care. Doctors, nurses, and 

it can save you money if your doctor hospitals are examples of health care 

accepts assignment. You still pay your providers. 

share of the cost of the doctor visit. 

Medicare-Approved Amount - The fee 

Clinical Breast Exam - An exam by your Medicare sets for a covered medical 

doctor/health care provider to check for service. This is the amount a doctor or 

breast cancer by feeling and looking at supplier is paid by you and Medicare for 

your breasts. This exam is not the same a service or supply. It may be less than 

as a mammogram and is usually done in the normal amount charged by a doctor 

the doctor’s office during your Pap test or supplier. The approved amount is 

and pelvic exam. sometimes called the “Approved 

Charge.” 

Copayment - In some Medicare health 

plans, the amount that you pay for each Medicare Managed Care Plan - These are 

medical service you get, like a doctor health care choices in some areas of the 

visit. A copayment is usually a set country. In most plans, you can only go 

amount you pay for a service. For to doctors, specialists, or hospitals on the 

example, this could be $5 or $10 for a plan’s list. Plans must cover all Medicare 

doctor visit. Copayments are also used Part A and Part B health care. Some plans 

for some hospital outpatient services in cover extras, like prescription drugs. Your 

the Original Medicare Plan. costs may be lower than in the Original 

Medicare Plan. 

Deductible - The amount you must pay

for health care, before Medicare begins Original Medicare Plan - A pay-per-visit

to pay, either each benefit period for health plan that lets you go to any doctor,

Part A, or each year for Part B. These hospital, or other health care provider

amounts can change every year. who accepts Medicare. You must pay the

deductible. Medicare pays its share of the 

Diethylstilbestrol (DES) - A drug given Medicare-approved amount, and you pay

to pregnant women from the early 1940s your share (coinsurance). The Original

until 1971 to help with common Medicare Plan has two parts: problems during pregnancy. The drug Part A (hospital insurance) and has been linked to cancer of the cervix

or vagina in women whose mother took Part B (medical insurance). 

the drug while pregnant. 

12

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Women with Medicare

Words To Know (continued)

Pap Test - A test to check for cancer of the 

cervix, the opening to a woman’s womb. 

It is done by removing cells from the 

cervix. The cells are then prepared so they 

can be seen under a microscope. 

Pelvic Exam - An exam to check if internal 

female organs are normal by feeling their 

shape and size. 

Preventive Services - Health care to keep 

you healthy or to prevent illness. For 

example, Pap tests, pelvic exams, yearly 

mammograms, and flu shots. 

Private Fee-for-Service Plan - A private 

insurance plan that accepts Medicare 

beneficiaries. You may go to any doctor or 

hospital you want. The insurance plan, 

rather than the Medicare program, decides 

how much you pay for the services you 

get. You may pay more for Medicare 

covered benefits. You may have extra 

benefits the Original Medicare Plan does 

not cover. 
U.S. DEPARTMENT OF

HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

7500 Security Boulevard 

Baltimore, Maryland 21244-1850 

Official Business

Penalty for Private Use, $300

Publication No. CMS - 02248

Revised April 2002

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Select "Publications." Or, call 1-800-MEDICARE (1-800-633-4227. 

TTY and ask for a free copy of this booklet. TTY users should call 

1-877-486-2048.