What you need to know about your Medicare Advantage OB/GYN coverage*
Posted on March 2, 2016
Have you recently transitioned to a Health New England Medicare Advantage plan, or are you thinking about joining one of our plans? If so, we would like to call your attention to an important benefit related to OB/GYN office visits that may differ from coverage you had with a previous plan.
Many employer plans cover an annual OB/GYN visit for a pelvic exam and Pap test. However, coverage under a Medicare Advantage plan is different. Health New England’s Medicare Advantage plans follow Medicare guidelines. Under our Medicare Advantage plans, the OB/GYN benefit is covered as follows:
- For all women, Pap tests and pelvic exams are covered once every 24 months plus one day from your last exam. When services are provided by an in-plan provider, no copay applies.
- If you are at high risk for cervical cancer or have had an abnormal Pap test and are of childbearing age, you are covered for one Pap test every 12 months.
- Additional tests or exams are covered when medically necessary; copay may apply.
If your OB/GYN’s office calls or sends you a reminder about your annual visit, please verify when your last appointment was before you make this appointment. Let your provider know that you are only covered for a preventive OB/GYN visit once every 24 months plus one day from your last appointment.
If your provider thinks you should be seen on an annual basis due to a medical condition, the plan will cover these medically necessary visits, which should be billed as medical, not as an annual routine preventive exam. You would still be responsible for your applicable copay.
For new Health New England Medicare Advantage plan members, this benefit would begin with your first preventive OB/GYN visit under your new Medicare Advantage plan. For example, if you are new to our plan as of October 1, 2015, and had your preventive OB/GYN visit on November 1, 2015, the next time you would be eligible for a preventive OB/GYN visit would be November 2, 2017.
If you have any questions regarding this information, please feel free to contact us at (413) 787-0010 or toll-free at (877) 443-3314. TTY/TDD users should call (800) 439-2370. Our Medicare Advantage Member Services Representatives will be happy to assist you.
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*Health New England Medicare Advantage is an HMO Plan with a Medicare contract. Enrollment in Health New England Medicare Advantage depends on contract renewal. This information is not a complete description of benefits. Contact the plan for more information. Limitations, copays and restrictions may apply. Benefits, premiums and/or copays/coinsurance may change on January 1 of each year. You must continue to pay your Medicare Part B premium.
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