Sexually transmitted infections (STIs) are infections transmitted through sexual contact, such as gonorrhea or syphilis. Screening and counseling may help identify, manage, and treat STIs.
Eligibility
Medicare Part B Part B, also known as medical insurance, is the part of Medicare that covers most medically necessary doctors’ services, preventive care, hospital outpatient care, durable medical equipment (DME), laboratory tests, x-rays, mental health services, and some home health care and ambulance services. covers screening tests for chlamydia, gonorrhea, syphilis, and/ or hepatitis B if you are:
- At high or increased risk of contracting an STI
- Or, pregnant
STI screenings are covered annually if you receive a referral Referrals are authorizations that Medicare Advantage Plans usually require for services not provided by your primary care provider (PCP). For example, Health Maintenance Organizations (HMOs) generally require you to get a referral from your PCP in order to see a specialist or get an eye exam. from your primary care provider (PCP) The primary care provider (PCP) is the doctor or other health care worker who manages your health care and gives you a referral to consult a specialist if you need it. In Medicare Advantage, many Health Maintenance Organizations (HMOs) require you to select a PCP and get their permission or referral before seeing a specialist. Preferred Provider Organizations (PPOs) and Private Fee-for-Service (PFFS) plans do not have this requirement. or at certain times during pregnancy. Your PCP should determine if you are at high or increased risk for STIs while taking your medical history, typically during an Annual Wellness Visit or prenatal visit.
Medicare also covers up to two face-to-face counseling sessions for sexually active adolescents and adults at increased risk for STIs, when they receive a referral from their PCP. These sessions may help prevent STIs by providing education on how to minimize risky sexual behavior. STI counseling should be provided in a primary care setting, such as a doctor’s office.
Note: If you receive STI counseling in an inpatient An inpatient is a patient who has been formally admitted into the hospital by a doctor. Most inpatient care is covered under Medicare Part A (hospital insurance). setting, such as a skilled nursing facility (SNF) Skilled nursing facilities (SNFs) are Medicare-approved facilities that provide short-term post-hospital extended care services. , different costs and coverage rules may apply. Medicare does not cover inpatient STI counseling as a preventive service.
Chlamydia and gonorrhea
Medicare covers screening tests for chlamydia and gonorrhea:
- Annually, if you are a woman at increased risk
- If you are pregnant and are 24 years old or younger (and during your third trimester of pregnancy if you engaged in high-risk sexual behavior after your first test)
- If you are pregnant and are at increased risk for an STI (and during your third trimester of pregnancy if you engaged in high-risk sexual behavior after your first test)
Syphilis
Medicare covers syphilis tests:
- Annually, if you are at risk for STIs
- If you are pregnant, regardless of your risk or age (and during your third trimester of pregnancy if you engaged in high-risk sexual behavior after your first test)
Hepatitis B
Medicare covers a test for hepatitis B at your first prenatal visit if you are pregnant, regardless of your risk or age, and at the time of delivery if you show new or continuing risk factors for STIs.
Costs
If you qualify, Original Medicare Original Medicare, also known as Traditional Medicare, is the fee-for-service health insurance program offered through the federal government, which pays providers directly for the services you receive. Almost all doctors and hospitals in the U.S. accept Original Medicare. covers STI screenings at 100% of the Medicare-approved amount when you receive the service from a participating provider. This means you pay nothing (no deductible or coinsurance). Medicare Advantage Medicare Advantage, also known as Part C, Medicare Private Health Plan, or Medicare Managed Care Plan, allows you to get Medicare coverage from a private health plan that contracts with the federal government. All Medicare Advantage Plans must offer at least the same benefits as Original Medicare (Part A and Part B), but can do so with different rules, costs, and coverage restrictions. Plans typically offer Part D drug coverage as part of Medicare Advantage benefits. Medicare Advantage Plans include Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), Private Fee-for-Service (PFFS) plans, Special Needs Plans (SNPs), and Medicare Medical Savings Accounts (MSAs). Plans are required to cover STI screenings without applying deductibles, copayments, or coinsurance when you see an in-network In-network means part of a private health plan’s network of providers. If you use doctors, hospitals, pharmacies, home health agencies, skilled nursing facilities, and durable medical equipment suppliers that are in your Medicare Advantage Plan or Part D plan’s network, you will generally pay less than if you go to out-of-network providers. provider and meet Medicare’s eligibility requirements for the service.
During the course of your screening, your provider may discover and need to investigate or treat a new or existing problem. This additional care is considered diagnostic, meaning your provider is treating you because of certain symptoms or risk factors. Medicare may bill you for any diagnostic care you receive during a preventive visit.