Arthritis is a medical condition that may include rheumatoid arthritis, osteoarthritis, gout, fibromyalgia, and more. The different parts of Medicare cover different care options for arthritis.
An estimated 54.4 million American adults have arthritis, according to the Centers for Disease Control and Prevention (CDC).
This article will provide an overview of Medicare coverage for the different services a person with arthritis may need.
It will also look at the extra help options that may be available when paying for arthritis-related care.
We may use a few terms in this piece that can be helpful to understand when selecting the best insurance plan:
- Deductible: This is an annual amount that a person must spend out of pocket within a certain time period before an insurer starts to fund their treatments.
- Coinsurance: This is a percentage of a treatment cost that a person will need to self-fund. For Medicare Part B, this comes to 20%.
- Copayment: This is a fixed dollar amount that an insured person pays when receiving certain treatments. For Medicare, this usually applies to prescription drugs.
Medicare is comprised of several parts, each of which may play a role in paying for arthritis care costs.
Medicare Part A
Part A pays for the costs involved with inpatient hospital stays and skilled nursing care.
This may apply to a person who requires surgical intervention to treat arthritis, such as a total joint replacement.
Medicare Part B
Part B is the Medicare portion that covers outpatient medical costs including doctors’ visits and durable medical equipment (DME).
Medicare will usually cover doctor’s visits related to arthritis, physical therapy, and some DME, such as splints, braces, walkers, or canes.
A person is often required to obtain prior authorization from Medicare before purchasing equipment or pursuing therapy services.
Medicare Advantage (Part C)
Part C is also known as Medicare Advantage. Private insurance companies provide these plans.
Medicare requires all Medicare Advantage insurers to provide at least the same level of coverage as original Medicare (parts A and B), but some companies may offer additional services.
As an example, a Medicare Advantage plan type called a Special Needs plan (SNP) is offered by some companies for those with rheumatoid arthritis, as the plans focus on a person’s unique needs for medications and therapies.
Medicare Part D (Prescription Drug Plan)
Part D, or prescription drug plans (PDPs), provides coverage for prescribed medication.
A person with original Medicare must enroll in a PDP separately, as private insurance companies administer the plans.
Often, Medicare Advantage plans will include coverage for prescribed drugs, so a person will not need to purchase a separate PDP.
Each PDP contains a listing of covered medications called a formulary. The formulary is divided into tiers, which may have different levels of copayments for arthritis medications.
A person with original Medicare may purchase a Medicare supplement plan.
Also known as Medigap, these plans cover some out-of-pocket costs, including copayments, deductibles, coinsurance, and excess charges.
Private insurance companies administer Medigap plans on behalf of Medicare, and they must follow Medicare’s rules.
More than 100 arthritis types exist, but the most common form is osteoarthritis.
Arthritis can cause pain, discomfort, and affect mobility. This can affect a person’s overall quality of life and health.
The following brief explanations cover the major arthritis types that may affect those aged 65 and older.
- Osteoarthritis: Protective cartilage in a person’s joints wears down, causing symptoms that include pain, stiffness, affected range of motion, and swelling.
- Fibromyalgia: Fibromyalgia is a condition that causes pain sensitivity and problems with processing pain. Symptoms include fatigue, widespread pain, depression, anxiety, and problems sleeping.
- Gout: Gout is an arthritis form that causes flare-ups that lead to joint pain. Typically, a person experiences discomfort in one joint, especially the big toe.
- Rheumatoid arthritis: Rheumatoid arthritis is an autoimmune disorder in which the body’s immune system attacks the joints. Symptoms include pain, stiffness, swelling, and tenderness in the joints.
Arthritis treatments vary based on the arthritis type and a person’s specific symptoms.
Medicare requires a person to have a PDP or drug coverage included within their Medicare Advantage policy if they have specific prescribed medication needs.
Drug plans may provide the coverage needed to treat the various forms of arthritis, including arthritic joint pain.
A person with arthritis may need to see a medical specialist for diagnosis and treatments. Examples of a specialist may include a rheumatologist or an orthopedist.
It is usually helpful for a person to check if the specialist accepts Medicare. If they do, the payment may depend on Medicare’s agreed-upon amount and the type of Medicare plan an individual holds, but a high percentage of the cost is typically covered.
Physical therapy services can help a person with arthritis gain strength and enhance mobility.
A person with arthritis may qualify for physical therapy under Part B if a doctor declares the services as medically necessary.
The Part B deductible will apply, as well as the 20% coinsurance for Medicare-approved services.
An individual may require surgical treatment for their arthritis, such as a knee, shoulder, or hip replacement.
If a doctor declares these or other procedures as medically necessary, Medicare may cover surgical treatments.
A person must usually obtain prior authorization from Medicare for these procedures to ensure they are covered.
Some people may also use alternative therapies, such as chiropractic care, pain management, or acupuncture services to treat arthritis.
Medicare has specific rules on how these services are covered, but it is usual for coverage to fall under Part B.
A variety of drug therapies are available to treat arthritis. These depend upon the arthritis type.
Drug therapies include:
- non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen or naproxen sodium
- corticosteroids, such as cortisone or prednisone
- pain medications, such as acetaminophen, hydrocodone, or oxycodone
- disease-modifying anti-rheumatic drugs (DMARDS), such as methotrexate and hydroxychloroquine
An estimated 25% of Medicare beneficiaries with rheumatoid arthritis take these medications, according to an article in the journal Arthritis & Rheumatology.
The authors reviewed 2,737 PDPs through standalone plans and Medicare Advantage. They found all plans covered at least one biologic DMARD, but many required prior authorization from the insurance company before the insurance company would pay for the drug.
The study’s authors found individuals paid between $2,712 and $2,774 for biologic DMARDs before they reached the “catastrophic” phase of prescription drug coverage, at which point prescription drug prices decrease dramatically.
A person may qualify for additional financial support to pay for arthritis treatment costs, and there are several options.
- Extra Help: Extra Help is a program available for assistance with prescription drug coverage. The level of Extra Help is income-based and may change annually.
- Medicaid: Medicaid is a state and federal program that helps people pay for insurance costs. Those eligible may receive help with deductibles and help to pay for medication.
- Medicare savings programs (MSPs): These are state-funded programs that help pay for insurance costs, including medications, premiums, coinsurance, and copayments.
Medicare helps cover multiple aspects of arthritis treatments although copayments, deductibles, and coinsurances still apply.
Many arthritis medications and surgical approaches require prior authorization from Medicare to ensure their costs will be covered.
Additional support is available through programs like Extra Help, Medicaid, and MSPs.
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