Original Medicare provides a comprehensive pulmonary rehabilitation program for a person who has chronic problems with breathing.
Original Medicare includes Part A, which is hospital insurance, and Part B, which is medical insurance. As providers offer the rehabilitation program (PR) in an outpatient setting, rather than in the hospital, the coverage falls under Part B.
This article discusses Medicare coverage and out-of-pocket costs for pulmonary rehabilitation, as well as eligibility requirements for coverage. It then describes the program and explains how a person can find assistance in their area.
Both original Medicare and Medicare Advantage cover up to two 1-hour sessions per day for up to 36 days of pulmonary rehabilitation (PR) for a person with moderate-to-very-severe chronic obstructive pulmonary disease (COPD).
For some individuals, coverage may extend to 72 sessions. Details of coverage are shown below.
In original Medicare, Part B covers the program.
If a person gets the service in a doctor’s office, they pay 20% of the Medicare-approved cost.
When someone gets the service in a hospital outpatient setting, they must also pay the hospital a copay for each session.
Sometimes a doctor may recommend more sessions than Medicare allows. If this happens, a person may have to pay all or part of the cost. This online tool can help a person check costs.
Medigap, which is Medicare supplement insurance, may cover part or all of the coinsurance, deductible, and copay costs associated with PR. A person can check the 10 different plans to find the one that works best for their needs.
Medicare Part D
A person with original Medicare is eligible to buy a Part D plan to get prescription drug coverage. However, Part D does not give coverage for PR.
Medicare Advantage is the alternative to original Medicare and provides all the benefits of Part A and Part B, which include PR coverage.
However, the out-of-pocket costs are different. Costs associated with Advantage plans include monthly premiums, coinsurance, copays, and deductibles. These expenses vary among plans.
Medicare’s requirements for coverage of PR programs are as follows:
- A person must have moderate-to-very-severe breathing conditions.
- A doctor must decide that the rehabilitation is medically necessary and provide a referral to the program.
- The program must comply with Medicare’s documentation requirements.
There are four stages of COPD, ranging from mild to very severe.
Pulmonary rehabilitation (PR) is a program for people with lung conditions that make it hard to breathe, including COPD.
A doctor may also recommend the program for people with other diseases and conditions that affect their breathing, such as:
- muscle-wasting disorders, such as muscular dystrophy, that affect the muscles a person uses to breathe
- cystic fibrosis, which causes a blockage in a person’s airways through a sticky mucus
- a lung disease that causes lung scarring, such as pulmonary fibrosis
A person might also be recommended for PR before and after lung surgery.
Doctors, nurses, physical therapists, and respiratory therapists work together to design a PR program tailored to the needs of each person. The program includes health education and exercises.
Although results vary, a person can expect some or all of the following benefits from the program:
- increased understanding and management of the disease
- improved strength, enabling a more active lifestyle
- reduced symptoms of depression and anxiety
- opportunities for peer support
Before the PR program starts, the healthcare team may ask a person to do one or more of the following tests:
- 6-minute walk test to gauge the capacity for exercise
- pulmonary function test to evaluate breathing
- exercise stress test to measure heart rate, blood pressure, and oxygen level during physical activity
When the program starts, it will include exercise training to build stamina and flexibility. It may also include some of the following:
- breathing techniques, such as yoga, to help alleviate the sense of being out of breath
- instruction in finding easier, energy-saving ways to do everyday tasks
- help to stop smoking
- psychological counseling for emotional problems
- nutritional counseling for optimal health
At the end of the rehabilitation, the healthcare team may retest a person to see how much their breathing has improved.
If someone believes they might benefit from a PR program, they may wish to discuss it with their doctor.
To get more information about the program, a person can contact the American Lung Association Helpline on 1-800-LUNGUSA (1-800-586-4872).
A person may also want to find out more about taking part in a clinical trial.
People with original Medicare may get coverage for pulmonary rehabilitation (PR) through Part B. They will need to pay coinsurance, the annual deductible, and possibly a copay.
Individuals with Medicare Advantage (Part C) also get coverage, but the out-of-pocket costs differ from those of original Medicare.
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