Without health care coverage, treatment for arthritis can be expensive. Does Medicare cover arthritis treatments, and if so, how?
Arthritis is a common condition that is the result of swelling or inflammation in the joints. There are many different types of the condition — most commonly osteoarthritis or rheumatoid arthritis — with their own causes and management plans.
Whatever the cause, arthritis can greatly impact your mobility and comfort, making it difficult to live with without assistance or making some lifestyle changes. Unfortunately, treatment for chronic conditions like arthritis can become prohibitively expensive. Luckily, there are several ways that Medicare beneficiaries can get assistance with the treatment and management of arthritis.
Arthritis Coverage for Original Medicare
When it comes to Original Medicare, several key medical costs are covered. Generally, arthritis can be treated or managed with a combination of medications and therapies. We’ll discuss the medication side of treatment a little later, but right now, let’s discuss how Medicare helps cover arthritis therapies and other, non-medical treatments.
Arthritis is often treated with a combination of physical therapy, occupational therapy, and lifestyle adjustments. Medicare covers many of these services in some way! Medicare Part B helps cover both outpatient physical therapy and occupational therapy when they’re medically necessary. In these cases, the Part B deductible applies and you’ll pay 20 percent of the approved amount. Medicare can also make a big difference by helping to cover durable medical equipment (DME) you may need. This type of equipment can help mitigate some of the mobility issues that arthritis can cause while you’re managing the condition.
Original Medicare may cover chronic care management services, which can help with arthritis treatment.
Additionally, in some instances, Original Medicare may cover chronic care management services, which can help with arthritis treatment. The requirements for this coverage are that you need to have two or more serious chronic conditions (like arthritis or diabetes) that are expected to last one year or more. Under this coverage, you’ll owe a monthly fee, the Part B deductible, and likely, coinsurance. Finally, if your arthritis progresses to the point where these methods aren’t enough, surgery may become medically necessary. When this happens, Medicare may help cover some form of joint replacement surgery. Specifically, the joint replacement surgery should be at an inpatient health care facility or ambulatory surgery center to be covered. If you’re an inpatient, Medicare Part A will cover the surgery, while Part B covers outpatient surgeries. Based on the type of surgery you get and where you get it, what you owe may differ, so it’s important to check with your provider before the surgery.
Medicare Part C, Medicare Supplements, and Arthritis
To cover some of your out-of-pocket costs for Original Medicare, you may want to enroll in a Medicare Supplement (or “Medigap”) plan. While Medigap plans C and F, which covered the Part B deductible, were shut off to new enrollees in 2020, other plans can help with other health care costs associated with arthritis management. For example, all Medicare Supplement plans offer some type of help with Part B coinsurance — for services like doctor’s visits — and many help cover the Part A deductible — which can help with joint replacement surgery costs.
Part C plans are required to cover the same services as Original Medicare but also usually offer additional coverage.
An alternative to Original Medicare and Medigap plans is having a Medicare Advantage plan. The advantage to Part C plans is that they are required to cover the same services as Original Medicare at a minimum but also usually offer additional coverage. For example, many Part C plans offer prescription drug coverage as part of the plan, negating the need for Part D. They may also have lower deductibles, copays, or coinsurances than Original Medicare. The specifics of this additional coverage, however, differ from plan to plan, since Medicare Advantage plans are offered by private insurance companies.
Does Part D Get Involved?
The type of drugs used to treat your arthritis, and the coverage you receive for them, largely depends on the type of arthritis you have. For example, osteoarthritis (OA) is typically treated with pain killers or nonsteroidal anti-inflammatory drugs (NSAIDs), since the arthritis is the result of degeneration of cartilage from use. Unless given in a prescription, Medicare will rarely, if ever, cover these drugs since they’re usually over-the-counter (OTC) ones, like ibuprofen. Rheumatoid arthritis (RA), on the other hand, may be treated with OTC drugs, but also disease-modifying antirheumatic drugs (DMARDs), biologics, or even steroids.
One study found that nearly all Part D plans cover at least one of the more common, expensive drugs for arthritis treatment, DMARDs.
The part of Medicare that covers your medications usually depends on where you take them. If you take them at the doctor’s office or clinic (for example), Medicare Part B should help cover them. If you take them at home, Medicare Part D will generally help cover them, as long as the drugs are covered by Part D. Luckily, one study found that nearly all Part D plans had coverage at least one of the more common, expensive drugs for arthritis treatment, DMARDs. It should also be noted that, like Medicare Part C, the specifics of what drugs are covered or partially covered and how much they cost are defined by individual plans. To learn more, consult your plan’s formulary for tier and cost information.
Whether that’s a cane to help you get around or surgery to replace the cartilage in your knee, Medicare likely has some way to ensure that medically necessary treatment is attainable and affordable. And, with all your options out there between Medicare Advantage, Medicare Part D, and Medicare Supplements, you can protect your out-of-pocket costs further.
Just like you, your health is one of a kind. What works for one person may not for another, so the information in these articles should not take the place of an expert opinion. Before making significant lifestyle or diet changes, please consult your primary care physician or nutritionist. Your doctor will know your own health best.