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Will Medicare Cover My COPD?

A guide to getting the COPD coverage your need when on Medicare

Some good news: fatal chronic obstructive pulmonary disease is on the decline. Between 1999 and 2019, age-adjusted deaths from COPD in American men went from 57% per 100,000 to 40.5% per 100,000. Among American women, age-adjusted death rates went from 35.3% per 100,000 to 34.3% per 100,000.i

That fall in numbers offers positivity, but if you’re living with COPD, you may still be wondering how you’re going to cover your health care costs. Let’s break down the various parts of Medicare so that you can carve your path.

What you’ll learn:

Original Medicare and COPD Care

Original Medicare will cover some medically necessary treatments for COPD.

Part A

Part A (hospital care) addresses hospital stays and skilled nursing facilities. This can include:

  • Healthcare if you are hospitalized for COPD
  • Limited home health care
  • Limited hospice care
  • Limited skilled nursing facility care
  • Home health services if your doctor certifies that you’re homebound

You will be responsible for the Part A deductible ($1,556 in 2022) as well as any other out-of-pocket expenses.

Part B

Part B (medical care) provides coverage for medically necessary and preventative services stemming from COPD. These include:

  • Pulmonary rehabilitation, which combines education, nutrition advice, counseling and physical training
    • If done in a doctor’s office, you’ll pay 20% of the Medicare-approved cost
    • If done in a hospital outpatient setting, you’ll also owe a copayment
    • You’ll also have to pay toward your Part B deductible ($233 in 2022) as well
  • Oxygen equipment and accessories
  • Smoking cessation counseling, up to eight visits in a 12-month period
    • These sessions are free if conducted with an approved provider
  • Lung cancer screenings, which Medicare will cover annually if:
    • You’re between the ages of 55 and 77
    • You currently smoke or quit within the last 15 years
    • You don’t have any lung cancer symptoms
    • Your doctor prescribes it
    • You’ve smoked at least one pack of 20 cigarettes daily for 30 years or more
  • Flu and pneumococcal shots

In addition to the deductible, you’ll also be subject to various out-of-pocket costs.

Living with More than One Chronic Condition?

It’s common for people with COPD to suffer from other health issues as well. There are several conditions considered to be comorbidities for COPD. These can include various forms of heart disease and even mood disorders, particularly depression. If you have COPD plus one or more other chronic condition, you may qualify for Chronic Care Management under Part B.

Some of other common conditions labeled as chronic by Medicare include asthma, arthritis and diabetes.

Living with multiple chronic conditions.

If you’re living with multiple chronic conditions, you may qualify for medicare part B chronic care management. Chronic care management services include around the clock access, a care plan crafted just for you, 20 minutes of related services per month, and regular check-ins with your doctor. These services are covered when provided by physician assistants, nurse specialists, midwives, or nurse practitioners. Please note that you might also qualify for a medicare advantage special needs plan, offering these services and more.

As part of this management, your provider will draft a plan with your health concerns, goals, medications, other providers, community services that you have or will need, and other relevant health information.

In addition to the care plan, you’ll get medication management assistance, 24-7 emergency care access, and other necessary help.

NOTE: The Part B deductible ($233 in 2022)ii and 20 percent coinsurance for provider visits both apply to chronic care management.

Medicare Advantage and COPD Care

Also known as Part C, these privately sold plans offer everything provided by Original Medicare (Parts A and B) as well as extended benefits that may include dental, vision, prescription drug and wellness program coverage. Given that these are network plans, you’re well advised to ensure that your preferred providers are in-network before enrolling.

You may find that certain COPD therapies not covered by Original Medicare are covered under Medicare Advantage. In addition, Medicare Advantage plans offer Chronic Condition Special Needs Plans, which are designed to serve those living with specific diseases such as COPD. While they offer provider networks, some allow you to go out of network to access a preferred professional. While you’ll need a primary care doctor and referrals to specialist services, some (including pap tests and annual mammograms) do not require referrals.

Care coordinators are one of the most notable benefits of a C-SNP. Coordinators make sure you’re staying current with your health needs and may engage in activities including scheduling appointments, getting your prescription drugs or monitoring other health-related activities.

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Prescription Coverage for COPD through Part D

Part D (prescription drugs) is an add-on to Original Medicare and is purchased separately from Parts A and B. Part D covers COPD medications such as:

  • Bronchodilators
  • Inhaled steroids

Keep in mind that Part D plans vary when it comes to formularies, so before you enroll, it’s wise to make sure that your individual medications are covered.

Medicare Supplement Insurance and COPD Care

Also known as Medigap, Medicare Supplement Insurance fills in the coverage gaps between Original Medicare and your healthcare costs. However, Medigap does not typically cover:

  • Eyeglasses
  • Hearing aids
  • Vision care
  • Dental care
  • Long-term care
  • Private-duty nursing

You may find it challenging to get approved by Medigap, however, if you are applying outside your Open Enrollment Period. If you apply during the enrollment period, there is no medical underwriting, meaning guaranteed approval. If you apply outside the enrollment period, companies can decline you for reasons including:

  • Current tobacco use
  • Regular use of more than three medications, including DuoNeb, Prednisone, Atrovent or Spiriva
  • If you use a nebulizer or oxygen

However, it is not impossible to get approved for Medigap when living with COPD. If you have any questions about your individual situation, please call a licensed Ensurem agent at the number on this page.

What is COPD?

COPD is a chronic inflammatory lung disorder that cause the lungs to experience obstructed airflow. Symptoms include:

  • Cough
  • Mucus production
  • Wheezing
  • Breathing difficulty

If you are living with COPD, you are also at heightened risk for developing lung cancer and heart disease among other conditions. Two contributing conditions are emphysema and chronic bronchitis, which typically occur in conjunction and vary in severity.

What are the Risk Factors for COPD?

Risk factors for COPD include:

  • Smoking or exposure to environmental tobacco smoke
  • Age
  • Genetic predisposition
  • Poor nutrition
  • Occupational hazards
  • Exposure to fumes and smoke from carbon-based cooking and heating fuels
  • Pneumonia or childhood respiratory infection

Talk to your doctor if you suspect that you may be at risk for COPD.

Conclusion

While COPD isn’t curable, it is treatable. While Original Medicare will cover some of these treatments, you’ll still be responsible for paying out-of-pocket for some services. Medicare health and supplemental plans can help you cover what’s not covered by Part A and B alone.

Finding the right plan for your needs that won’t leave you lacking in benefits or paying too much can be overwhelming. If you have any questions, don’t hesitate to reach out to a licensed insurance agent at the number on this page. We’re here to help!

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Ensurem Trusted Expertise

Education is crucial in finding the right Medicare solution for you. With so many Medicare resources out there, it can be difficult finding a source you can trust. That’s why Ensurem has a Compliance Program dedicated to ensuring our Medicare content meets Centers for Medicare & Medicaid Services (CMS) regulations. So, you can rest assured you’re getting the information you need to make the right coverage decisions.

Learn More Here

i Centers for Disease Control and Prevention, “Data and Statistics: COPD Death Rates in the United States.” Accessed March 4, 2022.

ii Centers for Medicare and Medicaid Services, “2022 Parts A and B Premiums and Deductibles/2022 Medicare Part D Income-Related Monthly Adjustment Amounts.” Accessed February 10, 2022.

Denise Austin, 65, Ensurem Ambassador

Best-Selling Author, Creator of Fit Over 50 Magazine

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