Will Medicare Cover My Arthritis?
Looking to use Medicare benefits to manage your arthritis-related costs? Different plan options meet a variety of needs. Let’s break down the parts to see which work best for you.
What you’ll learn:
- Original Medicare and Arthritis Care
- Medicare Advantage and Arthritis Care
- Coverage for Arthritis Medications Through Part D
- Medicare Supplemental Coverage
- What are the Different Types of Arthritis?
Original Medicare and Arthritis Care
Original Medicare (parts A and B) will cover services and supplies for osteoarthritis treatment if your doctor has determined that it’s medically necessary. It may also cover treatment for Rheumatoid Arthritis as a chronic care management service. However, you must have two or more serious chronic conditions to qualify. More on that below.
Part A (hospital care) addresses inpatient hospital stays as well as skilled nursing facilities. If you have surgery – including joint replacements such as hips or knees – Part A benefits cover this. Expect to pay a deductible of $1,556i (in 2022), but no coinsurance for an inpatient stay of less than 60 days.
Part B (medical care) covers visits to doctors and other providers. You’ll likely have to pay a coinsurance amount, and the Part B deductible applies. In most cases, you’ll also have to pay the Part B monthly premium for services.
If your health-care provider prescribes medications for you, be aware that Medicare Part B alone won’t cover these. Medicare Part B may cover medications administered to you in an outpatient setting, but it does not cover retail prescription drugs (those you would get at your local pharmacy).
Living with multiple chronic conditions?
You may also use Part B to defray costs associated with chronic care management if you suffer from at least one other chronic condition in addition to rheumatoid arthritis. Such conditions include cancer, diabetes and depression.
Chronic care management includes a plan listing your health issues, goals, medications, other providers, any community services you may need or already have, and other relevant health information.
Your care plan and its proposed execution will be spelled out, and you’ll be asked to sign an agreement for the service. Management includes preparation of the care plan, assistance with medication management, around-the-clock emergency care access, and other necessary help.
The Part B deductible ($233 in 2022)i and 20 percent coinsurance for provider visits both apply to chronic care management.
Medicare Advantage and Arthritis Care
These private insurer-provided plans (also known as Part C) are Medicare-approved and cover all bases from Part A and Part B with a few added benefits.
Thanks to the CHRONIC Care Act of 2018, Medicare beneficiaries with chronic conditions such as rheumatoid arthritis can receive greater flexibility for Medicare Advantage plans to cover non-medical benefits. These can include services and items related to home care that can useful to someone with arthritis, like:
- Custodial caregiving services
- Home-delivered meal services
- Specialized equipment like wheelchair ramps
- SilverSneakers or other gym memberships
There are Medicare Advantage Plans specifically designed for people living with chronic conditions called Chronic Condition Special Needs Plans (C-SNPs). Rheumatoid arthritis is considered a qualifying condition amongst these plans.
While some Special Needs Plans cover out-of-network providers, others do not, so be sure that you check with your plan to make sure you’ll be able to go to your preferred doctors. You’ll likely have to choose a primary care doctor and get referrals to see most specialists.
Special Needs Plans must also provide Medicare drug benefits (Part D) and will usually cover services or durable medical equipment related to your condition.
For example, some covered items within a C-SNP for rheumatoid arthritis may include:
- Doctor/provider visits
- Physical therapy
Before getting therapy services or getting specialized equipment, you’ll typically have to get authorization from Medicare.
Does Medicare cover physical therapy for arthritis?
Yes, Medicare does cover physical therapy for arthritis. Under Medicare Part B, outpatient physical therapy services are covered, including those necessary for treating arthritis. However, coverage may have some limitations and it’s important to check with your provider for specifics related to your situation.
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Coverage for Arthritis Medications through Part D
You won’t get prescription drug coverage with Original Medicare. That’s where Medicare Part D comes in. Sold by private companies, these plans have different lists of covered medications, so they can vary in terms of the types of arthritis drugs that they will cover.
Because of this, it’s important that you make sure your preferred medications will be covered under a particular plan’s formulary. Popular arthritis medications covered by Part D plans include Humira, Enbrel, Orencia and Remicade.
Medicare Supplemental Coverage
Also known as Medigap, these plans are offered by private insurance companies and provide a way to bridge the gap between your Medicare coverage and your medical needs. Specifically, they can help pay deductibles, coinsurance, copays, and other related fees related to care you receive for arthritis through Medicare Parts A and B.
What are the Different Types of Arthritis?
It’s important to understand the type of arthritis that you have so that you can better understand the type of coverage you’ll need from Medicare. There are two main types:
- Osteoarthritis, or damage to the cartilage of a joint. Cartilage allows for joint motion by cushioning the ends of your bones, but wear and tear or sudden injury can be harmful.
- Rheumatoid arthritis (RA), where your immune system damages the lining of the membrane enclosing all joint parts. Cartilage and bone sustain damage and can be destroyed. RA is a qualifying chronic condition for Special Needs Medicare Advantage Plans.
What are the Risk Factors for Arthritis?
- More candles on your birthday cake translates to greater risk.
- Family history. Arthritis is hereditary – if your parents or siblings have it, you’re more likely to as well.
- Women have rheumatoid arthritis more often, but men have gout (another type of arthritis) more often.
- Those who are heavier are more likely to develop arthritis.
- Previous injury. If you’ve injured a joint in the past, you’re more likely to develop arthritis in it.
Questions to Ask Our Experts
If you need a few questions to help get you started, you can ask our experts one of the following questions that best fit your needs.
- What types of disease control options are available for arthritis under Medicare?
- Are there any Medicaid services that can supplement my Medicare coverage for arthritis?
- Does Medicare cover the cost of durable medical equipment needed for arthritis treatment?
- What prescription drug plans are available to cover my arthritis medications?
- How do different Medicare plans compare in terms of coverage for arthritis treatments?
- Are therapy services for arthritis covered under Medicare?
- How does Medicare coverage work for autoimmune diseases like arthritis?
- Does Original Medicare or a Medicare Advantage Plan provide better coverage for arthritis?
- Can I get a Medicare Supplement Plan to help cover out-of-pocket costs associated with arthritis?
- How does Medicare handle coverage for outpatient setting treatments for arthritis?
- Normally, what are the associated costs when one choose to have Medicare cover arthritis treatment?
- Are all arthritis treatment costs approved by Medicare?
- How does Medicare cover prescription drugs for arthritis treatment?
- Will a Medicare Advantage Plan cover private companies that offer arthritis treatments?
- What are the monthly premiums associated with Medicare plans that cover arthritis treatment?
- Are joint replacements covered under Medicare for arthritis patients?
- How does Medicare handle out-of-pocket expenses and costs associated with arthritis treatment?
- Do all Medicare Parts provide coverage for chronic conditions like arthritis?
- Does each plan’s formulary include my arthritis medications?
- What happens if my arthritis treatment requires prior authorization under my Medicare plan?
According to the U.S. Centers for Disease Control and Prevention, more than 54 million Americans suffer from some sort of arthritis. There are an estimated 100 types of arthritis.
If you’re living with arthritis and need help choosing the right Medicare solutions to support your condition, we can help. Give us a call to talk to a licensed agent specializing in Medicare plans in your area.
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.
i 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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