Will Medicare Cover My High Cholesterol?

High cholesterol is a major issue in this country. Just shy of 94 million American adults aged 20 or older have it, as do 7% of American children and adolescents aged 6 to 19.¹ When you live with high cholesterol, you’re also living with a heightened risk for heart disease and stroke – respectively the leading and fifth-highest causes of death in the United States.

You may be wondering how you can use your Medicare benefits to defray costs related to your high cholesterol, so you can afford to receive the care you need to keep your condition in check. Let’s break down the various parts to help you determine the best choices for your individual situation.

Original Medicare and High Cholesterol Care

Medicare generally covers routine high cholesterol screenings once every five years at no cost to you (as long as your provider accepts Medicare).  

If you’re diagnosed with high cholesterol, Part B will typically cover medically necessary blood work to monitor your condition. 

Part A 
Part A (hospital care) covers hospitalizations and stays at skilled nursing facilities. If you need to stay at the hospital due to your high cholesterol or for any other reason, Medicare will cover the cost of the stay so long as it is 60 days or less in duration. You will be subject to a deductible ($1,556 in 2022).

Typically covered under Part A are:

• Inpatient hospital care 
• Skilled nursing facility care 
• Nursing home care 
• Home health care 
• Hospice care 

Laboratory work such as blood tests is also covered, as are surgeries.

Part B
Part B (medical care) covers services that are both preventative and medically necessary relating to high cholesterol. These often include:

• Any necessary bloodwork ordered by a doctor 
• One annual cardiovascular disease risk reduction visit 
• Obesity screenings 
• Counseling sessions 
• Eight annual smoking cessation sessions 

You’ll typically be responsible for 20% of the charges after meeting your Part B deductible ($233 in 2022) as well as other potential out-of-pocket costs. 

Living with More than One Chronic Condition?
High cholesterol can be linked to many different diseases like coronary heart disease, stroke, peripheral arterial disease, type 2 diabetes and high blood pressure. If you’re living with more than one of these conditions, you may qualify for Chronic Care Management under Part B. 

Part B Chronic Care Management services may include:

• Around-the-clock provider access 
• At least 20 minutes of related services monthly 
• An individually crafted care plan 
• Regular check-ins with your doctor or provider 

Medicare Advantage and High Cholesterol Care

Medicare Advantage, also referred to as Part C, covers everything encompassed by Original Medicare (Parts A and B), but also may include extended benefits including vision, dental, and prescription drugs. The most common types of Medicare Advantage Plans are:

• Health Maintenance Organization (HMO) plans 
• Preferred Provider Organization (PPO) plans 
• Private Fee-for-Service (PFFS) plans 
• Special Needs Plans 

You may find that Medicare Advantage covers membership to SilverSneakers, a nationwide senior fitness program connecting you free of charge to participating exercise classes and gyms. This may be an option if your doctor has recommended using exercise to defray high cholesterol. 

Prescription Drug Coverage for High Cholesterol through Part D

Part D (prescription drugs) is an add-on to Original Medicare and covers most high cholesterol medications. Many of these are statins, which can cut the amount of cholesterol produced by your liver, and include:

• Atorvastatin (Lipitor) 
• Lovastatin (Altoprev) 
• Pitavastatin (Livalo, Zypitamag) 
• Pravstatin (Pravachol) 
• Rosuvastatin (Crestor, Ezallor) 
• Simvstatin (Zocor) 

The American Heart Association recommends you talk to your doctor about cholesterol medication if you fall within one of the following categories²: 

•  Adults with a history of cardiovascular disease  
• Those with LDL-C level of greater than 190 mg/dL 
• Adults aged 40-75 years with diabetes 
• Adults aged 40-75 years with LDL-C level of 70-189 mg/dL and an elevated 10-year risk of developing cardiovascular disease 

Keep in mind that every prescription drug plan has its own formulary, so check to make sure your individual medications are on the list before making your enrollment decision.

Medicare Supplement Insurance and High Cholesterol Care

Also known as Medigap, these privately sold plans can help you cover costs not addressed by Original Medicare. These include:

• Copayments 
• Coinsurance 
• Deductibles 
• And more 

Medicare offers the following caveats about Medigap:³

• To enroll, you must have Original Medicare 
• Medigap differs from Medicare Advantage in that it is a supplement, not a link to benefits 
• You will pay a monthly premium 
• A Medigap policy covers only one person 
• Any licensed insurance company can sell you a Medigap policy 
• So long as the premium is paid, your Medigap policy cannot be cancelled, even in the event of health issues 
• Medigap does not cover prescription drugs 
• If you have a Medicare Advantage plan, you will not be able to buy a Medigap plan unless you are switching back to Original Medicare 

Many beneficiaries face a choice when enrolling in Medicare: replace Original Part A and B with Part C or supplement them with a Medigap policy. It’s best to make this decision when you first enroll in Medicare – during your Medicare Supplement Open Enrollment Period. This can be especially true for anyone living with chronic conditions. That’s because during the enrollment period, you are guaranteed accepted for any Medigap plan available in your area.

In most cases, if you try to apply for Medigap outside of this period, you’ll be subjected to medical underwriting. Depending on your health status, you could be denied or charged more for coverage.

High cholesterol isn’t always grounds for denial. It will depend on the insurance carrier, what questions they ask and if you have other related conditions.

What is High Cholesterol?

Too much cholesterol (a waxy substance found in your blood) can put you at risk for heart disease. As fatty deposits develop in your blood vessels, they can grow, sometimes blocking the blood from flowing freely through your arteries. Moreover, these deposits can break and clot, causing a stroke or heart attack. 

The National Heart, Lung, and Blood Institute recommends that a first cholesterol screening should be between the ages of 9 and 11 and then every five years following. If you are a male between 45 and 65 or a female between 55 and 65, you should have them every one to two years, and those over the age of 65 should receive them annually. 

There are no symptoms associated with high cholesterol. You must receive a screening to know if you have it. 

What the Risk Factors? 

The following can increase your risk of high cholesterol: 

• Age – high cholesterol is most common in those over 40 
• Alcohol use 
• Lack of exercise 
• Obesity 
• Poor diet with too much saturated fat or trans fats 
• Smoking

You can help fend off high cholesterol by: 

• Quitting smoking 
• Losing weight 
• Limiting the amount of animal fats and salt in your diet 
• Emphasizing fruits, vegetables, and whole grains 
• Eliminating or limiting your alcohol use 
• Exercising at least 30 minutes most days 
• Practicing stress management 

Moderation can be key here. Even if you are having trouble eliminating risk factors, limiting them can also limit your risk profile.

Conclusion

While high cholesterol is a prevalent problem in U.S. society, it doesn’t have to be a life sentence. It is important though to get your cholesterol issues in check to mitigate your risk of heart disease and stroke. Finding a plan that covers these types of services is a great place to start.  

Between Original Medicare, Medicare Advantage and the many supplemental insurance options out there, there’s a solution that will cover the services most important to you. If you’re unsure of what solution is best, we can help.  

To learn how you can best use your Medicare benefits to manage your health, give us a call to speak with a licensed insurance agent specializing in Medicare plans in your area.