How Does Medicare Cover Arthritis?

According to the Arthritis Foundation, arthritis is the leading cause of disability among adults in the U.S. It’s estimated that roughly 54 million adults have been doctor-diagnosed with arthritis.

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The most common form of arthritis is osteoarthritis – roughly 31 million Americans are affected by this type. Although the second type, rheumatoid arthritis, is less common, the number of women affected by this form of arthritis far outnumbers men.

Osteoarthritis causes the cartilage between the joints to deteriorate. Rheumatoid arthritis causes the lining of the joint to grow inflamed and swollen. Symptoms of arthritis may vary depending on what form of arthritis you have, but common symptoms include joint stiffness, pain, swelling in the joints and decreased body mobility.

Not only is living with arthritis physically painful, managing your arthritis can also be a pain and financial burden to your bank account, especially if you are retired or about to retire. Good news for those Americans with arthritis about to retire – Medicare does, in fact, help cover the cost to treat and manage your arthritis.

How will Medicare cover an arthritis diagnosis?

Diagnosing arthritis can be done by a variety of tests and doctor visits. Some of these tests may include x-rays, blood work, MRIs and CT scans. If you go to get tested either by a primary physician or a specialist such as a rheumatologist, these tests and doctor’s visits are considered “outpatient medical services.”

Medicare Part B covers medically necessary outpatient care for arthritis.  According to Medicare, a medical service is considered medically necessary if it is “needed to diagnose or treat an illness, injury, condition, disease, or its symptoms and that meet accepted standards of medicine.”

Although most people qualify for premium-free Part A, Medicare Part B is not premium-free. In 2019, most people pay $135.50 in monthly premiums for their Medicare Part B coverage. Once you meet the Part B annual deductible of $185, Part B covers 80% of expenses for outpatient medical services and you pay 20%.

It’s important to know that Medicare Part B doesn’t have an out-of-pocket spending cap, so you will have to continue to pay 20% of costs every time you use your Medicare Part B insurance. If you buy a Medicare Supplement plan, also known as a Medigap plan, you’ll have secondary insurance that pays your 20% after Medicare pays its share.

How will Medicare cover arthritis treatment?

Treatment for arthritis depends heavily on the type of arthritis you have. However, treatments for both types come in forms of surgery, medication and alternative medicine.

If your treatment plan requires surgery, Medicare Part A covers your in-patient hospital services such as your room, meals, and recovery. Part B pays for doctor services related to your surgery.

Medicare Part D covers most prescription drugs you take at home, but always confirm that the prescriptions you need are listed on the formulary. Common prescriptions for treating arthritis are nonsteroidal anti-inflammatory drugs (NSAIDs), corticosteroids, analgesics, and disease-modifying antirheumatic drugs (DMARDs).

Most Part D plans used a tiered copayment system; generic drugs are in the bottom tier and cost less out of pocket. DMARDs, biologics, and other specialty drugs are typically at a higher tier, so you’ll have a larger copayment.

Medical marijuana treatment

Currently, there are 23 states that have legalized medical marijuana to be used for certain medical conditions. Of those 23 states, only some have legalized it to be used for paint treatment in arthritis patients. Other countries whose legalization on medical marijuana are less strict such as Canada and Australia, have said that more than 1/3 of medical marijuana users use it for arthritis.

However, because the FDA hasn’t approved medical marijuana as a safe and effective medical treatment, Medicare will not cover it. On the other hand, the FDA has begun to recognized the potential of cannabis products. So, perhaps we will see a change in the future.

Is physical therapy covered under Medicare?

Yes! As long as physical therapy is medically necessary to treat your arthritis, Part B covers it. There are no spending caps for physical therapy services as of 2019. Before 2019, Medicare only paid about $2,000 for physical therapy services, but you don’t have to worry about that going forward.

Even though Original Medicare pays many costs associated with diagnosing and treating arthritis, you still have financial exposure. If you’re concerned about your out-of-pocket costs under Part A and Part B, you may want to consider a Medicare Supplement Plan.

Alternatively, you may find you come out ahead financially with a Medicare Advantage plan. These plans usually have lower copayments and coinsurance amounts, and your Part D prescription drug coverage is usually included. Plus, you’ll generally have just one deductible as opposed to separate deductibles for Part A and Part B. Many arthritis sufferers find that a Medicare Advantage plan makes more financial sense for them.

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