Medicare and Arthritis – How are you covered?

A special guest article by Danielle Kunkle of Boomer Benefits and Forbe’s Finance Council. Co-Founder at Boomer Benefits, a national insurance broker that helps Baby Boomers learn the ropes in regards to Medicare.

Arthritis comes in many forms; the two most common are rheumatoid arthritis and osteoarthritis. Osteoarthritis, the most common type, causes the cartilage between the joints to deteriorate, while rheumatoid arthritis causes the lining of the joint to grow inflamed and swollen.

Your symptoms can be slightly different depending on the type of arthritis you have. However, most people who suffer from arthritis experience joint stiffness, pain, swelling in the joints, and decreased flexibility and mobility.

Although arthritis can be a debilitating disease, Medicare can help you manage and treat it.Here’s what to know about Medicare coverage for arthritis.

Arthritis Diagnosis with Medicare

Several steps go into diagnosing arthritis. The first stop is usually your primary care physician’s office for an exam. Your doctor will check for pain, swelling, stiffness, or redness of the joints.

You may have blood work, or be referred for imaging tests such as x-rays, a CT scan, or an MRI. Depending on the results, you may see a rheumatologist, which is a medical specialist focused on arthritis-related diseases.

Most medically necessary outpatient diagnostic tests are covered under Medicare Part B. Medicare considers a service 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.” Generally speaking, however, if your doctor orders an outpatient test, Medicare typically covers it.

Your costs under Medicare include your monthly premium, an annual deductible, and a coinsurance amount. The Part B monthly premium is partially based on your income. Most people in 2019 pay $135.50 per month, although some with higher incomes pay an additional amount.

The Part B annual deductible is $185. Once you meet your deductible, Medicare pays 80% of the allowable charges for your care. Keep in mind, there is no out-of-pocket spending cap with Part B. You pay 20% of your costs every time you use Part B unless you have a Medicare Supplement Plan.

Arthritis Treatment with Medicare

The treatment you receive for your arthritis depends on the type of arthritis you have and its severity. Treatment usually includes a combination of medication, surgery, and physical therapy.

Prescription and OTC Drug Treatment for Arthritis

There are several medications used to treat arthritis. Some common ones include nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin and ibuprofen, topical pain-relieving creams, corticosteroids, prescription pain medications, and biologicals and disease-modifying antirheumatic drugs (DMARDs) such as Plaquenil and Humira.

Medicare Part D covers most prescription arthritis drugs, but you should check your plan’s formulary to see whether your specific medications are covered. The formulary also lists your copayment for that particular drug. Generally, you’ll pay less out-of-pocket for generic drugs and more for specialty biologics and brand-name medications. Most over-the-counter medications aren’t covered by Part D.

Some arthritis medications, DMARDs in particular, are administered in a doctor’s office; these drugs are covered by Part B.

Surgical Treatment for Arthritis

Common surgeries used to treat arthritis are joint replacement, joint repair, and joint fusion. Medicare coverage of surgical arthritis treatment depends on where you have the procedure.

For instance, Medicare Part A covers your inpatient hospital services such as room, meals, prescription medications, and nursing care.

However, Part B covers your surgeon’s fees. Medicare Part A has a $1,364 deductible for each benefit period. Once you meet the deductible, Medicare pays 100% of covered costs for up to 60 days as an inpatient. If you stay in the hospital beyond 60 days, there is a daily coinsurance amount.

Physical Therapy for Arthritis

Physical therapy is a common treatment for arthritis, especially after surgery. Before 2019, Medicare capped the amount it covered for physical therapy visits. However, as of 2019, there are no spending caps for physical therapy services. As long as the therapy is medically necessary, Medicare Part B covers 80% of allowable charges.

Protect Yourself from the Costs of Arthritis

Out-of-pocket costs for arthritis treatment with Original Medicare can easily add up to thousands of dollars a year. If you are enrolled in Part A and Part B, Medicare Supplement Plans pay some or all of your out-of-pocket costs. Medicare Advantage plans generally have one low deductible, and lower copayments and cost-sharing arrangements than Original Medicare. If you’re looking for ways to lower your arthritis treatment costs, exploring your Medicare options is a great first step.

Published by Chronic Eileen

Rheumatoid arthritis advocate, writer and speaker.