Arthritis is the term applied to over 100 different diseases that cause pain, inflammation, tenderness, and stiffness in one or more of the joints within the musculoskeletal system. According to a recent report from the Centers for Disease Control and Prevention more than 54 million people in America suffer from one form or another of arthritis.
The most common forms of arthritic conditions are osteoarthritis (OA) and rheumatoid arthritis (RA). OA is the breakdown of the hard tissue that covers and protects the bone endings where they meet to form a joint. This tissue is called cartilage. RA is an autoimmune condition where the body’s own immune system will attack the joints, starting with joint linings, and results in the loss of functional mobility and range of motion with those joints. There is no cure for OA or RA and without medical attention, the symptoms will worsen with age.
Arthritis treatments can reduce or stop the progress of a disease and provide an improved quality of life. The type of treatment you receive will depend on the form of arthritis that you have, and the coverage allowed by your insurance company. The type of Medicare benefits available will depend on the type of plan you are enrolled in. In addition to approved Medicare coverage that your insurance plan will pay, you may have to pay out-of-pocket for Part B copays, coinsurance, and deductibles.
Types of Arthritis Coverage with Medicare Benefits
Part A Coverage: This Medicare hospital insurance will cover the costs related to inpatient stays and nursing care while you are in the hospital or a skilled nursing facility. Hospital inpatient care for arthritis treatment may apply to total joint replacement surgery.
Part B Coverage: This Medicare medical insurance covers the outpatient costs related to arthritis treatment involving physician office visits, physical therapy, and approved durable medical equipment such as walkers, canes, wheelchairs, and braces. Medicare frequently requires that your doctor obtain a prior authorization for recommended physical therapy and for the use of medical equipment.
Part C Coverage: This private insurance coverage is commonly referred to as Medicare Advantage, often provides additional coverage, and may help to reduce your out-of-pocket costs. Medicare Advantage plans must include the same level of benefits covered by Original Medicare Parts A and B. Some Medicare Advantage are Special Needs Plans and cater benefits for people with specific conditions.
Part D Coverage: This is prescription drug coverage and will help pay for medications prescribed by your physician. Part D plans are managed by private insurance companies. If you have Medicare Parts A and B, you will need to enroll in Part D Prescription Drug Plan (PDP) separately. Prescription drugs are often covered in Medicare Advantage plans. Each drug plan has a list of medications that are covered, and those drugs may have different copayments related to arthritis medications. You can check with your insurance company or pharmacy for copayment information related to your specific medication.
Medigap Coverage: This is a Medicare Supplement plan that you can purchase from a private insurance company that helps cover some of the gaps in Original Medicare. Medigap plans must follow Medicare rules for the coverage of your out-of-pocket costs related to deductibles, excess charges, coinsurance, and copayments.
How Original Medicare Plans Help with Arthritis Expenses
If you have Part B Medicare insurance, you pay a monthly premium for medical coverage with an annual deductible that you must pay before out-of-pocket copayments are applied. For 2021 that basic monthly premium is $148.50 and the annual deductible is $203. After you have met the annual deductible, you can expect to pay Medicare-approved copayment or coinsurance costs for doctor visits, for hospital stays, for outpatient physical therapy, and for necessary medical equipment such as wheelchairs, walkers, canes, and braces.
Medicare does not pay for doctor-recommended over-the-counter medicines such as acetaminophen, Motrin, or Aleve to treat or manage OA arthritis symptoms.
Because RA is an autoimmune disease that frequently attacks several joints at the same time, Medicare Parts A and B will cover treatment for this disease as a chronic care management service. This means that you must have at least two chronic conditions that your personal care physician determines will last for a year or more. Those chronic conditions include the RA disease itself with other conditions such as heart disease, asthma, hypertension, or diabetes. You will still be required to pay your monthly Part B premiums, deductibles, and copayments.
If surgery for joint replacement becomes medically necessary, Medicare Parts A and B cover most of the surgical and recovery costs. As with non-surgical treatments, you will still be required to pay your monthly Part B premiums, meet your annual deductible, and your copayments or coinsurance.
While arthritis is a disease that can significantly impact your daily movements, there is help available for both the treatments and the costs. It is to your advantage to review your Medicare coverage and compare your options to find the plan that is right for you.