Does Medicare Cover Arthritis Diagnosis and Treatment?

As we age, changes in the musculoskeletal system increase the likelihood of arthritis in both men and women. Among Medicare Fee for Service beneficiaries, 34.7% have been diagnosed with arthritis. Arthritis is a medical condition that covers more than one diagnosis, including rheumatoid arthritis, osteoarthritis, gout, and even fibromyalgia; in fact, there are over 100 types of arthritis. Osteoarthritis is the most common type of arthritis among older people, and it is also one of the top causes of physical disability, loss of mobility, pain, and discomfort in older adults. Rheumatoid arthritis afflicts an estimated 25% of Medicare beneficiaries.

Without proper management, arthritis can affect a person’s overall quality of life and health. Kupuna may wonder, does Medicare cover arthritis diagnosis and treatment? Let’s take a look at Medicare coverage for arthritis and rheumatology services.


Does Medicare Cover Arthritis Diagnosis and Treatment?


Yes, Medicare covers arthritis diagnosis and treatment. When it comes to specific services for arthritis, the four parts of Medicare cover different treatments.


Medicare Part A


Medicare Part A is hospital insurance, so it pays for the costs of inpatient hospital stays, surgery, and skilled nursing care. This is relevant to arthritis patients who need surgical intervention such as synovectomy, arthroplasty, arthrodesis, or a total joint replacement (knee, hip, or shoulder).


Patients typically pay a deductible and coinsurance and/or copayments to access these services.


Medicare Part B


Medicare Part B is medical insurance. It covers outpatient medical care such as visits with your primary care physician and durable medical equipment (DME).


Part B typically covers doctor’s visits related to arthritis, physical therapy, and some DME, such as canes walker, braces, and splints. It is best to check with Medicare for prior authorization before buying medical equipment or scheduling physical therapy services. To get a diagnosis and proper treatment, beneficiaries may need to see a medical specialist such as a rheumatologist or an orthopedist.


Patients typically pay copayments and/or coinsurance to access these services and equipment.


Medicare Part C (Advantage plans)


Medicare Advantage plans are health insurance plans offered by private insurance companies that contract with Medicare. All Advantage plans must legally include all components of Medicare Part A and Part B and most plans offer additional services. There are specific plans that may benefit Medicare beneficiaries with arthritis, called a Special Needs Plan (SNP). Ask your Medicare agent if there is a SNP available to you that could help cover the medications and therapies you require to treat arthritis.


Most Part C plans come with a monthly premium and out-of-pocket expenses such as co-payments, co-insurance, and deductibles. Unlike Original Medicare, Medicare Advantage plans come with an annual out-of-pocket maximum that can help control spending for chronic illnesses.


Medicare Part D


Part D, or prescription drug plans (PDPs), provide coverage for prescription drugs. When a senior opts for Original Medicare (Parts A & B) they must enroll in a separate Part D plan to get prescription drug benefits. Prescription drug plans are sold by private insurance companies who contract with Medicare.


Note: Many Medicare Advantage plans include prescription drug coverage.


Each prescription drug plan has a list of covered medications called a formulary. If you are taking specific drugs to treat or manage arthritis pain, be sure that the plan you choose covers them.


Some Part D plans have a monthly premium and most have a deductible. In addition, beneficiaries will pay copays for prescribed medications based on the tier they fall into. For example, generic drugs fall into the lowest tier with a less expensive copay.


Medigap / Medicare Supplement plans


Kupuna who opt for Original Medicare may purchase a Medigap plan to cover some of the out-of-pocket costs, including copayments, deductibles, and coinsurance that they will pay for arthritis care.


Medigap plans are sold by private insurance companies who contract with Medicare and typically include a monthly premium.


Contact a PBC Agent for Help


Our independent insurance agents are dedicated to assisting people on Medicare and those who are ready to transition from employer coverage to personal retirement coverage. We help kupuna understand their benefits options and apply for additional coverage, as needed. Because we represent all the major Medicare Advantage and supplement plans in Hawaii, we are able to offer unbiased advice; all at no cost to our clients.


At PBC, our clients are our number one priority and we look forward to getting to know you and your needs. Call us today at (808) 738-4500 to see how we may be of assistance.

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