Does Medicare Cover Arthritis?

As the number one cause of disability among American adults, arthritis can be a debilitating condition. According to the Arthritis Foundation, nearly 55 million adults in the United States have been diagnosed with some form of arthritis.

In addition to being the most common form of disability, arthritis is also one of the top five most expensive conditions to manage. Not only is it costly to treat, but many people who suffer from arthritis also have massive losses in income due to not being able to work. In fact, medical costs and income losses due to the condition added up to a whopping $304 billion in 2013.

Since the cost of healthcare has only gone up since 2013, it’s important to know how Medicare will help cover your arthritis costs.

Prescription Treatment Under Medicare Part D

Medicare Part D covers prescription drugs that you administer yourself. There are five common classes of drugs that are used to manage arthritis. They are analgesics, biologics, corticosteroids, disease-modifying antirheumatic drugs (DMARD), and nonsteroidal anti-inflammatory drugs (NSAID).

Analgesics and NSAIDs can reduce pain and/or inflammation. These classes of drug come in prescription and over-the-counter (OTC) forms. Some common OTC drugs from these two classes include Tylenol, Advil, and Ibuprofen. Part D does not cover any OTC drugs.

However, if you need a stronger form of these drugs that requires a prescription, your Part D plan may cover it. Analgesics, NSAIDs, most corticosteroids, and some DMARDs come in some self-administered form such as a pill, cream, or self-injection. All of these forms of administration are subject to Part D coverage.

You can obtain Part D coverage either through a stand-alone drug plan or most Medicare Advantage plans. With a stand-alone Part D drug plan, you pay a monthly premium as well as cost-sharing amounts such as deductibles, copays, and coinsurance.

Prescription Treatment Under Medicare Part B

If your prescription medication isn’t self-administrable and requires a doctor to administer it in a clinical setting, then Medicare Part B may cover it. There are a few corticosteroids and DMARDs that are administered in a clinical setting.

However, the class of drug that is almost always administered by a doctor in a clinical setting is biologics. Biologics are genetically engineered drugs that are meant to control the immune system’s response.

There are many types of biologics, and within those types are many specific medications. One biologic medication is Infliximab. This drug takes two hours to be administered intravenously and is administered three times within six weeks, and then once every eight weeks.

With Medicare coverage under Part B, you pay a monthly premium just like you do with Part D. You will also have an annual deductible of $185 (in 2019). Once that deductible is met, Part B will cover 80% of the costs, and you will cover 20%. The brand-name version of Infliximab can cost anywhere from $1,000 to $2,500 for a single dose.

That means within your first six weeks of treatment, you could be looking at spending $1,500 on your coinsurance alone. However, if you have a Medigap plan that covers the Part B coinsurance, you could pay nothing besides your premium.

Surgical Treatment and Physical Therapy Under Medicare

Often times, arthritis patients require surgery to relieve some of the pain they experience. There are eight types of surgery that are generally used to treat arthritis. These include arthroscopy, arthrodesis, joint resurfacing, joint revision, minimally invasive total joint replacement, total joint replacement, osteotomy, and synovectomy.

If you are a candidate for one of these types of surgery, Medicare will cover it. While you are in the hospital, Medicare Part A will cover your room and board, while your Part B will cover your doctor services.

If your doctor suggests you go to a skilled nursing facility (SNF) to finish your recovery post-surgery, then your Part A deductible ($1,364 in 2019) will cover your first twenty days in the facility. In 2019, if you spend more than twenty days in the SNF, then you will pay a $170.50 daily copay for each day spent past day twenty.

Patients who receive one of these types of surgeries usually need assistance from a physical therapist to regain their mobility. Fortunately, Medicare no longer has a cap to how much they will pay for physical therapy appointments. As of 2019, Medicare Part B will help cover the costs of physical therapy appointments as long as they remain medically necessary to the patient.

Costs of Treatment with Medigap Plans

Medigap plans are add on plans to your Original Medicare (Parts A and B). These plans help cut costs for your out-of-pocket spending such as deductibles and coinsurance.

With a Medigap plan like Plan G, you could potentially only pay three things; your Part B and Plan G premiums and your Part B deductible. Medigap plans such as Plan G continuously help protect patients of serious conditions not go broke just for treating their disease.

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