Does Medicare Cover Arthritis Treatment?
Different Medicare parts cover different arthritis treatment costs. Your share of the costs depends on the plan you have, your type of arthritis and the treatment you receive. Original Medicare helps with surgical or medical costs while Medicare Advantage or Part D plans can help with medications.
Does Medicare Cover Arthritis?
Different Medicare plan options — Original Medicare, Medicare Advantage, Medicare Part D and Medigap — can help cover different costs associated with different types of arthritis.
What each plan covers may be determined by the type of arthritis you have, the type of treatment you need and whether your treatment requires prescription medications.
- Medicare Part A hospital insurance
- Part of Original Medicare, Part A covers care you receive in a hospital or skilled nursing facility. This would most likely come into play if you had surgery — such as a hip, knee or other joint replacement — that resulted from osteoarthritis. You would pay a deductible ($1,484 in 2021) and would not be responsible for a coinsurance payment so long as your hospital stay was fewer than 60 days.
- Medicare Part B medical insurance
- Medicare Part B — also a part of Original Medicare — can help with doctor visits and other medical services. It may also help with chronic care management services if you have arthritis and at least one other chronic condition, such as diabetes, heart disease or asthma. You have to pay a deductible ($208 in 2021) and then 20 percent of doctor visits. For chronic care management, you also have to pay a monthly fee. A Medigap policy may cover the fee.
- Medicare Advantage plans
- Medicare Advantage plans are sold by private insurers and must cover everything covered by Medicare Part A and Part B. But it may also provide additional benefits not offered by Original Medicare. Plans may cover prescription drugs for treating your arthritis. You may also be able to purchase a specialized type of Medicare called a Special Needs plan. It may help pay for unique treatments and medications for conditions such as rheumatoid arthritis.
- Medicare Part D prescription drug plans
- Original Medicare does not cover prescription drug costs. Medicare Part D plans are sold by private companies and cover a portion of the costs of your prescription medications. Each plan has its own formulary — or list of drugs it covers — so the type of arthritis drugs covered can vary from plan to plan. Check with your plan’s administrator to make sure your medications are covered.
- Medigap (Medicare Supplement insurance)
- Medigap plans are sold by private insurers and help cover some of your out-of-pocket costs if you have Original Medicare. They can help with coinsurance, copays, deductibles and some other charges — such as your monthly fee for chronic care management services.
Arthritis Treatments Medicare Covers
Medicare does not cover all types of common treatments for arthritis, and Original Medicare coverage requires you to pay some out-of-pocket costs for all arthritis treatments.
If you have a Medicare Advantage, Medicare Part D prescription drug or Medigap plan, you should check with your plan’s administrator to find out exactly what your plan covers for each specific treatment your doctor recommends.
The Different Types of Arthritis Explained
There are more than 100 types of arthritis, and more than 54 million Americans have some type of arthritis, according to the U.S. Centers for Disease Control and Prevention.
- Osteoarthritis (OA)
- OA is the most common type of arthritis, affecting 32.5 million American adults, and the most expensive to treat if joint replacements are required. This type of arthritis results from the “wear and tear” on the cartilage in your joints over time. It most commonly affects your hands, hips and knees. It can be treated by increased physical activity, physical therapy, weight loss, medications or surgery. Treatment may be covered by Original Medicare (and Medigap), Medicare Advantage and Medicare Part D prescription drug plans.
- Rheumatoid arthritis (RA)
- RA is an autoimmune disease in which your immune system attacks healthy cells in your body. This results in painful swelling — or inflammation — in different parts of your body. RA can be treated with medications or biologic therapies. Medicare Part B covers doctor visits if conditions are met. Medications may be covered by Medicare Advantage or Medicare Part D prescription drug plans. You will be responsible for some out-of-pocket-expenses.
- Fibromyalgia causes all-over body pain along with fatigue, sleep problems and mental or emotional distress. The CDC estimates that the disease affects about 4 percent of American adults, but its cause is not known. It can be successfully managed through prescription and over-the-counter medications, exercise, patient education, stress management, and cognitive behavioral therapy (CBT). Medicare Part B covers doctor visits if conditions are met. Prescription medications may be covered by Medicare Advantage or Medicare Part D prescription drug plans. You may still have out-of-pocket costs.
- Gout is an inflammatory arthritis caused by the build-up of uric acid in a joint — typically the big toe. There is no cure for gout, but it can be treated and managed through changes to diet and lifestyle in addition to certain prescription medications. Medicare Part B will cover doctor visits, and Medicare Advantage or Medicare Part D prescription drug plans may cover prescription medications. You will still have out-of-pocket costs.
- Lupus is a chronic, life-long autoimmune disease that is most common among women aged 15 to 44. It can damage any part of your body. It can be treated with prescription and over-the-counter medications. Medicare Part B can help cover doctor visits for treatment while Medicare Advantage and Medicare Part D plans can help with the cost of prescription drugs. You will be responsible for certain out-of-pocket costs.
Arthritis in its most common forms tend to be life-long conditions. Treating them can be expensive. The CDC estimates that in 2013, people with arthritis had an additional $2,117 in medical costs related to their condition.
If you are diagnosed with arthritis, you should carefully consider your Medicare plan options to find one that best suits your needs for treating arthritis along with other conditions you may have.
7 Cited Research Articles
- U.S. Centers for Medicare & Medicaid Services. (2020, November). Arthritis Disparities in Medicare Fee-for-Service Beneficiaries. Retrieved from https://www.cms.gov/About-CMS/Agency-Information/OMH/Downloads/Data-Snapshots-Arthritis.pdf
- Medical News Today. (2020, October 29). Does Medicare Cover Arthritis. Retrieved from https://www.medicalnewstoday.com/articles/does-medicare-cover-arthritis
- U.S. Centers for Disease Control and Prevention. (2020, February 27). Cost Statistics. Retrieved from https://www.cdc.gov/arthritis/data_statistics/cost.htm
- U.S. Centers for Disease Control and Prevention. (2020, February 20). Arthritis Types. Retrieved from https://www.cdc.gov/arthritis/basics/types.html
- U.S. Centers for Medicare & Medicaid Services. (n.d.). Chronic Care Management Services. Retrieved from https://www.medicare.gov/coverage/chronic-care-management-services
- U.S. Centers for Medicare & Medicaid Services. (n.d.). Medicare Costs at a Glance. Retrieved from https://www.medicare.gov/your-medicare-costs/medicare-costs-at-a-glance
- Arthritis Foundation. (n.d.). Know Your Rights – Under Medicare. Retrieved from https://www.arthritis.org/health-wellness/treatment/insurance-management/understanding-health-coverage/medicare-rights