Medicare’s Coverage of Orthopedic Conditions
Medicare Part A and Part B will help cover orthopedic doctor and hospital visits with Medicare-approved providers. Part B will also pay 80% of the Medicare-approved cost of medically necessary orthotic devices after you’ve met your deductible if your doctor and suppliers are enrolled in Medicare.
Does Medicare Cover Orthopedic Doctors?
Medicare Part B will help cover your orthopedic doctor visits once you’ve reached your deductible of $233. After the deductible has been met, you will pay a 20% coinsurance.
Orthopedic doctors are musculoskeletal specialists. They diagnose and treat conditions and disorders that affect the bones, joints, muscles, tendons and ligaments.
In most cases, you can go directly to a specialist with Medicare. The doctor, hospital or facility must be enrolled in Medicare and accepting new Medicare patients. Still, it’s best practice to review the details of your plan before scheduling an appointment to verify whether you need a referral.
- Bone health
- Foot and ankle surgery
- General orthopedics
- Hand surgery
- Hip and knee replacement
- Orthopedic oncology
- Shoulder and elbow surgery
- Spine surgery
- Sports medicine
- Trauma surgery
You can use the federal government’s comparison tool to find orthopedic doctors and surgeons near you who are enrolled in Medicare. Considerations when choosing a specialist include board certifications and hospital affiliations.
Orthopedic Conditions Covered Under Medicare
Medicare covers the diagnosis and treatment of several orthopedic conditions that affect the functionality of the body’s musculoskeletal system. How much you pay out of pocket will depend on the condition, the tests prescribed to diagnose it, the treatments you undergo, your specialist’s Medicare status and your Medicare plan.
For example, osteoporosis — a disease that weakens your bones, leaving you prone to fractures and breaks — is diagnosed by a bone density test. Medicare will pay for your test if you meet certain criteria, such as a history of primary hyperparathyroidism or steroid use. Medicare Part D typically covers a portion of bisphosphonates, the most common medications prescribed to treat osteoporosis.
Arthritis is another orthopedic condition that commonly affects Medicare beneficiaries. A doctor diagnoses arthritis through physical examination, X-rays and lab tests, which are typically all covered by Original Medicare (Part A and Part B).
According to the Mayo Clinic, osteoarthritis and rheumatoid arthritis are two of the most common types of arthritis. But there are other types of arthritis covered by Medicare.
- Original Medicare helps pay for an osteoporosis injectable medication and home visits from a health nurse to inject the drug if you meet certain conditions. According to the Centers for Medicare and Medicaid Services, once you’ve paid your Part B deductible, you will owe 20% of the Medicare-approved drug cost. Part A covers your visits from the home health nurse entirely.
- Coverage varies based on your type of arthritis and your Medicare plan. Part C, also known as Medicare Advantage, will provide the same level of coverage as Original Medicare, and possibly additional services, to help treat your arthritis.
- Foot Pain and Problems
- While Medicare doesn’t cover routine foot care, Part B could help cover foot injuries or relevant diseases. Diabetes-related nerve damage to your feet is the most common foot condition that is covered under Medicare.
- Carpal Tunnel Syndrome
- Part B will cover 80% of the Medicare-approved costs once you’ve met your deductible if you decide to get a surgery to treat your carpal tunnel. A doctor who is enrolled in Medicare will have to deem the procedure necessary for you to gain coverage.
Older Americans face the highest risk for orthopedic conditions due to the loss of mobility and physical independence, which results in higher mortality rates. According to the National Center for Biotechnology Information, musculoskeletal disorders are one of the most common conditions that affect retirees.
Basic measures such as staying physically active, eating a healthy diet and visiting your orthopedic doctor regularly can promote orthopedic health. However, if an orthopedic condition worsens, Medicare will cover surgeries or procedures that become medically necessary.
Orthopedic Surgeries and Procedures
Medicare Part A can help cover hospitalization for surgeries, such as hip or knee replacements, as well as drugs and rehab as part of your inpatient treatment. Medicare Part B will help cover doctor visits and durable medical equipment, such as canes or braces, that you may need after your surgery. A Medicare Supplement (Medigap) plan can help cover the out-of-pocket costs Original Medicare doesn’t cover.
If you need to be hospitalized for a surgery related to an orthopedic condition, Medicare Part A ensures that you would not be responsible for a coinsurance payment for the first 60 days of inpatient treatment once your deductible has been paid for that benefit period. The Medicare Part A deductible for 2022 is $1,556.
Orthopedic surgeries and procedures help treat musculoskeletal disorders. Your doctor could recommend joint replacement or reconstruction if other methods, such as physical therapy or braces, fail to improve your condition.
- Back surgery
- Hip and knee replacement
- Shoulder replacement
Medicare Part B also covers preventive services, such as bone density tests every 24 months, to help diagnose conditions and assess a patient’s response to medications.
Medicare Coverage for Orthotic Devices
A doctor may prescribe an orthotic device to support or treat injured or weakened muscles, joints and bones. Orthotics fall under the category of Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS), so Medicare covers some of the costs associated with these devices.
- Arm, back, leg and neck braces
- Custom-molded and extra-depth shoes
- Therapeutic shoe inserts
Once a Medicare Part B beneficiary has met their deductible, they are typically responsible for paying 20% the Medicare-approved cost of their orthotic device. In order to qualify for Medicare coverage, the beneficiary must have a doctor deem the device medically necessary.
Common orthopedic conditions that could lead to requiring a medically necessary back brace, for example, include scoliosis, spinal stenosis and herniated disks.
Different braces are available for different conditions. For frontal compression fractures or post-surgery healing from spinal fusion, you may need a hyperextension brace. To protect you from low back pain, trauma, infections, muscular weakness or osteoporosis, you may need a clinical use brace in the form of a standard brace, belt or jacket designed to immobilize or support the spine.
Your doctor may refer you to an orthotist — a health professional who designs, builds, and fits braces and other devices — to find the Medicare-covered device that meets your needs.
Does Medicare Cover Podiatry?
Podiatrists treat all types of orthopedic conditions that affect your foot, ankle and relevant parts of your leg. Medicare will cover podiatry if a doctor deems the services and treatments as medically necessary.
According to the National Association of Insurance Commissioners, medically necessary services are within the generally accepted standards of medical care and are provided to diagnose, treat, cure or relieve a health condition, illness, injury or disease.
While Medicare will not pay for routine foot care, medically necessary foot care is covered. This includes your exams and treatments, especially if you have severe diabetic foot disease.
Medicare will not pay for a doctor to trim your toenails, remove calluses, clean your feet or perform other types of foot care that are considered routine.
But Original Medicare does cover treatments for disease or foot injuries, such as hammer toes, bunion deformities and heel spurs. Foot exams are also covered every six months for beneficiaries with diabetes, diabetes-related nerve damage known as diabetic peripheral neuropathy, and loss of protective sensations.
Plantar fasciitis is one of the most common orthopedic conditions for both men and women. It occurs when the plantar fascia — the tissue on the bottom of your foot that creates your arch — becomes swollen or irritated.
Doctors diagnose plantar fasciitis based on a patient’s medical history and a physical examination. Medicare Part B typically covers podiatry visits to diagnose or treat a medical condition.
- Foot arch issues
- Tight Achilles tendon
- Stabbing pain near your heel
According to the American Academy of Family Physicians, 80% of people with plantar fasciitis improve within 12 months with nonoperative treatments, such as stretching, strengthening exercises and heel padding.
However, if your doctor determines you need surgery, Original Medicare will help cover the costs once you have met your deductibles. Endoscopic fasciotomy has become the standard surgical treatment for plantar fasciitis. It is an outpatient procedure covered under Medicare Part B.
Your out-of-pocket costs will vary depending on your Medicare plan. Medigap can help cover these costs.
Stress fractures are small cracks in your bones that occur over time with repeated motions. Common symptoms of stress fractures include increased swelling with activity, pain and tenderness.
Medicare Part B will help pay for a magnetic resonance imaging (MRI) to diagnose fractures in your feet. Part B also covers braces and crutches. Once you’ve met your deductible, Medicare will cover 80% of the costs for your needed tests and approved orthotic devices.
Typically, stress fractures don’t require surgery to heal. But if your doctor says you need surgery, Medicare Part A will cover all hospitalization costs for 60 days once you’ve reached your $1,556 deductible for that benefit period.
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