Medicare and Arthritis: What’s Covered and What’s Not?

The simple answer is: no. There are costs you may be responsible for.

If you have Medicare Part B (medical insurance), you’ll most likely pay a monthly premium. In 2021, for most people that amount is $148.50. In 2021, you’ll also probably pay $203 for your annual Part B deductible. After the deductible, you typically pay a 20 percent copay of Medicare-approved amounts for:

• most doctor services (including as a hospital inpatient)
• outpatient therapy
• durable medical equipment, such as a walker or wheelchair

Medicare won’t cover over-the-counter medications (OTC) that your doctor may recommend for managing osteoarthritis symptoms, such as:

• acetaminophen (Tylenol)
• OTC NSAIDs (Nonsteroidal anti-inflammatory drugs) such as naproxen sodium (Aleve) and ibuprofen (Motrin)

Rheumatoid arthritis (RA) is an autoimmune disease that causes painful swelling (inflammation). It typically attacks the joints, often many different joints at the same time.

Original Medicare (parts A and B) may cover treatment for RA as a chronic care management service. Chronic care management coverage requires that you have two or more serious chronic conditions that your doctor expects to last at least a year, such as:

• arthritis
• heart disease
• diabetes
• asthma
• hypertension

As with other treatments, expect out-of-pocket expenses, such as Part B premiums and copays.

If your arthritis has progressed to the point that your doctor feels joint replacement surgery is medically necessary, Medicare parts A and B will cover much of the cost, including some of the costs of your recovery.

Just like with other treatment, you may have out-of-pocket expenses, such as Part B premiums and copays.

You can purchase insurance from private companies that will cover some, and perhaps all, of the additional expenses not covered by original Medicare, such as:

• Medigap. Medigap is a supplemental insurance that can help pay copayments, coinsurance, and deductibles.
• Medicare Part C (Medicare Advantage). Medicare Advantage plans are like a PPO or HMO that provide your parts A and B coverage in addition to other benefits. Most include Medicare Part D and many offer extra coverage such as dental, vision, hearing, and wellness programs. You cannot have both Medigap and Part C, you must choose one or the other.
• Medicare Part D. Medicare Part D prescription drug plans cover all or part of the costs of specific medications. Not all medications are covered, so it’s a good idea to confirm coverage and ask about alternative medications, such as generic versions, to help avoid unexpected costs.

The first step is to make sure that your doctor accepts Medicare or, if you’ve purchased Medicare Part C, that your doctor is on your plan.

Discuss the specifics of all recommended arthritis treatments with your doctor to see if it’s covered by your Medicare coverage or if there are other options you may want to consider.

Treatment may include some or all of the following:

• medication (OTC and prescription)
• surgery
• therapy (physical and occupational)
• equipment (cane, walker)

• Original Medicare will cover medically necessary services and supplies for the treatment of arthritis, including joint replacement surgery.
• There are typically out-of-pocket expenses not covered by original Medicare. Depending on your specific needs, it may be worthwhile to explore options to go along with your Medicare coverage, such as:
  • Medigap (Medicare supplemental insurance)
  • Medicare Part C (Medicare Advantage)
  • Medicare Part D (prescription drug coverage)

Medicare plan options and costs are subject to change each year.