Medicare covers the treatment of Rheumatoid Arthritis (RA), including inpatient and outpatient services. Your cost-sharing under just Medicare alone, however, can be extensive. Planning for the right supplemental and drug protection can help you keep those costs under control.
Rheumatoid arthritis is significantly different from the more common type of arthritis or osteoarthritis (OA), which is a degenerative condition of the bones and joints.
Rheumatoid arthritis is an autoimmune disease, which means that your body’s immune system mistakes its own healthy cells for “invaders” such as bacteria. Your body produces antibodies to fight them.
RA is also a systemic disease, potentially affecting organs such as the heart, lungs, eyes, skin, and vascular system, as well as muscles and ligaments. While there is currently no cure for rheumatoid arthritis, there are several prescription medications and biologic therapies that can treat the symptoms and slow the disease progression.
If you are a Medicare beneficiary and you have rheumatoid arthritis, here’s what you should know about Medicare coverage for treatment of RA.
Medicare Coverage for Drugs that Treat Rheumatoid Arthritis
Medicare covers drugs for RA differently depending on the type of medication you’re prescribed, and the way it’s administered. Drugs administered in a clinical setting fall under Part B and drugs you take on an outpatient basis fall under Part D.
RA Drugs that Fall under Medicare Part D
Most drugs to treat the pain and swelling of RA are taken by mouth at home. These include non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen and celecoxib, as well as corticosteroids such as prednisone, for example.
Any drugs like these that you pick up at the pharmacy yourself are usually not covered under Part B. Instead they will fall under Medicare Part D.
If you have Part D coverage for prescription drugs, either as stand-alone coverage to complement Original Medicare or through a Medicare Advantage plan with prescription drug coverage, Part D will pay for most of your RA medications. Depending on your chosen plan, you will be responsible for the copays, coinsurance, or deductible amounts your plan requires.
Some RA Drugs Will Fall under Medicare Part B
Rheumatologists, the doctors who specialize in treating people with RA, sometimes take an aggressive approach to treatment, with the aim of getting “tight control,” where disease activity is maintained at a low level.
To do that, they typically use disease-modifying antirheumatic drugs, or DMARDs. Sometimes, a biologic DMARD is used to help target specific processes in the disease. Although some DMARDs can be taken at home, many, including biologic DMARDs, are given by infusion in the doctor’s office or in an outpatient hospital setting.
If you get your rheumatoid arthritis medication in the doctor’s office, Part B covers 80% of the allowable charges for most RA drugs, after you’ve met your Part B deductible.
Something to keep in mind when it comes to DMARDs and biologic DMARDs: These drugs tend to be very expensive and your cost-sharing may be quite high, especially for biologics, which can cost $20,000 or more per year.
There is no annual cap on out-of-pocket expenses under Original Medicare, so it is critically important the people with RA have a Medigap plan to pay that other 20%.
Why Getting DMARDs at the Doctor’s Office Benefits You
If you have Medicare plus a comprehensive Medicare supplement like Plan F or Plan G, getting your DMARDs at your doctor’s office is wise. Medicare will pay 80% and your supplement will pay the other 20%.
On the other hand, if you take DMARDs at home, Part B typically won’t cover your treatment. Instead the treatment will usually fall under your Part D drug plan, where you can spend a significant amount of money in the donut hole.
With the high cost of DMARDS, your out-of-pocket costs under Part D could easily hit the catastrophic level.
One 2015 study by the National Institutes of Health showed that Part D plans required an average 30% coinsurance amount for biologic DMARDs. Non-biologic DMARDs typically required a fixed copayment, usually at the top tier of the plan, often in the $50 range.
Other Coverage Under Medicare for Rheumatoid Arthritis Treatment
In some cases, your doctor may recommend surgery, such as a joint replacement. This is sometimes recommended if your joints become permanently damaged to the point of disability. The most common joint surgeries are hip and knee replacements, although in some cases, other joints may be replaced.
If your doctor recommends joint replacement surgery for RA, Part A covers your hospital care. It also covers any inpatient rehabilitation services you need after your surgery. You need to pay your Part A deductible ($1,364 in 2019) plus 20% of all allowable charges.
Even under Medicare, this type of surgery can be tens of thousands of dollars. Without supplemental coverage, your out-of-pocket costs could easily several thousand dollars under Original Medicare. This is without any additional rehab services your doctor may order.
Once again, if you have a comprehensive Medigap plan like Plan F or Plan G, it will pay these costs for you. Both plans pay for your Part A deductible and cover the 20% of surgery that Part B will not cover.
New Physical Therapy Rules in 2019
Many rheumatoid arthritis patients seek a physical therapist’s help for managing their condition. Usually, these visits are ongoing and occur on a regular basis.
In past years, Medicare had a set spending cap in place for how much they were willing to pay for physical therapy visits. The limit was just a little less than $2,000 for the year for physical therapy and speech therapy combined.
However, 2019 brings good news. The Centers for Medicare and Medicaid Services has eliminated the spending caps for physical therapy. Now, Medicare Part B will pay for your PT visits as long as they remain medically necessary.
Managing Medicare Out-of-Pocket Costs for Treatment of RA
The unfortunate fact is that RA treatment can be extremely expensive, even with Medicare coverage. You have a couple of options to help you manage your out-of-pocket expenses. These are Medigap plans, which we’ve discussed briefly above, and Medicare Advantage plans.
In some cases, a Medicare Advantage plan with prescription drug coverage may offer lower deductibles, copayments, and coinsurance amounts than Original Medicare. They also have the advantage of annual maximum out-of-pocket limits on your spending. These vary from plan to plan and year to year, though, and can be as much as $6,700.
However, there is some security in knowing that your approved medical costs will never exceed a particular dollar amount each year under a Medicare Advantage plan.
The downside is that you may have to use your plan’s network providers. Some people prefer not to jump through hoops (think referrals) to see specialists and get the treatment you need. While some Medicare Advantage plans allow you to treat outside your plan network, your out-of-pocket spending would generally be higher.
For many people, a Medicare Supplement Plan, or Medigap, is the most reliable option. There are different Medigap plan options available. Several plans will cover your Part A and/or Part B deductibles. Most also cover your 20% coinsurance amounts under Part A and Part B.
Keep in mind, also, that while Medicare doesn’t cover natural treatments for rheumatoid arthritis, you’ll find that there are many options out there for this. If you consider things like turmeric supplements for rheumatoid arthritis, just keep in mind that those are out of pocket costs as well. Many of these options may be more affordable than RA medications but check with your doctor before trying anything new.
Medicare Enrollment Periods and RA
Because RA is a chronic, systemic condition, if you think you might want Medigap coverage, it’s important to sign up when you first become eligible during your one-time Medicare Supplement Open Enrollment Period.
Here’s why it matters: You cannot be denied Medigap coverage if you enroll during your Medicare supplement open enrollment window. You will be approved regardless of your health status or pre-existing conditions. You also cannot be charged more for your plan than anyone else based on your health status.
If you wait and decide you want a Medigap plan later, you may be subject to medical underwriting. Many companies will refuse to issue Medigap coverage to people with RA or will charge astronomical premiums that make the coverage affordable.
If you have rheumatoid arthritis and are approaching Medicare eligibility, research your Medigap options. You’ll want to find a company with proven long-term rate stability. Enroll as soon as you can avoid missing your open enrollment period. Once it expires, it is gone forever.
The good news is that Medicare does cover most treatments for rheumatoid arthritis. Whether you choose Original Medicare or a Medicare Advantage plan, you’ll have more coverage than Medicare by itself. To make sure that your out of pocket costs stay in your control, talk to a Boomer Benefits agent today.
We can help you evaluate your options. We can discuss possible out-of-pocket expenses under various Medicare Advantage plans versus Original Medicare plus Medigap and Part D. We’ll help you make the best choice for you. As always, and we’ll be here for your questions after the policy is in force as well.
Call us at 1-855-732-9055 or use the orange button below to request our help.
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