Arthritis and Medicare – How are you covered?
Today I am presenting a post from a friend of mine, Danielle Kunkle Roberts who works with a company ‘Boomer Benefits‘ that helps Medicare recipients choose supplemental and Medigap plans. I asked Danielle if she would write a primer for my site on how Medicare works and helps us understand how we can maximize benefits while reducing cost of secondary coverage. She has given us a great high-level look at Medicare and some of its parts, specifically how Medicare is used to cover Arthritis issues. What Danielle has written is not an advertisement for her company. But I have to say that she provides a wonderful service, and she has helped me in the past to understand Medicare. If you would like to get in touch with Danielle feel free to call her at 817-249-8600 or drop her an email at Medicarehelp@boomerbenefits.com
Arthritis and Medicare – How are you covered?
by Danielle Kunkle Roberts
Based on the numbers from the Arthritis Foundation in 2018, about 61 million of the 91 million Americans who suffer from arthritis are 65 or older.
Medicare is the primary insurer for Americans age 65 and over; if you’re a senior suffering from arthritis, that’s good news. Medicare helps pay the costs for diagnosing and treating arthritis. Here’s what you should know about your coverage.
Prescription and OTC Management
Prescription medication is a primary way arthritis is managed. In the Medicare system, Medicare Part D supplies your prescription drug coverage. Most Medicare Advantage plans have Part D prescription drug coverage included, but if you have Original Medicare (Part A and Part B), you’ll need to buy a separate Part D plan.
Many people rely on common over-the-counter (OTC) medications to manage mild pain, while prescription painkillers and anti-inflammatories are the treatment of choice for more chronic and/or severe pain management. Medicare Part D does not cover any OTC medications, which is typical of other private insurance plans, too.
However, some Medicare Advantage plans offer an OTC allowance to their beneficiaries. Depending on the plan you choose, you may get $25 a month, for example, to use on approved over-the-counter medications and devices.
Drug Plan Formularies
If you’ve been diagnosed with arthritis prior to beginning Medicare and are currently taking certain medications, you should check your drug plan formulary to make sure your medications are covered.
Medicare.gov’s plan finder tool is a great resource to help you find the right Part D plan. . You simply enter your ZIP code and the prescriptions you take, and you’ll see which Part D plans in your area cover your prescription drugs.
Part D Payment Stages
With every Part D plan, there are four payment stages. The stages are deductible, initial coverage, coverage gap (donut hole), and catastrophic coverage.
As of 2019, the maximum allowed deductible for a drug plan is $415. Once you have met your deductible, you will move on to stage two, initial coverage. During this stage, you will pay the plan’s copayment for each prescription. Once you and your plan have spent a total of $3,820, you move into the donut hole.
While you’re in the donut hole, you pay 37% of generic drug costs and 25% of brand-name drug costs. Once you and your plan have spent a total of $5,100 for the year, you’re in catastrophic coverage. With catastrophic coverage, you pay no more than 5% of your drug costs.
Surgical Treatment and Doctor Services
Sometimes, surgical treatment is the best option for arthritis sufferers. If you opt for surgical treatment, Medicare Part A and Part B cover your costs. Medicare Part A will cover your room and board while you are in the hospital for inpatient surgery. Medicare Part B pays for your doctor services and drugs administered to you by a professional while you’re in the hospital.
In 2019, the deductibles for Part A and Part B are $1,364 and $185. The Part A deductible ($1,364) is per benefit period so you could end up paying this more than once per year if you’re admitted to the hospital more than once. The Part B deductible ($185) is paid once per year and resets on January 1st.
Once you meet your deductibles, Part A covers your first 60 days in the hospital at 100%, while Part B covers 80% of your doctor services as either an inpatient or an outpatient. For instance, if you need physical therapy (PT) after your joint replacement, Medicare Part B covers 80% of your medically necessary treatment.
Medicare Premiums
Each part of Medicare has its own monthly premium. Most people qualify for premium-free Part A, but everyone pays for Part B. As of 2019, the Part B base premium is $135.50. Part D premiums depend on the plan you choose, but generally, the nationwide average is about $30 per month.
To help with out-of-pocket costs such as deductibles, copays, and coinsurance, you may want to consider a Medigap plan. These cover some or all of your out-of-pocket costs under Part A and Part B. Alternatively, you could consider a Medicare Advantage plan. These tend to have lower copayments and coinsurance amounts, and there is usually just one deductible per year. You may be able to find a $0 premium Medicare Advantage plan in your area, although keep in mind that you must continue to pay your Part B premium if you enroll in Medicare Advantage.
This is great information and I want to thank you and Danielle for posting this. An important thing to consider is the difference in how Medicare Part B and Medicare Part D work. Part D is prescription drug coverage and many of the RA drugs either aren’t covered at all by Part D or have high copays because (1) of the formulary restrictions and (2) because they’re delivered to the patient to self administer (pills or injections). However, if the person goes to the doctor or to the hospital and has them order the medication and do the injection at a doctor’s office or medical facility, that comes under Part B coverage. I know many Medicare patients (myself included) that are on infused medications because they’re more affordable under Part B (administered at an medical facility) than drugs covered under Part D. I have often seen RA patients come into the infusion center and get an injection because that helps them afford their treatment plan. Thanks again for great information on an important topic that can be very confusing!
Carla, what a great comment. I appreciate you highlighting this key difference.
Oh my! You know the NHS drives me round the bend and up the wall, but at least I don’t have to cope with any of this! Being belittled, humiliated and disbelieved – sure, but hey, I get all that for free. 😸
Every system has it,, well system. It is very confusing. Unfortunately Medicare is so quirky and it only applies to those who are disabled and over 65. Making things simple for older people might seem a no-brainier, but then again it is our politicians who designed it.
Hey Penguin, I hear our President wants to put NHS in a trade deal.
Don’t worry, I am President Trump and I am here to help you. LOL.
What I said before … DON’T Get me started on politicians …or worse, rich twits playing at politics!
LOL. I knew that would get the proper reaction. That imposter has no idea what NHS even is.
Don’t get me started on politicians! 😂
Hi Rick- This information is so important. I blindly believed that once Medicare kicked in, it covered everything- as it should. Then I started hearing about the donut hole, and slowly more and more that was not covered. It’s making me consider selling my house and moving to one of the universal coverage countries as I approach the need. Goodness knows, having to buy all sorts of extra coverage I will never be able to retire here!
Oh I know, it is so scary. Sheryl and I thankfully have made modest provisions but it seems to never be enough. I find the system mostly works except for the coverage gaps. If you do find a country that will take two more, let us know and we might come with you. We (meaning me) talk about the same thing often.
Getting sick in retirement is scary. Not just because of the debilitating effects on our physical body, but also its burdensome effects in our finances. Being sick is expensive in our country!
This arthritis for one, reading the part of the possibility of paying for Part A deductible multiple times a year sent shivers to my spine! Because that’s just a small part of the bigger expenses one might have to face when struck by arthritis. What more if a person needs to deal with other medical condition, not just one.
What’s best with this article is that Danielle informed us of the possible costs one might face in this case. I think it is important that we should explore what Medicare covers and does not cover in every medical condition, such as cancer, Alzheimer’s, cataracts, etc. That way, people won’t get unwanted surprises later on.
Also, understanding Medicare coverage will empower people to plan ahead, and take necessary actions to fill the coverage they might need since Medicare don’t cover everything. What a Medigap or Medicare Supplement plan may provide may be able to help someone who needs a lot of medical attention and is expecting to pay lots of out-of-pocket costs. Deductibles, copays, and coinsurances may seem harmless at first glance, but mind you it can debilitate someone even those who are financially capable.
On the other hand, In the infographic above. In number 5, is it really “considered Medicare plan” or it should be “consider a Medigap plan”.
Anyways, thanks for sharing a very informative article. More power!
Thank you for the note. I will let Danielle know. Actually, I should have caught it myself.