Medicare does cover treatment for Rheumatoid Arthritis (RA). While your cost-sharing can be expensive, Medicare covers inpatient and outpatient services.
Rheumatoid arthritis is an autoimmune disease, which is very different from the more common type of arthritis called osteoarthritis. RA means that your body’s immune system mistakes its healthy cells for bacteria.
While there currently isn’t a cure, there are medications that can treat the symptoms and slow the progression of the disease.
Medicare beneficiaries should know the following about Medicare coverage for when it comes to RA treatment.
Drug and Hospital Coverage
Medicare coverage for your RA-related medications differs depending on the type of medication that you take and how it’s administered. The medications that you take at home fall under Medicare Part D, while the medications taken at a clinic are classified under Medicare Part B.
Most of the drugs taken to manage the pain and swelling are picked up from the pharmacy and taken at home. If you have Medicare Part D, it will cover most of the RA medications that are necessary. Depending on your plan, you will still be responsible for the copay, coinsurance, and deductible amounts.
The doctors who specialize in the treatment of people with RA, rheumatologists, will sometimes take an aggressive approach and want to try “tight control,” where the disease activity is kept at a low level. Typically to do that, rheumatologists use disease-modifying antirheumatic drugs (DMARDs). Although DMARDs can sometimes be taken at home, many are given by infusion in a doctor’s office or in an outpatient hospital setting.
DMARDs can become very expensive, and that’s important to take into consideration since there is no annual cap on out-of-pocket expenses under Original Medicare.
If you have Medicare Part B and take DMARDs at home, they are typically not covered. The treatment typically falls under the Medicare Part D plan, which can end up making you spend a lot of money in the donut hole.
It is recommended, if you have a comprehensive Medicare supplement like Plan F or G, that you get DMARDs at the doctor’s office. By doing this, Medicare will pay for 80% and your supplement will cover the other 20% of costs.
If your doctor suggests surgery, such as joint replacement, Medicare Part A covers your hospital care. Along with that, it also covers inpatient rehabilitation services that you will need after surgery. You will be expected to pay your Medicare Part A deductible plus 20% of allowable charges. With this type of surgery, costs can go up to tens of thousands of dollars, even under Medicare. These expenses could come out-of-pocket without supplemental coverage.
Out-of-Pocket Expenses
Since the costs of RA treatment can be expensive, you have a few options to help you manage your out-of-pocket expenses. Your options are Medigap plans and Medicare Advantage Plans.
Medicare Advantage plans with prescription drug coverage may offer lower deductibles, copayments, and coinsurance amounts than Original Medicare and also have annual maximum out-of pocket limits for your spending. The prices of these plans vary from year to year and can exceed $6,000.
While there may be some security in knowing your approved medical costs won’t exceed a certain amount every year, the downside is that you could have to use your plan’s network providers. Some Medicare Advantage plans will allow you to get treatment outside of your plan, but those always have a higher out-of-pocket spending amount.
Enrollment
Since RA is a chronic condition, you may want Medigap coverage. It’s important that you sign up for Medigap when you first become eligible during your Medicare Supplement Open Enrollment Period.
The reason that this is important is because you can’t be denied Medigap coverage if you enroll during your enrollment window. If you have RA and haven’t already passed you Medicare eligibility, look into your Medigap options.
