Medicare and Rheumatoid Arthritis

• by Christian Worstell
• March 6, 2021
• Reviewed by John Krahnert

Rheumatoid Arthritis (RA) affects approximately 1.5 million Americans and typically develops between the ages of 40 and 60.¹

Fortunately, Medicare does cover rheumatoid arthritis treatment for qualified beneficiaries who need chronic care management services. Medicare will also help cover the costs of inpatient and outpatient care for beneficiaries suffering from RA.

Learn more about your treatment options and how to find a rheumatologist near you that accepts Medicare.

Does Medicare cover rheumatoid arthritis treatment?

A few different rheumatoid arthritis treatment options are covered by Medicare in various ways, such as:

• Prescription medication
  Some oral medications are used to treat the pain and swelling brought on by Rheumatoid Arthritis.
  
  These include non-steroidal anti-inflammatories that are covered by many Medicare Part D prescription drug plans or Medicare Advantage plans (Medicare Part C) that offer prescription drug coverage.
  
  
• Disease-modifying antirheumatic drugs (DMARDs)
  Disease-modifying antirheumatic drugs, or DMARDs, are a more aggressive form of medication that is usually administered by infusion in a doctor’s office or outpatient hospital setting. DMARDs are typically covered by Medicare Part B (medical insurance).
  
  Biologics are a type of DMARD that target certain steps in the inflammatory process. These are typically injected or given as an infusion and can also be covered by Medicare Part B.
  
  Once you meet your Part B deductible ($203 per year in 2021), you typically pay 20 percent of the Medicare-approved amount for your DMARD treatment.
  
  
• Surgery
  In some cases, a joint replacement surgery may be recommended if your joints become permanently damaged to the point of disability. Medicare Part A (hospital insurance) covers some of the costs of hospital care necessary for such a procedure, along with any inpatient rehabilitation that might follow.
  
  After you meet your Part A deductible ($1,484 per benefit period in 2021), you may be responsible for coinsurance costs of up to $742 per day in 2021 for inpatient hospital stays that last longer that 90 days.
  
  
• Therapy
  A doctor may recommend physical or occupational therapy to keep your joints flexible through exercise. A therapist can even teach you new ways to perform daily tasks that are less strenuous on your joints.
  
  Outpatient physical therapy is covered by Medicare Part B when deemed “medically necessary” by a prescribing doctor.

Does Medicare cover home health care?

Medicare covers limited home health care for beneficiaries who meet the following conditions:

• You are homebound, meaning that it’s extremely difficult to leave your home, and you need help to do so.
  
  
• You need skilled nursing services or skilled therapy care at least once every 60 days.

In order to qualify, you’ll need to have a face-to-face meeting with a doctor within 90 days before starting home health care, or within 30 days after starting care.

You’ll also need to have a doctor sign a home health certification confirmation and receive care from a Medicare-certified home health agency.

Home health care benefits may be covered by Medicare Part A or Part B, and benefits can include skilled nursing care, therapy and care provided by a home health aide.

Medicare Advantage plans can cover rheumatoid arthritis treatments

The CHRONIC Care Act of 2018 expanded coverage for Medicare beneficiaries with chronic conditions such as rheumatoid arthritis. The bill granted greater flexibility for Medicare Advantage plans to cover non-medical benefits going forward.

Thanks to the bill, Medicare Advantage plans may now cover additional services and items related to home care that can be of use to someone with rheumatoid arthritis.

These can include, but aren’t limited to:

• Caregiving services for custodial care (dressing, bathing, eating, etc.)
• Home-delivered meal services
• Wheelchair ramps
• SilverSneakers gym memberships

There also may be Medicare Special Needs Plans specifically for beneficiaries suffering from rheumatoid arthritis. A Special Needs Plan is a type of Medicare Advantage plan that features benefits designed especially for people with a certain condition.

How do I find a rheumatologist near me that accepts Medicare?

A Medicare Advantage plan may be structured as an HMO or PPO, with a select network of participating health care providers from which to choose. Contact your plan directly to find a rheumatologist near you that accepts your Medicare plan.

Or call 1-800-557-6059 1-800-557-6059 TTY Users: 711 24/7 to speak with a licensed insurance agent.

This article is for informational purposes only. It is not healthcare advice. Speak to your doctor or healthcare provider about your specific healthcare needs.

¹ National Institute of Arthritis and Musculoskeletal and Skin Diseases. What People With Rheumatoid Arthritis Need to Know About Osteoporosis. (Apr. 2016). Retrieved from www.bones.nih.gov/health-info/bone/osteoporosis/conditions-behaviors/osteoporosis-ra?_ga=2.55996587.143207217.1550770098-1967891149.1548791924#one.