Does Medicare Cover Rheumatoid Arthritis?

Key Takeaways:

• Rheumatoid Arthritis (RA) is a common disease that affects more than 1.3 million Americans. About 75% of RA patients are women.

• Medically necessary treatment for Rheumatoid Arthritis is covered under traditional Medicare. 

• Most drugs for Rheumatoid Arthritis (RA) are covered under Medicare Part D, and some medications used to treat RA may be covered under Medicare Part B.

• Medicare Advantage plans may offer more comprehensive coverage, prescription drug coverage through Special Needs Plans.  There may be Special Needs plans available specifically for Medicare beneficiaries with rheumatoid arthritis in your area.

• We highly recommend getting supplemental insurance for covering out-of-pocket costs, as Rheumatoid Arthritis expenses can add up fast even with Medicare coverage.

• But remember, you can only enroll in a Medigap plan during your Medigap Open Enrollment Period. It begins when you are both 65 years old or older and enrolled in Medicare Part B.  See our Medicare Supplement Open enrollment calculator to determine yours. 

 What is Rheumatoid Arthritis?

Rheumatoid arthritis is a chronic autoimmune disease that primarily affects the joints, causing inflammation, pain, and stiffness.

In RA, the immune system mistakenly attacks the lining of the joints, known as the synovium, leading to inflammation and joint damage.

RA is a chronic condition that typically worsens over time. If you don’t get rheumatoid arthritis treatment and start disease control, it can lead to permanent joint damage and disability.

What are the RA symptoms?

Symptoms of RA may include:

• joint pain

• stiffness

• swelling, particularly in the hands, wrists, and feet

• fatigue

• low-grade fever

• loss of appetite

• general feelings of malaise.

There is no cure for RA, but rheumatoid arthritis treatment options include medications such as nonsteroidal anti-inflammatory drugs (NSAIDs), disease-modifying antirheumatic drugs (DMARDs), and biologic agents.

In addition to medications, physical therapy services, regular exercise, and lifestyle changes can also help manage symptoms and improve the overall quality of life for people with RA.

What Are Medicare Chronic Care Management Services (CCM)?

For patients with chronic conditions like RA, there’s a lot to take care of. CCM is a comprehensive care plan that will help you keep track of Medicare-approved medications, appointments, therapies, etc.

Does Medicare cover services like this? During your first appointment evaluation, your health care provider will ask many questions and make sure Medicare covers your CCM services.

How Are Rheumatoid Arthritis Medicare Covered?

Does Medicare cover rheumatoid arthritis? Does Medicare cover RA drugs? Read on to find out about the covered drug therapies to reduce your out-of-pocket expenses.

RA Drugs Covered by Medicare Part D

Covered medications under Medicare Part D (prescription drug plans) can vary depending on the plan, but in general, most plans will cover medications commonly used to treat rheumatoid arthritis (RA).

The following types of RA prescription medications are typically covered under Medicare Part D for rheumatoid arthritis treatment:

• Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen and naproxen

•Disease-modifying antirheumatic prescription drugs (DMARDs) such as methotrexate, hydroxychloroquine, and sulfasalazine

• Biologic agents such as adalimumab, etanercept, infliximab, and rituximab

Remember to always refer to your specific plan to understand which medications Medicare covers and at what cost.

RA Drugs Covered Under Medicare Part B

While most arthritis medications are covered under Medicare Part D, some medications used to treat RA may be covered under Medicare Part B.

The following types of RA drugs may be covered under Medicare Part B:

• Injectable biologic agents such as abatacept, adalimumab, anakinra, etanercept, golimumab, infliximab, rituximab, and tocilizumab

• Injectable synthetic DMARDs such as abatacept and tocilizumab

• Intravenous infusion medications such as infliximab, rituximab, and tocilizumab.

We’d like to remind you that Medicare Part B will only cover medications administered in a clinical setting and may require prior authorization.

Also, Medicare Part B may only cover a portion of the cost of these drugs, with the remainder of the cost being covered by the patient or their supplemental insurance.

Will Medicare Cover Joint Replacements Due to Rheumatoid Arthritis?

Yes, Medicare will generally cover joint replacement surgery for people with rheumatoid arthritis (RA) if certain criteria are met.

Medicare Part A (hospital insurance) covers hospital care and hospital inpatient care related to joint replacement surgery, while Medicare Part B covers the physician’s services and outpatient services (outpatient hospital setting care) related to the surgery.

The following criteria must be met for Medicare-covered RA surgery:

1) The joint replacement surgery must be deemed medically necessary by a healthcare provider.

2) The patient must have tried and failed other treatments, such as medications and physical therapy, for their RA joint pain.

3) The patient must have a certain level of functional impairment due to joint pain, which can be determined by a physician or other healthcare provider.

Remember that while Medicare typically covers joint replacement surgery for RA, there may be certain out-of-pocket costs such as deductibles, coinsurance, and copayments.

After you meet your Part A deductible ($1,600 per benefit period in 2023), you may have to pay coinsurance costs of up to $800 per day in 2023 for inpatient hospital stays longer than 90 days.

Will Medicare Advantage Plans Cover Rheumatoid Arthritis Treatments?

Yes, Medicare Advantage (Medicare Part C) plans are required to cover the same categories of  services and treatments as Original Medicare, including treatments for rheumatoid arthritis (RA).

This means that RA treatments such as medications, physical therapy, and joint replacement surgery will generally be covered under Medicare Advantage plans.  keep in mind, “the same category” does not mean the same coverage or cost.

The CHRONIC Care Act of 2018

The CHRONIC Care Act of 2018 expanded coverage options for Medicare beneficiaries who have chronic conditions like rheumatoid arthritis. It gave Medicare Advantage plans more flexibility to cover non-medical benefits, which can be beneficial to those with rheumatoid arthritis.

Thanks to this bill, Medicare Advantage plans may now cover a wider range of services related to home care, including but not limited to caregiving services for tasks like bathing and dressing, home-delivered meal services, wheelchair ramps, and gym memberships through programs like SilverSneakers.

On top of that, there may be Special Needs Plans available specifically for Medicare beneficiaries with rheumatoid arthritis. Special Needs Plans are a type of Medicare Advantage plan that provides benefits tailored to individuals with specific medical conditions.

So if you’re looking for more comprehensive coverage than what Medicare plans provide, you could consider enrolling in a Medicare Advantage plan. These plans often offer prescription drug coverage with lower copays and coinsurance than Original Medicare.

But specific coverage policies and costs can vary depending on the Medicare plan, which may affect the availability of certain RA medications.

Also, Medicare Advantage plans may have different cost-sharing policies for RA treatments.

Unlike Original Medicare, Medicare Advantage plans have a maximum out-of-pocket limit, which means you won’t have to pay more than a certain amount for your arthritis treatments and services. Maximum Out of Pocket spending for 2023 is $8,300 in-network, up from $7,550 in 2022.

Keep in mind that Medicare Advantage plans have a network of providers, so rheumatoid arthritis patients may need referrals or prior authorization to see specialists and receive certain treatments.

Can I Get A Medicare Supplement Plan if I Have Rheumatoid arthritis?

Yes, you can generally enroll in a Medicare Supplement plan (also known as Medigap) if you have rheumatoid arthritis.

Medigap plans are offered by private insurance companies and will cover the costs that Original Medicare (Part A and Part B) doesn’t cover, such as deductibles, coinsurance, and copayments.

Medigap plans are standardized, so the coverage is the same regardless of which company you choose.

Things To Keep in Mind

Remember that Medigap plans do not cover prescription drugs, so if you need coverage for medications related to your rheumatoid arthritis, you will need to enroll in a separate Medicare Part D prescription drug plan.

You can only enroll in a Medigap plan during your Medigap Open Enrollment Period, which begins when you are both 65 years old or older and enrolled in Medicare Part B.

During this time, you have a guaranteed issue right, which means that insurance companies cannot deny you coverage or charge you a higher monthly premium based on your health status, including your rheumatoid arthritis.

With Rheumatoid Arthritis, Get A Medicare Supplement When New To Medicare

We highly recommend this option. Rheumatoid arthritis treatments can get expensive… If you don’t have supplemental coverage, you may pay thousands of dollars for high-cost specialty drugs, durable medical equipment, etc.

But the cost of inpatient or outpatient setting coverage will be close to zero if a person has supplemental medical insurance and gets RA. In this case, Medicare will cover treatment of RA almost completely.

Contact us today if you have any more questions about rheumatoid arthritis Medicare coverage or other Medicare benefits!

If you would like to see what else Medicare covers, check out my article “What Does Medicare Cover?”