Does Medicare Cover Arthritis Care?
Key Takeaways
- Arthritis includes over 100 types, with osteoarthritis and rheumatoid arthritis being the most common. Treatments vary and may include medication, physical therapy, or surgery.
- Early diagnosis is essential for better outcomes.
- Medicare covers arthritis-related diagnostics and treatments like physical therapy and surgery if deemed medically necessary.
- Original Medicare doesn’t cover prescription drugs used to manage arthritis symptoms — these require a separate Part D plan or Medicare Advantage prescription drug plan.
- Specialized plans (C-SNPs) are available for people with rheumatoid arthritis.
Does Medicare cover arthritis care? The answer is yes; Medicare covers arthritis care, but the exact benefits depend on your eligibility, the type of arthritis, and the recommended treatment.
Medicare arthritis coverage includes diagnostic tests and medically necessary treatments ordered by a doctor, such as physical therapy or surgery. However, Original Medicare doesn’t cover prescription medication to manage arthritis symptoms.
Learn more about your options when it comes to managing your arthritis on Medicare.
What is Arthritis?
Arthritis is a general term for diseases that affect joints and connective tissues. Arthritis commonly causes joint pain, swelling, and stiffness, which can make it challenging to stay active, work, and live independently.
Arthritis impacts 1 in 5 U.S. adults, affecting people of all age groups. However, it’s even more pronounced in older demographics. More than 50% of adults over 75 have arthritis.
While there is no cure for arthritis, it can be treated and managed. But with over 100 types of arthritis, there isn’t a one-size-fits-all treatment. Early detection is crucial for identifying a treatment plan, slowing disease progression, and minimizing long-term damage.
Common Types of Arthritis
- Osteoarthritis: The most common form of arthritis, osteoarthritis damages joint cartilage between bones. It typically impacts the hands, hips, and knees.
- Rheumatoid arthritis: RA is the most common form of autoimmune arthritis. It causes the body to mistakenly attack itself, leading to stiffness, joint issues in the hands and feet, and sometimes eye and skin problems.
- Ankylosing spondylitis: This inflammatory disease causes vertebrae of the spine to fuse.
- Gout: A form of inflammatory arthritis, gout typically flares up for a week or two, then subsides. It causes swelling and pain in the joints, but it’s one of the easiest forms of arthritis to control with lifestyle changes.
- Psoriatic arthritis: This inflammatory autoimmune condition often develops in people who have psoriasis, typically causing inflammation of the shoulders, knees, back, and pelvis.
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Medicare Arthritis Coverage
| Treatment Type | Original Medicare | Medicare Advantage |
|---|---|---|
| Prescription medications taken at home | No for drugs taken at home | Yes, if bundled with Part D |
| Prescription medications administered at the doctor’s office | Yes, through Part B | Yes |
| Over-the-counter medications | No | Yes, if offered as an additional benefit |
| Physical therapy | Yes, through Part B | Yes |
| Surgery | Yes, through Part A | Yes |
- Prescription medications: Depending on the type of arthritis, prescription medications may help reduce inflammation, alleviate pain, or slow disease progression. Some pills and shots can be administered at home, while others require an in-office IV.
- Over-the-counter medications: OTC products like aspirin, ibuprofen, and acetaminophen can help relieve pain and inflammation. However, doctors don’t recommend taking them long-term.
- Physical therapy: PT helps people with arthritis increase their mobility, strengthen their muscles to support their joints, improve their flexibility, learn to use assistive devices, and maintain their physical independence.
- Surgery: Doctors may recommend surgery if the arthritis cannot be treated with other methods. Some types of surgery repair damaged cartilage, correct bone alignment, replace part or all of a joint, or add supportive pins, plates, or rods. Part A covers surgery done in a hospital while Part B covers outpatient surgery.
How Medicare Covers Arthritis
Original Medicare covers diagnostic tests, doctor visits, and some treatments for arthritis. However, there are a few stipulations. Medicare only covers medically necessary services ordered by a doctor to diagnose or treat a specific condition. You also need to get your care from a facility that accepts Medicare.
Original Medicare consists of two parts: Part A and Part B. Part A is hospital insurance, covering inpatient procedures. For example, if you need joint replacement surgery, Part A would help pay.
Part B covers outpatient services and preventative care, including rheumatologist or other specialist appointments, exams, physical therapy, and assistive devices. Part B usually covers 80% of the cost of your care after you meet your annual deductible. Individual appointments may also require a copay.
Part B also covers medications that you wouldn’t give yourself, such as infusions or certain steroid shots. For example, biologics sometimes require an IV infusion at a doctor’s office, which falls under Part B.
Depending on your situation, you may also qualify for chronic care coverage. For a monthly fee, Original Medicare will help pay for a healthcare provider to manage your care. To qualify, you must have two chronic conditions expected to last longer than a year.
Part D Coverage for Arthritis
Medicare Part D covers prescription drugs and some immunizations that Original Medicare doesn’t cover. You must purchase a Part D plan separately from a private insurer, or enroll in a Medicare Advantage prescription drug plan, which bundles Part D coverage.
All Part D plans have a formulary or a list of drugs they cover. Each plan must cover a certain amount of drugs per category. That includes arthritis medications like opioids, nonsteroidal anti-inflammatory drugs (NSAIDs), and disease-modifying antirheumatic drugs (DMARDs). Name-brand medications are often more expensive and can be more difficult to cover.
Part D doesn’t cover over-the-counter medications for pain management, like acetaminophen or ibuprofen.
How Medicare Advantage Covers Arthritis
People with arthritis may consider getting alternative health insurance through Medicare Advantage. Sold by private insurance companies, these plans must cover at least as much as Original Medicare, including medically necessary diagnostic tests, treatments, and surgery. However, they usually expand benefits beyond what Original Medicare offers.
With most Medicare Advantage plans, your cost and coverage options are affected by the plan’s network. Insurance companies negotiate pricing with certain healthcare providers, facilities, and pharmacies. You’ll pay less if you get care within the preferred network. Some plans let you go out of network for a higher cost, while others won’t cover those services at all.
Those with Rheumatoid arthritis (RA) are also eligible for a Chronic Condition Special Needs Plan, or C-SNP, a specialized Medicare Advantage plan tailored for RA care.
Chronic Condition Special Needs Plans for Arthritis
A subset of Medicare Advantage, Special Needs Plans support specific groups of people. Chronic Condition Special Needs Plans, or C-SNPs, tailor their benefits around certain health conditions, such as cancer, diabetes, or autoimmune diseases.
Rheumatoid arthritis, as an autoimmune disease, is the only type of arthritis eligible for a C-SNP. All C-SNP plans include Part D coverage.
How Much Arthritis Care Costs With Medicare
The cost of diagnosing and treating arthritis depends on your specific situation. Some forms of arthritis, like gout, are easier to control and only flare up occasionally. Others can cause irreparable damage to the joints, requiring more serious treatment.
To understand how Medicare covers arthritis care, we’ll look at potential costs of rheumatoid arthritis treatment. RA requires more expensive care as the disease progresses. People who are unresponsive to traditional DMARDs may start taking biologic DMARDs, usually as an injection or infusion.
Here’s how the cost of RA treatment could break down with Original Medicare. It’s important to note that Original Medicare doesn’t have an out-of-pocket maximum. in general, you’ll pay 20% of the costs for your care.
- Part A: This part of Original Medicare covers inpatient care, like hospitalizations or skilled nursing facility care. You’ll pay $0 for the first 20 days in a skilled nursing facility, and $0 for covered home health care.
- Part B: If you receive biologic infusions at an outpatient care facility, Medicare will cover 80% of the cost after you meet your deductible ($257 in 2025).
- Part D: Original Medicare won’t cover prescription drugs, including biologic injections you take at home. You must add a Part D plan to get coverage.
Medicare Advantage Costs
With Medicare Advantage, your costs may look different. Medicare Advantage plans have a maximum out-of-pocket cost of $9,350 in 2025.
- Premium: Most plans charge a monthly fee in addition to the Part B premium.
- Deductible: This is how much you need to pay before your plan starts to contribute. The deductible amount varies by plan.
- Cost-sharing: You’ll have to pay a portion of the cost for your care. This could be a flat amount, such as a $50 specialist visit. You may also owe a percentage of the total, called a coinsurance. Your coinsurance may be less than 20% for biologic infusions.
- Network fees: You may pay more for out-of-network care.
- Prescription drug coverage: Medicare Advantage prescription drug plans include Part D benefits. Your plan may cover a biologic DMARD prescription. In 2025, you won’t pay more than $2,000 out of pocket for covered prescription drugs.
Other Benefits To Consider
- Occupational therapy: If a doctor certifies that you need occupational therapy, Medicare will covers 80% of the cost. Occupational therapy helps you learn skills and techniques to make your daily activities easier. An occupational therapist may also fit you for assistive devices or install them at your home.
- Assistive devices: Canes, walkers, scooters, and wheelchairs can all help people with arthritis. Medicare covers 80% of medically necessary durable medical equipment.
- Physical therapy: Physical therapists develop a training plan to increase strength, mobility, and independence. If a doctor orders physical therapy for you, Medicare covers 80% of the cost.
- Acupuncture: Acupuncture may relieve pain and some symptoms of arthritis. Medicare only pays for acupuncture if you have chronic low back pain.
- Skilled nursing facilities: Original Medicare covers short-term care in a skilled nursing facility. You’ll pay $0 for the first 20 days and $209.50 per day up to 100 days in 2025. After that, you’re responsible for all costs.
Putting It All Together
Arthritis affects joints and tissues, making it harder to move, work, and live independently. There are more than 100 types of arthritis, so each person’s treatment plan and costs will vary. Medicare covers diagnostic tests and different kinds of treatment, including physical therapy, occupational therapy, and surgery.