Pain is a common symptom of several conditions and diseases. Many types of pain conditions target seniors, such as arthritis and osteoporosis. For this reason, doctors who participate in Medicare generally know a good deal about treating chronic pain. Pain management takes several forms, and Medicare covers each differently. Here’s what you should know about how Medicare covers pain relief.
Medicare Coverage for Prescription Pain Medications
One of the most common ways to manage chronic pain is with prescription painkillers, many of which are opioids. Opioids such as hydrocodone, oxycodone, and oxymorphone have been go-to prescriptions for years. Although these medications relieve pain, they can also cause several side effects such as dizziness, sleepiness, and, often, addiction.
Opioids are not a recommended long-term solution for pain relief. However, doctors may recommend them for the short-term. That’s how Medicare Part D covers them. Medicare Part D is the primary source of prescription drug coverage under Medicare. While each Part D prescription drug plan is different, opioids generally have quantity limits.
Quantity limits restrict certain medications from being overused. If the prescription has a quantity limit, then the plan will only cover a specific amount of the drug each time it’s filled. Also, there may be time restrictions between prescriptions. If a beneficiary’s health care provider thinks the restriction shouldn’t apply to their patient, they can request an exception from the plan.
Part D plans must cover at least two medications in each therapy class. Therefore, doctors will have at least a couple of options for pain relief.
Medicare Part D Costs
While all Part D plans offer similar features, their costs, covered drugs, and restrictions vary from plan to plan. The carrier who sells the plan customizes coverage. Under Part D, beneficiaries pay either a copay or coinsurance for their prescriptions.
Medications are often categorized by tiers. Low-tier drugs have lower copays and higher-tier medications cost more out-of-pocket. For example, if tier-three drugs have a $47 copay and hydrocodone is a tier-three medication, the beneficiary would pay $47 at the counter.
However, Part D plans can have a deductible of up to $415 as of 2019. Therefore, the beneficiaries may have to meet the deductible before the copayment or coinsurance applies.
Over-the-counter medications are not covered by Medicare. However, Medicare Advantage plans sometimes have an over-the-counter allowance benefit. This means that a Medicare Advantage plan can give its beneficiaries an over-the-counter allowance that they can use to purchase approved over-the-counter health products.
Medicare Coverage for Physical and Occupational Therapy
Physical and occupational therapy are two other popular forms of pain relief. Both types of therapy are similar, and Medicare covers them the same way. Therapy is considered a doctor service and thus covered under Part B.
Medicare Part B covers medically necessary physical and occupational therapy sessions. As long as the sessions continue to be needed, Part B will cover it. Recently, there were caps on how much Part B would pay for therapy sessions. However, those rules are no longer at play.
Part B has an annual deductible of $185, as of 2019. After the beneficiary pays the deductible, Part B will pay 80% of covered services, and the beneficiary must pay the remaining 20%. For example, if a beneficiary has a physical therapy session at the beginning of the year, they would have to pay up to $185 out-of-pocket for that session. If the session is more than $185, Part B will cover 80% of the difference, and the beneficiary will be billed for the remainder. From then until the end of the year, Part B will immediately cover 80% of allowable charges.
Medicare Coverage for Pain Relief Surgery
Although surgery may not be the first recommendation for pain relief, it can be part of the treatment plan for several conditions and diseases that cause pain. For example, a doctor may recommend surgery for joint repair to a patient with chronic arthritis. Medicare Part B will cover surgeries that are considered medically necessary to treat or diagnose a condition or disease. Therefore, if the doctor can present the necessary medical codes, Part B may cover pain relief surgery.
Medical procedure costs are hard to estimate, as there are usually several parts of Medicare involved. If a hospital admits a beneficiary for surgery, Part A, Part B, and Part D may pay for a part of their services.
Part A Coverage for Surgery
Part A covers inpatient hospital stays, as well as skilled nursing facility stays, medications as part of inpatient treatment, and other hospital services. The Part A deductible as of 2019 is $1,364. This Part A deductible is per benefit period and could apply more than once a year.
This deductible covers the first 60 days of an inpatient hospital stay. If the stay exceeds 60 days, then the beneficiary will owe a daily copay. However, if the beneficiary is never admitted as an inpatient, Medicare Part A doesn’t pay for anything.
Part B Coverage for Surgery
Part B pays for the majority of services received while in the hospital for surgery. This means that Part B covers the surgery itself, lab work, some medications, and more. The costs for surgery under Part B is just like most other Part B services. Beneficiaries can expect to pay a deductible, copay, and/or coinsurance for their surgery.
Part D Coverage for Surgery
While Part A and Part B cover certain medications while beneficiaries are in the hospital, Part D covers prescription medications that the beneficiaries administer to themselves.
For example, Part A covers anesthesia needed during surgery if the beneficiary is an inpatient. Part B will cover other medications administered to the beneficiary while in the hospital, such as pain relief and anti-nausea medications through an IV. Part D, however, covers medications that the beneficiary gives themself, such as a pill.
Pain Management that Medicare Doesn’t Cover
Lifestyle Changes for Pain Relief
While prescriptions, therapy, and surgery can effectively relieve pain, these services aren’t the only forms of pain relief. Beneficiaries should discuss with their doctor ways to relieve pain through lifestyle changes, such as exercise, diet, and more. However, beneficiaries who require medical pain relief can rest assured that Medicare will offer substantial coverage.
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