Medicare helps pay for the cost of many pain management options. Coverage may come from different parts of Medicare depending on the type of treatment.
An estimated
High impact chronic pain limits a person’s activities, and in people aged 65 and over, an estimated
Original Medicare, Medicare Advantage, and prescription drug plans cover pain management, but which benefit the coverage falls under will depend on how the treatment is given or administered.
In this article, we discuss the parts of Medicare that help pay for pain management.
We may use a few terms in this piece that can be helpful to understand when selecting the best insurance plan:
- Deductible: This is an annual amount that a person must spend out of pocket within a certain time period before an insurer starts to fund their treatments.
- Coinsurance: This is a percentage of a treatment cost that a person will need to self-fund. For Medicare Part B, this comes to 20%.
- Copayment: This is a fixed dollar amount that an insured person pays when receiving certain treatments. For Medicare, this usually applies to prescription drugs.
Medicare helps pay for pain management in the following ways:
Medicare Part A
Part A pays for eligible hospital admissions, hospice, and skilled nursing facility care.
If a person’s pain is managed by prescription medication while an inpatient in a hospital or hospice, the cover will come from Part A.
Some hospice care may require an individual to pay a $5 copayment for pain medication.
Medicare Part B
Part B helps pay for outpatient services, such as those to diagnose and treat medical conditions, as well as preventive care.
Covered services that may be recommended for pain management include:
- acupuncture
- screenings and counseling for alcohol use disorder
- behavioral health integration services
- chiropractic services for subluxation
- depression screening
- individual and group therapy
- medication adjustments
- occupational therapy
- physical therapy
In some instances, prescribed drugs may be covered under Part B, such as when a doctor is required to administer the medication in their office.
Medicare Advantage (Medicare Part C)
Medicare Part C, also known as Medicare Advantage, is administered by private insurance companies.
These plans combine the benefits of parts A and B, and coverage will be the same and subject to the same rules.
Some plans offer additional benefits, which may include extra pain management services. A person can check with their plan provider to explore the coverage options available to them.
Medicare Part D (prescription drug plans)
Private insurance companies also administer Part D prescription drug plans (PDPs).
Some pain management may be covered from Part D, such as prescription opioids and Medication Therapy Management (MTM).
General out-of-pocket costs include:
- Part B deductible, which is $198 in 2020
- Part B standard monthly premium of $144.60
- Part B coinsurance, which is usually 20% of eligible costs
- Part C premium if a person has a Medicare Advantage plan
- Part D premium if a person has a PDP
Out-of-pocket expenses for pain management may vary depending on the type of therapy, and the person’s Medicare plans.
Without Part D a person would likely pay for all prescription drugs themselves, out of pocket.
Original Medicare pays for many medical expenses, but it does not cover everything.
Medicare supplement insurance, also known as Medigap, can help cover some out-of-pocket expenses. Starting January 1, 2020, Medigap policies cannot cover the Part B deductible, so those new to Medicare will not be eligible for this discontinued benefit.
Medicare Part D plans have a list of the drugs they cover. This is called a formulary. Each plan can have a different formulary that may limit the kind of pain medication a person’s doctor can order.
Medicare may limit some services for pain management, including chiropractic care, acupuncture, and physical therapy.
A doctor may order different therapies to help manage chronic pain. The type ordered will depend on the cause of the pain. Doctors may recommend treatment including:
- Acupuncture: research suggests that this form of traditional Chinese medicine may help low back pain. Part B covers up to 12 visits in 90 days for low back pain.
- Alcohol use disorder screening and counseling: alcohol use can increase with chronic pain and may lead to different health problems. Part B covers one screening and up to four brief counseling sessions a year.
- Chiropractic services: data suggest chiropractic care is as effective as physical therapy to
treat lower back pain. Part B covers chiropractic care to correct subluxation only. No other tests or services are covered. - Depression screening: chronic pain can trigger depression and depression can make pain worse. Part B covers yearly screenings with doctors who can order treatment or give a referral.
- Medication: doctors may order prescription medications or over-the-counter drugs to help control pain. Part D may cover some helpful drugs, including opioids, antidepressants, or seizure medications.
- Medication therapy management (MTM): this Part D program is used for people with complex needs. Its aim is to ensure the drugs are working as hoped and manage costs.
- Occupational therapy: Part B covers this service with a 20% coinsurance and the Part B deductible. A therapist evaluates how pain limits a person’s activities. They help individuals with durable medical equipment or strategies to manage pain.
- Physical therapy: used to improve strength or correct how a person uses their body, this therapy can change and improve posture, and reduce pain. Coverage comes from Part B and is subject to 20% coinsurance, and the Part B deductible.
Medicare does cover pain management, but how it is covered will depend on the type of service or treatment.
Pain management delivered to a person who is an inpatient at a hospital will normally be covered under Part A.
Part B pays for out-patient services, such as acupuncture, screenings, and physical and occupational therapy.
Part D covers prescription drugs and often includes Medication Therapy Management for those with complex needs.
Medigap plans can help to pay out-of-pocket costs, including deductibles, copayments, and coinsurance.