Does Medicare Cover Chronic Conditions?
Yes, both Original Medicare and Medicare Advantage cover chronic conditions. Medicare maintains a list of conditions they classify as chronic and are therefore covered. Coverage for chronic conditions within Medicare may include the following treatments:
- Medical services such as doctor visits and skilled nursing services
- Physical therapy and occupational therapy
- Counseling and therapy for drug or alcohol addictions
- Mental health counseling and therapy
- Coverage for treatments such as kidney dialysis or depression treatments
- Ambulance and emergency services
- Medical devices such as oxygen machines or wheelchairs
Table of Contents
Caring For Your Long-Term Health and the Impacts of Chronic Disease
Almost 60% of Americans suffer from at least one chronic condition, the most common illnesses being diabetes, heart disease, and cancer. According to the Centers for Disease Control and Prevention (CDC), four out of ten Americans have two or more chronic diseases, and chronic diseases are the number one cause of death and disability of Americans.
Experts believe that the problem of chronic disease will grow as Americans age; Continued tobacco use, a lack of physical activity, and poor nutrition amplify these illnesses.
Knowing how Medicare approaches these conditions can give you the advantage of receiving the best care possible. Early and consistent treatment can improve the quality of life and comfort for Medicare beneficiaries.
How Does Medicare Cover Chronic Conditions?
There are several parts to Medicare, and each part plays a different role in coverage.
- Part A covers inpatient services such as hospital stays, hospice, and home care.
- Part B is medical insurance and covers services such as doctor visits, outpatient services, and medical equipment.
- Part C is Medicare Advantage. These plans must offer the same coverage as Original Medicare (Part A and Part B) and often provides more.
- Part D is drug coverage and helps cover the cost of prescription drugs.
What Qualifies as a Chronic Condition?
Medicare defines a chronic condition as a long-term illness or disability requiring ongoing skilled services and treatment. Medicare has an extensive list of what they consider to fall into this category. It is important to note that just because a condition is considered chronic in the medical world, Medicare may not qualify it as such. Additionally, a condition may not be classified as chronic but still be covered elsewhere under Medicare.
What Chronic Conditions Are Covered?
Medicare extended its list of qualifying conditions in 2021. As of now, the following conditions covered by Medicare include:
- Alcohol abuse
- Alzheimer’s Disease/Dementia
- Atrial Fibrillation
- Autism Spectrum Disorders
- Chronic Kidney Disease
- Chronic Obstructive Pulmonary Disease (COPD)
- Drug/Substance Abuse
- Heart Failure
- Ischemic Heart Disorder
- Schizophrenia and psychotic disorders
Other disorders or diseases, such as epilepsy and Parkinson’s, are also covered.
What Treatments Are Covered?
In order for any services or treatments to be covered by Medicare, the services must do the following:
- Maintain the status of the patient’s condition; or
- Slow the deterioration of the patient’s condition; or
- Improve the patient’s condition
Medicare coverage includes some of the following treatments:
- Treatments for cancer, such as chemotherapy or radiation
- Treatments for kidney disease, such as dialysis
- Weight management and health counseling for diabetes or obesity
- Therapy and counseling for depression or mental illness
- Treatment and counseling for drug or substance abuse
Other treatments, such as breathing therapy for a patient that suffers from asthma or COPD, may be covered as well. Contact your Medicare representative to find out if Medicare covers your specific needed treatment.
What Chronic Conditions Are Not Covered?
Medicare does not cover the following when it comes to long-lasting conditions:
- Assisted living needs
- Dental decay or issues
- Hearing loss or issues
- Vision loss or issues
- Cosmetic needs
What Treatments Are Not Covered?
If Medicare does not cover the condition, the treatment will also not be covered. These include:
- Long-term care, which refers to an extended stay in a care facility that provides medical care and assisted living
- Dentures or dental care
- Hearing aids
- Eyewear or eye care
- Cosmetic surgery
What Other Medicare Parts Cover Chronic Condition Management?
Medicare Part A, Part B, and Part D are not the only Medicare coverages to be familiar with when dealing with chronic conditions. Medicare Part C and Medicare supplement plans may also help cover costs and treatments.
Medicare Advantage (Part C)
If an individual elects to go with a Medicare Advantage plan, that plan will be in place of Medicare Parts A and B. A Medicare Advantage plan is sold through private companies and must meet certain requirements set by the federal government, which means they must cover all the same services that Medicare Part A and B cover. Therefore, they match Medicare on what is considered chronic and what treatments are covered.
The premium for a Medicare Advantage Plan and the out-of-pocket costs will likely differ from Original Medicare. However, it’s worth noting that many Medicare Advantage plans offer additional coverage and benefits that Original Medicare does not. If you’re suffering from a chronic condition (or multiple) and have special needs, it’s worth shopping around for a plan that best suits you.
The plan you choose will greatly affect what is covered when it comes to your conditions. For example, the most popular Medicare Supplement plan is Plan G; this plan covers everything that Medicare Part A and Part B cover and covers 100% of Medicare Part B excess charges, which can help protect beneficiaries who need treatment that exceeds what Medicare will approve.
In comparison, the Medicare Supplement Plan A does not cover any excess charges for Medicare Part B. Therefore, if a recipient has a Medicare Supplement Plan A, it would not cover any excess expenses for doctor visits, medical devices, or therapy sessions.
What If You Have Multiple Chronic Conditions?
Within Medicare, there is “chronic condition management.” This service is available to Medicare recipients who have two or more long-lasting conditions. Not only does it help to cover services and medication, it helps the patient with a comprehensive plan to maintain or better their health.
Medicare may pay for a healthcare professional to work directly with the patient to coordinate best practices for the patient’s condition management. These practices may include:
- Organizing a list of all the patient’s medical providers, medications, and treatments
- Outlining the patient’s health goals
- Coordinating activities that may improve the patient’s condition, such as exercise or community involvement
How Much Do Chronic Condition Management Services Cost?
Chronic condition management services, or CCM, may be available to any Medicare recipient with two or more chronic conditions — such as diabetes and kidney disease — but what the recipient pays for these services may differ from person to person.
CCM is covered under Medicare Part B but is subject to the deductible and copays associated with Part B. A patient with a Medicare Supplement plan may not pay anything out of pocket for CCM. However, a patient with no Medicare Supplement or a less extensive plan may face high charges for this service.
How to Get Care for Chronic Conditions Through Medicare
When a recipient of Medicare needs CCM services, they should start by talking with a medical professional to develop a comprehensive plan for the betterment of their health and condition. This service is provided through Medicare Part B. Like most claims filed through Medicare, the provider will submit the bill for the CCM services to Medicare for payment.
Chronic Care Management Services
A patient must be enrolled in Medicare Part B and have two or more long-lasting conditions as defined by Medicare to qualify for CCM services. The patient will need to meet with a medical professional, such as a doctor or nurse, to discuss their conditions and how they would benefit from CCM.
The overall goal of CCM is to better the patient’s overall health. This is done by the patient and health care professional establishing an understanding of the patient’s health and making a plan to help manage and improve the patient’s condition. Medicare offers these services not only to help the patient but it also helps Medicare cut down on overall costs.
Special Needs Plans (SNPs)
A special needs plan, also known as an SNP, are plans that provide extra benefits for Medicare recipients with specific conditions that need additional health care or treatments. For example, if an individual has congestive heart failure, they may want to join an SNP to receive extra benefits for that condition.
Qualifying for a Chronic Condition SNP
An individual must be enrolled in both Medicare Part A and B and fall into one of three following Medicare SNP categories to be eligible for an SNP:
- Dual eligibility SNP (D-SNP): The Medicare recipient is eligible for both Medicaid and Medicare.
- Chronic condition SNP (C-SNP): This indicates the Medicare recipient suffers from one or more chronic or life-threatening conditions. Some of these conditions recognized by Medicare include cancer, chronic heart failure, end-stage renal disease, HIV/AIDs, and dementia.
- Institutional SNP (I-SNP): This means that the Medicare recipient needs a level of care beyond what can be provided in a hospital or doctor’s office and may need to live in an inpatient facility for 90 days or more. These facilities include nursing homes, rehabilitation facilities, and psychiatric hospitals.
Once an individual knows that they are eligible to join an SNP, they should contact their local Medicare office to see what plans are available in their area. It is important to note that some SNP plans may only include certain doctors and facilities.
Additional Programs That May Be Available
Although Medicare may be the primary program to help manage and cover chronic conditions, other programs may be available to give added support, such as Medicaid, a State Pharmaceutical Assistance Program, Medicare Extra Help, or a Patient Assistance Program.
Medicaid is an income-based, government-funded health insurance program that provides services to low-income families, children, pregnant women, and people with disabilities. Medicaid is a great option for people with long-lasting conditions because it has zero to low out-of-pocket expenses and covers a vast array of services.
State Pharmaceutical Assistance Programs (SPAPs)
State Pharmaceutical Assistance Programs (SPAPS) are state-run programs that help low-income adults suffering from disabilities help pay for prescription medication. For example, someone suffering from COPD may be classified as disabled and suffering from a chronic condition. If they meet the state’s income guidelines, they may be able to receive assistance to pay for medications and lower their out-of-pocket expenses.
Medicare Extra Help
Medicare Extra Help is a program that helps Medicare recipients offset the cost of their Medicare Part D costs, such as premiums, copays, and deductibles. If a Medicare recipient qualifies for both Medicare and Medicaid, receives SSI, or qualifies for the Medicare Savings program, they are automatically qualified for Medicare Extra help. Other Medicare beneficiaries can apply through their local Medicare office and must qualify based on income.
Medicare Savings Program
A Medicare Savings Program is a state-funded program that helps offset the cost of Medicare Part A and B premiums. Some programs may also help with Part A and B deductibles, coinsurance, and copays. A recipient must qualify based on their state’s income guidelines to be eligible. A recipient would need to contact their local Medicare office to see what programs are available to them and how to apply.
Patient Assistance Programs (PAPs)
A patient assistance program (PAP) is offered by outside entities, such as a nonprofit or government agency, that help individuals who either have no medical insurance or are underinsured to afford their medications. While Medicare recipients have insurance, there may be a case where Medicare will not cover a certain drug. In this case, the recipient may look into using a PAP to help cover some or all of the cost.
Putting It All Together
All in all, Medicare has many options for chronic condition coverage, from covering doctor visits to medical equipment. If there is something that Medicare does not cover or does not cover in full, there are many additional programs, such as Medigap or Medicare Extra Help, to help reduce out-of-pocket expenses. Understanding what is covered, how to obtain coverage, and what additional resources are available is the first step to ensuring you can maximize your available resources.