Medicare coverage can be different from employer and Affordable Care Act coverage. Therefore, it can be challenging to know if Medicare will cover a specific service and how it will cover it. When it comes to any orthopedic treatment you need while enrolled in Medicare, here is what you need to know.
What is Orthopedics?
Orthopedics is a branch of medicine that focuses on the body’s musculoskeletal system. Orthopedic physicians and surgeons provide treatment to help correct your bones, muscles, tendons, ligaments, nerves, and joints. Sometimes the treatment can be surgical or nonsurgical.
Original Medicare’s Coverage on Orthopedic Treatment
Generally, orthopedic treatment would involve X-rays, office visits, physical therapy, surgery, and other medical services. Medicare Part B helps cover medically necessary services needed to treat, diagnose, or monitor a health condition for you. Part B specifically will help cover outpatient medical services that you receive.
Most services that aren’t preventive services apply toward the Part B deductible. This means you’ll be responsible for the first $233 for Part B services. Once you’ve met the annual deductible, Medicare Part B will cover 80% of the Medicare-approved cost for these services. You are responsible for the remaining 20%.
As an inpatient, Medicare Part A will help cover your room and board in the hospital. However, the surgery would still fall under Part B since it is a medical service. Therefore, if you are an inpatient and receive orthopedic treatment, you’ll likely see claims sent to Part A and Part B. To better understand how Medicare Part A and Part B work, visit boomerbenefits.com/understanding-medicare.
Orthopedic Shoes
Some orthopedic specialists might recommend certain braces depending on your condition. If your provider prescribes you a leg brace that requires orthopedic shoes, then Medicare will help cover the cost of those shoes. Orthopedic shoes are used as part of some treatment plans and can be very beneficial.
The Part B deductible and 20% coinsurance apply to the orthopedic shoes. You would also need to get the shoes from a Medicare-approved supplier that accepts Medicare Assignment.
Medigap Coverage on Orthopedic Treatment
If you’re researching Medicare, you’ve likely learned about Medigap plans. Medigap plans, also known as Medicare Supplements, are secondary insurance plans. They will help pay the remaining costs after Original Medicare pays. This means whatever Medicare covers, your Medigap plan must cover as well.
If Part B pays 80% of the cost of orthopedic treatment, your Medigap plan will help cover the remaining 20%. However, if Medicare denies a service, your Medigap plan won’t cover it. A Medigap plan has no choice on whether or not they will pay. They always have to pay if Medicare pays.
Medicare Advantage Coverage on Orthopedic Treatment
When you enroll in Medicare Part A and Part B, you can enroll in a Medicare Advantage plan. You will receive your Part A and Part B benefits through your Advantage plan if you do. Medicare would no longer be the one managing your care.
An Advantage plan must offer the same benefits as Part A and Part B, but your cost-sharing can be slightly different. Instead of paying the Part B deductible and coinsurance for Medicare Part B services, your plan will have a set copay or coinsurance for each service. For example, X-rays may have a $40 copay, and a specialist visit may have a $50 copay. Your cost-sharing will vary with each plan. Additionally, some services may require prior authorization from your plan.
These details are laid out in the plan’s Summary of Benefits document. If you know you may need orthopedic treatment in the future, view this document to understand how your plan will help cover your needs.
Summary
Medicare does cover medically necessary orthopedic treatment such as office visits, physical therapy, surgery, and more. Your cost-sharing for these services will depend on the plan you enroll in. You can view your plan’s coverage documents to know exactly how you’ll be covered.