Does Medicare Cover Pain Management?

Nobody likes being in pain. It’s literally something our bodies are designed to avoid. However, around 20 percent of Americans live with chronic pain, making it a major problem for one-fifth of U.S. citizens. It’s even more prevalent in seniors, with estimates ranging from 25 percent to 85 percent dealing with some level of chronic pain.

If you’re one of those suffering with chronic pain, what do you do? You can look into pain management, but what would that cost you? If you’re enrolled in Medicare, you have coverage options.

Determining the Cause

Often, the cause is pretty clear when you’re in pain. Something physical, like a broken bone or injured back, makes itself apparent pretty quickly. Sometimes, however, the cause isn’t quite clear. Finding out what exactly is causing your pain is the first step to managing and ultimately treating it. Medicare can help you with figuring out what’s causing your pain by covering much of the costs with diagnostic tests. This can include screenings, blood tests, and non-laboratory tests like x-rays. These tests are generally covered under Medicare Part B for outpatient care.

Medicare can help you with figuring out what’s causing your pain by covering much of the costs with diagnostic tests.

For non-laboratory tests, you’ll pay 20 percent of the Medicare-approved cost if you’ve met your annual deductible. You may also owe a copayment if the test is given at an outpatient care facility, like an emergency department or surgery center. If you’re receiving a laboratory diagnostic test and your doctor says it’s medically necessary, it may be fully covered by Medicare once you’ve met your annual deductible.

If your tests are given as part of inpatient care, it’s covered by Medicare Part A. This is rarer because these types of tests are usually given as part of outpatient care, even if you’re in the hospital. This is called observation status. To get the tests covered by Medicare Part A, your doctor must order the inpatient care and the hospital needs to formally admit you.

Treatment Coverage

Once you discover what is causing the pain, you can begin treating it. Depending on the cause and your treatment options, different parts of Medicare will offer you coverage. This can also change what costs you may be expected to pay.

Therapy Treatment

If your treatment for chronic pain goes the therapeutic route — like physical therapy, occupational therapy, or acupuncture — it will likely be covered under Medicare Part B. Since you’ll most often be going to therapy appointments instead of in a care facility, your treatment will likely be considered outpatient care. That said, there is also a chance that you may receive both physical and occupational therapy as part of inpatient care. This may be following a surgical procedure or something that had you in the hospital already. In this case, you’d be covered by Medicare Part A. Wherever you’re receiving the care, your doctor must certify that it’s medically necessary to receive coverage.

There is also a chance that you may receive both physical and occupational therapy as part of inpatient care.

If you’re covered by Medicare Part B and you’ve reached your annual deductible, you’ll pay 20 percent of the Medicare-approved amount. Your therapy may also require the use of durable medical equipment (DME), which would be covered by Medicare Part B. You would owe 20 percent of the approved amount. If you’re receiving inpatient care and your therapy is covered by Part A, it’ll be covered as part of your inpatient daily copay after meeting the deductible.

Surgical Solutions

In some cases, your pain may be caused by something that requires surgery. For example, you may need a joint replacement or diskectomy. More often than not, this surgery will be covered under Medicare Part A as inpatient care if you meet your deductible and the surgery is medically necessary. It’s hard to say exactly what you’ll owe with Medicare since surgery costs can differ greatly.

More often than not, this surgery will be covered under Medicare Part A as inpatient care if you meet your deductible and the surgery is medically necessary.

There are instances where your surgery may be covered by Medicare Part B, but only if it is given at an outpatient surgical center or as part of outpatient care at a health care facility. Once you meet your Part B deductible, you’ll owe 20 percent of the Medicare-approved amount. You may also owe a copay.

Prescription Drugs

Finally, your doctor may treat your chronic pain with prescription medications. Unless given as part of inpatient care — which would be covered by Medicare Part A — or outpatient care — which would be covered by Medicare Part B — Original Medicare doesn’t offer prescription drug coverage. To receive that coverage, you’ll need a Part D plan or a Medicare Advantage plan with prescription drug coverage. These can cover drugs that are used to treat a condition that’s causing pain or to manage pain while you’re recovering. You may also qualify for a Medication Therapy Management program, which can help you use the medications safely. Since each Medicare Advantage and Part D plan is offered by a private insurance carrier, the actual costs that you may encounter will vary based on your individual plan.

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Chronic pain isn’t just some medical mystery to be solved. It’s a grinding issue that can hinder your quality of life greatly. The problem is that there are so many health conditions and injuries that can cause chronic pain. This lends itself to many causes, but also many solutions. As with any chronic issue, there isn’t always an instant fix. Without coverage, treating your chronic pain can become expensive. Luckily, your Medicare coverage can help you to afford many of the pain management solutions you and your doctor may choose.