Is acupuncture covered by Medicare? Only if you have chronic low back pain as defined by Medicare.

Let’s look at what that means and what treatments are available.

This article is part of our series “What Does Medicare Cover?” Click the link to read about more frequently asked coverage questions in that article.

Medicare Acupuncture Coverage for Lower Back Pain

If you have chronic lower back pain, Medicare will cover a certain amount of acupuncture visits for you. It is covered under Medicare Part B.

What is considered “Chronic Lower Back Pain?”

According to the CMS, chronic lower back pain is defined as

– Lasting 12 weeks or longer

– Having no known cause (not related to cancer that has spread, inflammatory, or infectious disease)

– Pain not associated with surgery or pregnancy

https://www.medicare.gov/coverage/acupuncture

How Many Acupuncture Sessions are Covered by Medicare?

If you are diagnosed with chronic lower back pain, you can receive up to 12 acupuncture visits in 90 days under Medicare Part B.

What Does Acupuncture Cost with Medicare?

Remember, there are still costs involved with Original Medicare under Part B.

• If you only have Original Medicare, then you will be responsible for a Part B co-insurance of 20%.
• Medicare pays 80% of the cost of services.

Medicare Co-Insurance Coverage Options

For the 20% you are responsible for, you can either:

• First, cover the cost of the co-insurance yourself “out-of-pocket”.

• Or, if you have a Supplement (Medigap) Plan, then your plan might pick up the rest. This depends on what letter plan you have purchased. The most popular plans pick up the entire co-insurance. These include:
  • Plan F (with no Part B Annual Deductible)
  • Plan G (with a Part B Annual Deductible)
  • Click here to learn more about Plan F vs Plan G and which one you can get.

• Finally, if you have a Medicare Advantage (MA/MAPD) Plan, then your plan may include benefits for acupuncture visits.
  • MA/MAPD plans all structure their benefits differently. However, they are all required to provide AT LEAST what Original Medicare covers.
  • Some may pay for a certain amount of visits or have co-pays for each visit.

If any of this is confusing to you, please see our article on How to Choose a Medicare Plan for help.

Where Can you Get Acupuncture Covered by Medicare?

Medicare will only cover an acupuncture treatment at select facilities with certain providers. (You can’t just go to any person advertising needle services.)

According to Medicare.gov,

Acupuncture must be given by a doctor, or by another health care provider (like a nurse practitioner or physician assistant) who has both of these:

– A masters or doctoral level degree in acupuncture or Oriental Medicine from a school accredited by the Accreditation Commission on Acupuncture and Oriental Medicine

– A current, full, active, and unrestricted license to practice acupuncture in the state where care is being provided

https://www.medicare.gov/coverage/acupuncture

There are programs on acupuncture created specifically for doctors and medical providers. If you want Medicare to cover your visit, you will need to find one of these trained providers that actively accept Medicare. (In addition, if you are on a Medicare Advantage Plan, make sure your provider is a part of your network.)

Conclusions

At this time, coverage of acupuncture treatments by Medicare is limited to chronic lower back pain.

If you are looking for Medicare covered treatment for back pain, make sure you find a medical provider that is properly trained and accepts Medicare as payment.

Your full cost for the service will depend on what supplemental Medicare plans you also have in addition to Medicare Part B.

Other Related Coverage Questions:

• What Does Medicare Part B Cover?
  
• What Are my Costs with Medicare Part B?

• What Does Medicare Part A Cover?

• Does Medicare Cover Chiropractic Services?

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The Most Frequently Asked Medicare Coverage Questions

• This is a quick directory answering what Medicare will and will not cover.
• We will list out frequently asked questions, brief answers, and links to more in depth articles if we have them.

Medicare Ambulance Coverage

Medicare does cover ambulance coverage for approved emergency situations. Original Medicare covers 80% of the cost of service. You additional plans will cover all or part of the rest.

• Read more about Medicare ambulance coverage here.

Medicare and Hearing Aids

Does Medicare cover hearing aids? While there might be some Medicare Advantage Plans that have hearing benefits, in general, Original Medicare does not cover hearing aids. Read here for your answers.

• Also, read this article if you are looking for low cost hearing aid alternatives.

Medicare Chiropractic Coverage

In regards to Chiropractic Coverage, what does Medicare cover, if anything? According to our article on Medicare Chiropractic Coverage,

Yes, when deemed medically necessary, Medicare does cover chiropractic services. Original Medicare Part B pays for 80% of the cost of chiropractic services. You will pay the other 20% is the co-insurance – unless you have supplemental insurance.

https://medicarelifehealth.com/does-medicare-cover-chiropractic

Medicare Cataract Coverage

Does Medicare cover cataract surgery? Yes, Medicare Part B covers cataract surgery. Please read more here.

Does Medicare Cover Rehab?

How Long Does Medicare Pay for Rehab? It depends on what Medicare Plan you have.

Medicare often pays for at least part of medically necessary rehab.

However, how it pays, and how much it pays, for your rehab is dependent on what type of care you need and what kind of Medicare plan you have.

https://medicarelifehealth.com/how-long-does-medicare-pay-for-rehab

• Read this article to learn if and how your Medicare plan covers rehab.

Medicare Denture Coverage

Does Medicare cover dentures? No, as a rule, dental services are not covered by Original Medicare – including dentures. As an exception, if dental work is preformed in a hospital emergency setting, it may be covered under Original Medicare Part A. (More at Medicare.gov.)

There are select Medicare Advantage (MA or MAPD) Plans that have dental benefits. You can read more about these plans (also called Medicare Part C) in this article.

Stem Cell Therapy Coverage

Does Medicare Pay for Stem Cell Therapy? Sometimes, yes. However, the cases in which it does pay are very limited. Stem Cell Therapy is expensive and controversial. As a result, Medicare’s list of approved cases is short.

• Read this article to learn if and when Medicare will pay for stem cell therapy.

Medicare MRI Coverage

Does Medicare Cover MRI’s and how much do they cost? Read our article on MRI’s coverage and cost here.

Original Medicare Coverages

Original Medicare refers to the basic coverages put in place by the Federal Medicare Program. The Center for Medicare and Medicaid Services breaks down the coverages into four parts. (Although Part C and D are provided by private insurance companies.)

In addition to the four parts of Medicare, beneficiaries also have the opportunity to add a Medigap Plan. (Also called Medicare Supplement Plans, these plans pick up the extra costs and co-pays that Original Medicare does not.)

• Click the link to read, What Does Medicare Part A / Part B / Part C / Part D Cover?

For more information, here are our detailed articles about each part.

• Medicare Parts A, B, C & D Explained

• What Does Medicare Part A Cover?

• Part B Coverages, Premiums, Deductibles.

• Part A and Part B Yearly Changes to Cost and Coverages

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Does Medicare Cover Chiropractic Care / Services?

Yes, when deemed medically necessary, Medicare does cover chiropractic services. Original Medicare Part B pays for 80% of the cost of chiropractic services. You will pay the other 20% is the co-insurance – unless you have supplemental insurance.

“Medically necessary” chiropractic care is defined as manual manipulation of the spine to correct a subluxation by a qualified provider such as a chiropractor. (Medicare.gov source info).

What is a Subluxation?

A subluxation is when one or more of your bones moves out of position. In other words, your spinal vertebrae are out of position or misaligned. According to experts, this can cause back or neck pain, headaches and immobility.

Chiropractors can manipulate the spine to correct these misalignments and alleviate pain. This is Medicare’s expected use of chiropractic care.

How Much Does Medicare Pay for Chiropractic Adjustment?

When used for a Medicare approved reason, Medicare will pay for 80% of the cost of your chiropractic care. However, since it is part of Original Medicare Part B (Doctor / Professional Services), the Medicare Part B Deductible will apply.

There is no cap on the amount of times you can see the chiropractor in a year with Original Medicare. However, you have a Medicare Advantage Plan or a supplement plan, there may be different rules.

Let’s look at each of those extra insurances to see how they work with Medicare Part B.

Does Medicare Advantage Pay for Chiropractic Care?

The US Government and CMS (the Center for Medicare / Medicaid Services) requires Medicare Advantage Plans to cover at least what Original Medicare covers. So yes, Medicare Advantage plans will have some benefit for chiropractic care.

It will depend on each individual plan what that looks like. Some plans have a co-pay or co-insurance due each time you use the chiropractor. Also, some may have a cap on fully covered care. Finally, some plans may require a referral from a PCP (Primary Care Physician), so make sure to check with your plan for coverages and options.

Does Medigap Pay for Chiropractic Care?

Medigap (which is also called Medicare Supplement) Plans help to cover costs where Original Medicare leaves off. Some of them cover all extra costs and co-insurances not paid by Original Medicare.

As mentioned earlier, chiropractic services are covered with Medicare Part B. To see what a particular supplement will cover, you will need to look at how they cover the uncovered costs of Part B. For example:

• Medigap Plan F covers all costs that Medicare does not. (This includes the Part B yearly deductible.) So, if you have Plan F, you will not pay any co-pays or co-insurances to see a chiropractor for approved care.
• Also, read “Is Medicare Plan F Going Away?”

• Medicare Plan G also covers all costs that Medicare does not – except for the Medicare Part B yearly deductible. So, if you have Plan G, you would first pay the Part B deductible for rendered and approved services. Then, once that deductible was satisfied, you would not pay anything else for your services.

• Other Medigap Plans cover some or all of the Part B coinsurances. If you want to see a chart and in depth explanation of each Medicare Supplement Plan, please click here.

A note of warning from Medicare.gov:

“Medicare doesn’t cover other services or tests ordered by a chiropractor, including X-rays, massage therapy, and acupuncture (except for low back pain). If you think your chiropractor is billing Medicare for services that aren’t covered, you can report suspected Medicare fraud by calling 1-800-MEDICARE (1-800-633-4227). TTY: 1‑877‑486‑2048.”

https://www.medicare.gov/coverage/chiropractic-services#

Conclusions on Medicare Coverages of Chiropractic Care

• Yes, if you have Medicare Part B, you are entitled to 80% coverage of your Medicare approved uses of the chiropractor (after your yearly Part B Deductible applies).

• If you have additional coverage, through a supplement or a Medicare Advantage Plan, you may have additional coverage for the remaining 20%.

• If you have questions on whether or not your care will be considered a covered service, you can talk with your primary care physician, directly to Medicare, or if you have additional insurance, to your private insurance company. They can also give you a better idea of your actual costs – including any co-pays, deductibles or co-insurances.

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Yes, Medicare covers cataract surgery.

Medicare Part B covers the costs associated with cataract surgery. This includes if you need corrective lenses as a result from surgery. (Such as glasses or contact lenses.)

Let’s get into the necessary details you will want to know before cataract surgery. (Such as, how much will I pay?) But first, what is a Cataract? And second, why would you need cataract surgery?

What is a Cataract?

According to the National Health Institute:

• Cataracts are a cloudy area in the eye’s lens that affects vision.

• To start, cataracts are a very common eye problem in older people.

“When you’re young, the lens in your eye is clear. Around age 40, the proteins in the lens of your eye start to break down and clump together. This clump makes a cloudy area on your lens — or a cataract. Over time, the cataract gets more severe and clouds more of the lens.”

National Health Institute

• Interestingly, over half of Americans over the age of 80 have either had cataracts (and just lived with them) or have had surgery to remove them.

• According to the Center for Medicare and Medicaid Services, cataract risk increases not only with age, but with long -term exposure to sunlight, diabetes, and smoking. In addition to using some medications, drinking too much, or having a family history of cataracts.

What is Cataract Surgery?

Cataract surgery is the removal of your cloudy eye lens, and then the replacement of your original lens with a new, artificial lens. It is done in an outpatient setting in a hospital or an ambulatory surgical center. This means, you are in and out without an overnight hospital stay.

Why Would You Have Cataract Surgery?

Some people’s cataracts do not bother them enough to do anything about them. If you are trying to stave off surgery, you can try

• getting stronger glasses,
• or a magnifying device or lenses,
• reducing glare with your glasses or sunglasses,
• or just increasing the amount of light in your living areas.

However, if it gets to the point where you are having trouble seeing, you may need surgery. According to the National Health Institute, people who have cataracts may notice:

• Blurry Vision
• Hazy/Halo Vision
• Seeing Dulled Colors
• Trouble Reading
• Poor Night Vision
• Seeing Double

Some people just get cataracts naturally with age. While others will develop them after another eye surgery, eye trauma or glaucoma issues. Source NHI.

How Much Does Cataract Surgery Cost on Medicare?

The CMS Medicare.gov website has a “Procedure Price Lookup” page where you can see the average costs of medical procedures.

Remember, this is not an exact price of what you will pay. It is just an estimate, but it can be very helpful. (Your actual costs will depend on if you have extra insurance, what your doctor charges, any facility charges, where you live, and any other variable medical costs involved with your care.)

How to Look Up Your Cost Estimate on Medicare.gov

If you want to know how much Cataract Surgery costs on average, you can visit their website. Then, type in “Complex removal of cataract with insertion of lens.” (This is under code: 66982.)

When we looked up this procedure at the end of 2020, the average cost was:

• Ambulatory Surgical Centers Total Cost of $1,777
  • Patient Pays $355
  • Medicare Pays $1,422
• Hospital Outpatient Surgery Total Cost of $2,786
  • Patient Pays $557
  • Medicare Pays $2,229

Here is a screenshot from the date we looked it up. (However, prices change, so please use the tool for an up to date estimate.)

• This is providing you with an estimate of what Original Medicare will pay for.
• However, you most likely have additional insurance in the form of a Medicare Supplement (Medigap) Plan or from a Medicare Advantage Plan.

Are Eyeglasses Covered by Medicare with Cataract Surgery?

According to Medicare.gov, the only time that Medicare covers eyeglasses or contact lenses is if you need them after cataract surgery for corrective purposes. In this case, you would still be responsible for 20% of the cost.

In addition, the corrective lenses would be under Medicare Part B, so the Part B Deductible would also apply. This is unless you have supplemental coverage (for example, Medigap or Medicare Advantage).

Does Medicare Cover Eyeglasses or Contacts in General?

Typically, Original Medicare will not cover contact lenses or eyeglasses outside of cataract surgery. However, there are Medicare Advantage Plans that have an eyeglass or contact benefit included. The amount varies from plan to plan and from year to year. These are outside of, or in addition to, cataract surgery corrective lenses needs.

Conclusions

Cataract surgery is covered by Medicare Part B. If you are considering cataract surgery, the first thing to do is to talk with your medical providers.

Then, consult with your insurance provider’s information or personnel on cost. Ask them what your financial responsibility is for the costs Original Medicare Part B does not cover (the 20% coinsurance).

Depending on what kind of plan you have, you may be responsible for all, some, or none of the co-insurance costs.

Disclaimer:
This information isn’t intended to replace professional medical advice, diagnosis, or treatment.

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Does Medicare Cover Ambulance Services?

Yes, Medicare covers ambulance services in approved emergency situations. As with all Medicare covered costs, you will pay 20% of the cost of service, unless you have additional coverage.

Let’s break down in more detail – what is covered and how it gets paid for.

Does Medicare Pay for Ambulance Services?

Medicare Part B covers ambulance services. (Part B is medical insurance. To learn more about what Part A and Part B offers, visit this page.)

What does the government describe as covered ambulance services? Well, they include:

• Emergency ground transportation to a hospital (including critical access and skilled nursing facilities)
• Emergency air transportation (via helicopter or airplane) when ground transportation is not available or is not adequate

Does Medicare Cover Non-Emergency Transportation?

No, Medicare does not typically cover non-emergency transportation. For example, you will not be able to get an ambulance to a doctors appointment.

However, there are certain Medicare / Medicaid programs that do offer non-emergency transportation to people who need it. Also, according to CMS (Center for Medicare Services), there are a few instances where Medicare may provide non-emergency ambulance services:

“In some cases, Medicare may pay for limited, medically necessary, nonemergency ambulance transportation if you have a written order from your doctor stating that ambulance transportation is medically necessary. For example, you may need a medically necessary ambulance transport to a dialysis facility if you have End-Stage Renal Disease.”

https://www.medicare.gov/coverage/ambulance-services

What are My Costs with Medicare Ambulance Coverage?

First, it is good to remember that the reason for your ambulance ride must be considered a “Medicare approved” service. Otherwise, your ride might not be covered at all. Also, CMS states that the ambulance can only take you to the nearest medical facility considered appropriate for your needs. (You can read more about it here.)

Next, if you only have Original Medicare Part B, then you will pay the 20% of the ambulance bill that Medicare does not pay. (If you only have Medicare Part A, then ambulance services are not covered. You will need to enroll in Part B to have them covered.)

However, most people have a supplement or a Part C (Medicare Advantage) Plan in addition to Medicare Part A and Part B. Original Medicare works together with your private insurance options to pay for ambulance services. Let’s look at both options and how they cover ambulance rides.

Medigap Ambulance Coverage

Remember that with Original Medicare Part B, the government pays for 80% of the cost of a Medicare covered ambulance ride. You are responsible for the rest, unless you have a Medigap plan. Also known as Medicare Supplement plans, these plans help you pay for the co-insurances, deductibles, and co-pays that Original Medicare does not pay for.

Coverage By Specific Medicare Supplement Letter Plan

In exchange for a monthly premium, Medigap plans will help you pay for some or all of your personal costs of Medicare approved services. The Part B Co-insurances or co-payments are

• Paid in full by Medigap Plans A, B, C, D, F, G and M.
• Plan K pays for 50%;
• L pays for 75%,
• And N pays for all minus a co-pay.

You can read more about the supplement coverage chart in our article: What are Medicare Supplements here.

Medicare Advantage Ambulance Coverage

Medicare Advantage (Part C) plans are private insurance options that “replace” Original Medicare as your only Medicare coverage. They offer everything that Original Medicare offers, and also offer extra benefits are services on top of what is covered in Part A and Part B.

Medicare Advantage plans cover at least what Part B covers for ambulance rides. In addition, they also may cover the 20% that Part B doesn’t cover, but they way they do that is specific to each individual private insurance company.

For example, some Medicare Advantage plans will have a set co-pay for ambulance use, or they may have a percentage they cover. They may also distinguish between air and ground emergency transportation in how they cover costs.

It is important to know that every Medicare Advantage plan has a set max out-of-pocket cost that you can never go above each year. So, for example, if your MA plan had you pay 10% of the cost for air transportation, then you would be responsible for that cost only up to the max out-of-pocket limit set for your plan.

Remember, each Medicare Advantage plan is different, and if you are a MA plan beneficiary, you will need to look at your plan information or “Summary of Benefits” to see how your costs will be covered.

If you want to compare Medicare Advantage vs Medigap plans, you can read more here.

Other FAQ’s

Here are a few other frequently asked questions:

• Does Medicare cover air ambulances?
  Yes, as long as it is a “Medicare approved” service, then it is covered. If you need an emergency air transportation and it is considered a necessary, approved situation, then Medicare will pay for it. Remember, you will be responsible for a 20% co-insurance payment unless you have additional coverage (like with a Medigap or Medicare Advantage plan).
• Does Medicare cover life flight?
  Life Flight or LifeFlight is just a branded name of a company that provides emergency air transportation services. If you use their services for a Medicare approved expense, then it will be covered accordingly.

Conclusions

Yes, Medicare will cover ambulance service for approved and necessary emergency transportation needs. You will still have co-insurance unless you also have a Medicare Supplement Plan or a Medicare Advantage Plan. Do you need help finding coverage in addition to what you receive through Original Medicare (Part A and Part B)? Then please reach out to us.

• If you live in Nebraska, please contact us here.

• If you live anywhere else in the lovely United States of America
  • Read more about Medicare Plans here or
  • Find an agent here.

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Original Medicare Rehabilitation

Rehab, or Inpatient Rehabilitation Care, is part of Medicare Part A or “Hospital Insurance.” To learn more about what Part A covers, click here.

Rehab administered in an outpatient setting or by doctors / medical providers can be covered by Part B when considered necessary by Medicare Standards. One example of a covered program is Cardiac Rehabilitation Programs.

“Medically Necessary”

Original Medicare will pay for part of your rehab in most cases if your care is considered “medically necessary” by CMS (Center for Medicare and Medicaid Services) standards.

According to CMS, medically necessary rehabilitation requires:

• certification by a doctor that you have a medical condition that requires rehab
• continued professional medical supervision
• coordinated care from doctors and therapists

How Many Days does Medicare Pay for Rehab?

If you only have Original Medicare, you will have costs associated with rehab for each benefit period.

• For the first sixty days, a deductible will apply (in 2020, $1,364).
• After that, a $341 coinsurance will apply to days 61-90, and $682 coinsurance from day 91 and beyond.
• Finally, if you are going beyond 91 days in rehab, you will only have 60 more “lifetime reserve days” for coverage. What this means is that Medicare will only cover 60 rehab days total in your lifetime after you hit the 90 benefit period limit. These lifetime days do not start over each year. As a result, if you run out of lifetime reserve days, you will be paying 100% of all costs for rehab when you run out.

For more information on inpatient rehab, please visit this medicare.gov page.

Medicare Supplements (Medigap)

Medicare Supplements are designed to pick up the costs that Original Medicare does not cover (such as deductibles, coinsurance and co-pays.)

Click here to read more about Medicare Supplements.

There are some Medicare Supplements that pick up just about all costs that Medicare does not pay. (As long as they are “covered services.”) You can consult this chart to see what plan pays what.

Medicare Plan F and Plan G offer the most extensive coverage and among the most popular plans.

• Click here to learn more about Medigap Plan F
• Click here to learn more about Medigap Plan G

Medicare Advantage Rehab Coverage

Private insurance companies run Medicare Advantage plans. They are designed to “replace” Original Medicare. They cover at least what Original Medicare covers plus they offer additional coverage and extra benefits and services to their beneficiaries.

• You can learn more about Medicare Advantage here.
• In addition, you can learn about the differences between Medicare Advantage and Medigap Plans here.

Each Medicare Advantage Plan will be different in regard to their Medicare rehab coverage. However, they most often offer additional coverage or a different structure as to how they cover rehab days – both inpatient and outpatient.

Additionally, all Medicare Advantage Plans (also called MA / MAPD plans) are required to have a “max-out-of-pocket” limit for each annual benefit period. This means that you will not pay more than that predetermined amount each year for your covered health services.

Now that we have looked at the various plans and how long they cover rehab, let’s look at a few specific examples that Medicare addresses.

Does Medicare Pay for Physical Therapy?

Sometimes, when people ask if Medicare pays for rehab, they are referring to outpatient physical therapy.

Medicare covers some costs for outpatient physical therapy when it is considered “medically necessary” as we defined earlier in this article.

Medicare Part B helps pay for physical therapy, and if you only have Original Medicare, you will pay 20% of your medical costs.

How Long Does Medicare Pay for Physical Therapy?

According to CMS, “Medicare law no longer limits how much it pays for your medically necessary outpatient therapy services in one calendar year.”

Finally, always remember to make sure that your physical therapy is considered both medically necessary and a Medicare covered service. If it is not, you may end up paying for all of it.

How Long Does Medicare Pay for Cardiac Rehab?

If you have recently had a heart attack or some other cardiac event (see here for more information on what “events“ CMS covers), Medicare will cover most costs for Cardiac rehabilitation programs. These programs usually are covered for as long as they are needed.

Medicare covered costs can include both regular cardiac rehab and “Intensive Cardiac Rehabilitation” Programs (ICR).

According to CMS, programs can address exercise, education and counseling in some form, and can either be held in an outpatient hospital setting or at a doctor’s office.

In regards to costs, just remember…

• Original Medicare will cover 80% of approved medical bill amounts under Part B. (Part B deductibles may apply).
• If you have a Medigap Plan (aka Medicare Supplement) then that plan will pick up additional costs according to your plan’s letter specifications. (See the Medigap chart above or visit our Medigap Page for more information.)
• Or, if you have a Medicare Advantage Plan, your plan will list out how it covers cardiac rehab costs and what your copayments will be, if any.

How Long Will Medicare Pay for Nursing Home Rehab?

If you need rehab that extends beyond a stay as an inpatient at a regular hospital, your doctors may transfer you to a “Long-Term Care Hospital” (LTCH). Long-Term Care Hospital stays are different than living in a Long-Term Care facility (also called a nursing home). They are still considered a hospital setting, so they are covered by Medicare Part A.

Under Original Medicare, your coverage lengths and payment amounts are the same as the inpatient rehab amounts we detailed out above in the section, “How Many Days does Medicare Pay for Rehab?.” Or, you can find them on the government website here.

However, your benefit period does not start over if you are transferred from one hospital to another (including a LTCH). So, you will not have to pay another deductible.

Conclusions

We understand that Medicare rules and costs are often confusing. This is especially true when you are confronted with rehab options. Your coverage lengths and costs will often be different depending on how you have your Medicare coverage set-up.

If you need more help in answering questions regarding your specific plan, you can reach out to your insurance agent or plan directly. If you are looking for an agent, you can contact us for help.

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When does Medicare pay for stem cell therapy? The answer is: in a limited amount of cases.

Stem cell therapy is still controversial and expensive. Moreover, there are limited amounts of studies available on specific therapies and procedures. As a result, Medicare’s coverage of stem cell therapies, including transplants, is minimal.

If you have a sick loved one, or if you yourself are sick, it makes sense to want to research every option available for quick healing. During your search, you may run into “stem cell therapy” as a treatment option. Sometimes, stem cell news can bring up confusing and conflicting stories. Let’s start with the basics of stem cell therapy and then discover what Medicare covers for treatments.

What is a Stem Cell?

To start, according to the Mayo Clinic, a stem cell is a “master cell” that forms a base for the creation of all the body’s other cells. (For example, brain cells, organ cells, blood cells or bone cells.) That is a simple way to look at a complex body function.

However, the main take away is, stem cells are the ONLY cells that naturally have the ability to generate new cells.

Because of their generative ability, the study of stem cells holds great possibilities for healing diseases. As a result, researchers call stem cell therapy “the next chapter” in healing our organs, blood and tissues. Effectively, reducing the need for organ transplants.

What is Stem Cell Therapy?

Doctors and researchers are creating and studying new procedures every year that will help heal organs, but the science is still new, and the verified and approved procedures and treatments are few and expensive.

Stem Cell Therapy is also called regenerative medicine. According to the Mayo Clinic it, “promotes the repair response of diseased, dysfunctional or injured tissue using stem cells or their derivatives.”

Stem Cell Therapy is a fascinating subject for anyone needing an organ transplant or experiencing organ dysfunction / organ failure. Organ donors are few and transplant lists are long. The possibility of stem cell therapy being able to be a solution is promising and exciting.

In addition, there is also hope that stem cells will be able to offer treatments in spinal cord injuries, diabetes, Parkinson’s, and heart disease.

However, not only is research expensive, it is also controversial.

So, What is the Controversy Behind Stem Cell Therapy?

The controversy behind stem cell therapy lies within where the studied stem cells are harvested. You can get stem cells from embryos, adult tissues, or even, as more recently discovered, in amniotic fluid as well as umbilical cord blood.

However, the best, more versatile stem cells are embryonic stem cells. Not only do these cells have more regenerative potential, but they also are not changed or affected by any environmental factors (like adult cells would be.)

Harvesting stem cells leads to strong ethical debates on “personhood” and whether or not researchers should be using embryos for stem cells. You can read more on that debate here.

What Does Medicare Cover for Stem Cell Therapy?

As mentioned, because the science is new and studies on procedures and their affects are limited, Medicare has a very limited coverage of Stem Cell Therapies. The CMS (Centers for Medicare and Medicaid Services) closely follow the recommendations of the FDA (Federal Drug Administration) on what procedures are considered necessary and effective.

According to the CMS, Medicare Part A covers stem cell transplants under “certain conditions”. (Part A is also responsible for transplant coverage.) Usually, these conditions start with having you try other Medicare-approved options first if stem cell therapy is not the charted first course of action.

First, know that coverage can be different in each state. However, when procedures are standardized, CMS will release new information on what is Medicare-approved nationally.

Examples of Medicare-Approved Stem Cell Therapies

The CMS has a page on “Coverage with Evidence Development,” and on this page you can find new information on coverage and research. For example, on this page, you can see information on “Allogeneic Hematopoietic Stem Cell Transplant for Multiple Myeloma.” In regards to this specific disease, stem cell therapy was approved by CMS for Medicare coverage in this specific way:

“CMS will cover items and services necessary for research under §1862(a)(1)(E) for a allogeneic hematopoietic stem cell transplant (HSCT) for certain Medicare beneficiaries with multiple myeloma (MM) using the Coverage with Evidence Development (CED) paradigm. “

https://www.cms.gov/Medicare/Coverage/Coverage-with-Evidence-Development/allo-MM

You will also find additional information on the CMS website for the following stem cell therapies:

• Allogeneic Hematopoietic Stem Cell Transplant for MDS
• Allogeneic Hematopoietic Stem Cell Transplant for Multiple Myeloma
• Allogeneic Hematopoietic Stem Cell Transplant for Myelofibrosis
• Allogeneic Hematopoietic Stem Cell Transplant for Sickle Cell Disease

Another example, is AuSCT or Stem Cell Therapy/Transplantation for Amyloidosis

According to CMS, AuSCT can treat AL Amyloidosis, a “rare blood disorder” affecting your heart, kidneys, nervous and gastrointestinal systems.

In this transplantation, stem cells are retrieved from a patient’s bone marrow or blood, stored, and then transplanted back into the patient following high dose chemotherapy used to treat various cancers.

Read more here.

National Coverage Listings are Not All-Inclusive

Of course, that list does not cover all the potential uses for stem cell therapy, but it is a place to start. Additionally, since each state’s Medicare coverage can be different, your medical providers and doctors are good places to go for Medicare coverage questions.

Where Can You Receive Medicare Covered Stem Cell Treatments?

Very few medical facilities have the equipment or expertise for specific stem cell therapies. For this reason, approved stem cell transplants (and cornea transplants) are not limited to just Medicare-approved facilities.

This flexibility can be good news for Medicare beneficiaries looking to schedule these unique procedures. On the other hand, according to Medicare.gov, all other transplants, must be done at Medicare-approved centers and facilities.

Does Medicare Cover Stem Cell Therapy for Knees?

One popular use for stem cell therapy is repairing injured knees. Unfortunately, it is not covered by Medicare at this time. In addition, stem cell therapy is not Medicare-approved for other stem cell treatments for arthritis and joint connection issues (i.e. tears and pain in ligaments and tissues).

You can certainly go outside of your Medicare coverage to have these treatments done, but be careful of clinics using non-FDA-approved techniques and making unsubstantiated claims. You can read the FDA’s warning here.

Conclusions

In Summary, if you are wondering “is stem cell therapy covered by Medicare?”

• Your best first step is to consult with your doctor and medical providers to get information on what specific therapies would be applicable to your unique situation.
• Then, specifically ask them about stem cell therapies available.
• Remember, each area of the country might have different rules and treatments available.

The post Does Medicare Pay for Stem Cell Therapy? appeared first on Medicare Life Health.

There are a lot of acronyms in Medicare, and even more in insurance. We know, it can get very confusing when you are not hip to the “Medicare/ insurance world” lingo. As a result, one of the most repeated acronym questions we hear is: What is MAPD?

Medicare MAPD plans are private insurance plans offered by Insurance Carriers to replace Original Medicare. Also called Medicare Part C, they offer a single payer option to beneficiaries. In addition, they offer extra benefits to members above and beyond what is covered in Medicare Part A and Part B. Finally, they also include a Part D drug plan.

What does MAPD Stand for?

MAPD Stands for: Medicare Advantage Prescription Drug.

If the plan does not offer drug coverage, then it is just called a MA (Medicare Advantage) Plan. As mentioned, these plans are also called Medicare Part C, and insurance companies offer Medicare MAPD plans with extra benefits to take the place of Original Medicare.

What Do Medicare Advantage Plans Cover?

Medicare Advantage Plans are regulated by the CMS (Centers for Medicare and Medicaid Services). This agency makes sure that every plan offers at least the same standards of care and coverage that Original Medicare offers. Most plans offer additional benefits, not covered by Original Medicare, such as vision, dental, hearing and even gym memberships such through organizations like SilverSneakers or Renew Active.

Medicare Advantage Plans are often set up as managed care plans with networks of doctors and hospitals members have access to. To learn more about how these networks work, please read, HMO vs PPO – Which is Better?

Costs of MAPD

Medicare Advantage Plans often come with lower premium costs than Supplement Plans. Some of them even offer “zero premium” options. They are not technically “free” because everyone still has to pay their Medicare Part B Premiums directly to the government each month.

However, they are low cost options because the government is paying the insurance company to take beneficiaries onto their books and off the government books. Essentially, the Medicare Advantage Insurance companies are replacing beneficiaries Original Medicare with their Part C plan and becoming a single-payer.

PDP vs MAPD

PDP is an acronym to Prescription Drug Plan. We also refer to it as Medicare Part D. You can read more about PDP Drug Plans here.

Similarities between PDP and MAPD Plans

• Just like Medicare Advantage (Part C), PDP plans are not administered by the U.S. government, but instead by private insurance companies. Just like MAPD Insurance plans, you can shop to find the best PDP plan for your needs each year.

• And also, just like Medicare Advantage Insurance plans, you do not have to go through medical underwriting to be accepted into a Part D plan.

• You can enter into a PDP (or MAPD) plan each year during AEP – the Annual Enrollment Period which runs from October 15th – December 7th.

Differences Between Medicare Advantage and Part D Plans

• First, if you have Original Medicare, you will need a PDP plan in addition to Parts A & B to cover your prescription drugs needs. They are not included.
• Additionally, beneficiaries on Original Medicare + a PDP Part D Drug Plan often also have a Medigap Plan (Supplement) to cover the 20% of costs, co-pays and co-insurances that Medicare does not cover.

• MAPD Healthcare Insurance Plans, on the other hand, include all three of these options in one (Parts A + B + D).
• As a result, you will not need a standalone PDP plan or a Medigap Plan in addition. All you need is your MAPD Plan (aka Medicare C).

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The post What is MAPD? appeared first on Medicare Life Health.

Attained Age vs Issue Age

Medicare Supplement Insurance Companies all price their plans differently. One of the biggest differences between plan prices is whether or not an insurance company uses attained age vs issue age to price their Medigap plans.

Background Information: What is a Medicare Supplement?

Medicare Supplement plans, also called Medigap Plans since they cover the gaps in Original Medicare coverage, are issued by private insurance companies.

Click here to read a simple, but comprehensive introduction to Medicare Supplement (aka Medigap) Plans.

Standard Coverages from Each Medicare Supplement Plan

The government tells each company what should be included/covered in each Medigap Letter Plan. As a result, they are standard in coverage. However, the insurance companies can price each plan differently, and each company does so according to its needs in each market (part of the country) they sell in.

Medigap Costs & Pricing Considerations

The way each private insurance company prices its plans has an effect on what the plan will cost you now, and then again down the road as premiums are re-evaluated each year.

Medigap Plans do tend to increase in price each year (some more than others if new people cannot enroll in them, such as Plan F or C).

Shop Your Plan, While You are Healthy

As a result, it is a good idea to shop your Medigap Plan year to year if you are still healthy enough to get medically underwritten into a new plan. (What this means is, switching Medigap plans, when you are not guaranteed to be issued one, is dependent on you being healthy enough for an insurance company to accept you into the new plan.)

• Call an Independent Insurance Agent to see what options are available to you in your area. (Ask about Plan G.)
  
• Call Carly, your Medicare Author and Independent Agent if you life in Nebraska or Iowa. Or if you live elsewhere, find an agent here.

Attained Age vs Issue Age vs Community Rated Pricing

Remember, when you are comparing private insurance companies plans, pricing is the only difference between letter plans. The coverage is the same for each letter plan, and set by the government, so pricing is your biggest consideration.

Additionally, you need to consider HOW the plan is priced, not just WHAT each plan costs. The way each plan is priced will affect how the price changes year-to-year.

There are three ways that insurance companies can price their Medigap Plans: Attained Age, Issue Age, and Community Rated Pricing.

Attained Age Pricing of Medigap (Medicare Supplement) Insurance Plans

Attained Age Plans are priced (or rated) based on your current age.

Medigap plans that use this pricing are based on your attained age. Your plan price rises as you get older. Premiums might start lower for younger beneficiaries on these plans, but when they hit certain ages set by the plan, their premiums will increase.

Attained age plans can also go up because of other factors (such as inflation or company actuarial assessments.)

Issue Age Pricing of Medigap Plans

Issue Age Rated Policies (or “entry age-rated”) have premiums based on the age you are when you purchase your plan. Or, as CMS puts it, when you are “issued” the plan. For example, when buying a new plan, a 70-year-old beneficiary will pay more for the same plans as a 65-year-old beneficiary.

This means that the younger you are when you buy this kind of policy, the less you will pay for it. In addition, the policy will not go up in price as you age, because of your age. It may go up for other reasons, but not because of your age.

Community Rated Pricing of Medigap Plans

The CMS (Centers for Medicare and Medicaid Services) and private insurance companies sometimes call Community Rated Plans “no-age-rated” plans, as their pricing has nothing to do with the age of their beneficiaries.

The price of the plan is not dependent on your age. If the plan goes up, it is not because your age went up. The increase in price may have been dependent on other factors (such as inflation).

Other Pricing Considerations

Insurance companies have other ways to raise or lower their Medigap Plan prices. According to CMS, these include:

• Plan discounts like household discounts, smokers ratings, or payment processing discounts.

• Discounts for people that apply through medical underwriting versus being a guarenteed issue.

• Using “Medicare Select” network providers in certain types of plans.

• Choosing “high-deductible” versions of specific Medigap letter plans.

Conclusions and Actions

In conclusion, since each private insurance company can price their plans differently, it is important to ask how your current supplement is priced or supplements you are considering are priced.

The pricing structure affects not only what you are paying now for your Medigap plan, but what you will also be paying in future years.

Again, call Carly, your Medicare Author and Independent Insurance Agent if you life in Nebraska or Iowa. Or if you live elsewhere, find an agent here.

Further Reading

• Read this article, if you need guidance on deciding what Medicare Plan type is right for you.

• Start here, if you need to learn the basics of Medicare, who can get it, and what it covers.

• Need to know how to apply for Original Medicare? Read this.

• Need Part D Coverage Information? Read this article on Prescription Drugs Coverage.

• Finally, start with this article, if you want to read the differences between the two paths of Medicare: Medicare Advantage vs Medigap.

The post Attained Age vs Issue Age appeared first on Medicare Life Health.

When people talk about Medicare Plan G, they are referring to the Medicare Supplement Plan G. It can also be called a Medigap Plan G. Plan G is on its way to becoming the most popular Supplement Plan.

2020, is the first year that people newly aging into Medicare cannot choose a supplement that covers the Medicare Part B Deductible. This included Plans F and Plan C. However, people who have already turned 65 before January 1, 2020 can still choose a plan F or C at any point going forward. They are considered “grandfathered in.”

Although, people age 65 before January 1, 2020 can still choose a Plan F or Plan C, it doesn’t mean that they should. These plans may get more expensive at a faster rate since they cannot enroll younger beneficiaries into them going forward. It makes sense then for everyone to learn about Plan G and all the other plans that are still available to everyone in Medicare.

What Does Medicare Plan G Cover?

Medicare Plan G is a Medigap Plan. This means it picks up the charges and fees that original Medicare does not cover.

Here is a list of the charges and fees that Plan G 100% covers, where Original Medicare leaves off:

• Part A Coinsurance
• Medicare Part A Deductible
• All Part B Co-payments and Coinsurance
• Medicare Part B Excess Charges
• The First 3 Pints of Blood
• Foreign Travel Emergencies (up to plan limit)
• Hospice Care Coinsurance
• Skilled Nursing Facilities Coinsurance

What Does Medicare Plan G Not Cover?

• What Plan G does not cover is the Medicare Part B Deductible. As of 2020, no one aging into Medicare on or after January 1, 2020, can apply for a supplement that covers the Part B Deductible.

Why? Well, the U.S. Legistlature passed a bill called the MACRA bill, or “The Medicare Access and CHIP Reauthorization Act of 2015”, that said so. It is a small attempt to keep Medicare costs lower for tax payers and assure our system is sustainable for future generations. Will it be enough? Who knows, that is beyond this article.

Plan G vs Plan F

The only difference in coverage between Medigap Plan F vs Plan G is the Part B Deductible. (Click here to learn more about 2020 Fees and Changes to Medicare Part B.)

Plan F and Plan G both have the most extensive coverage out of all the Medigap Plans. They cover 100% of the costs that Medicare leaves behind (minus the Part B Deductible for Plan G).

Even though this is the only difference between these two plans, Plan G’s will often be much less expensive to buy than Plan F’s – even after you take the Part B Deductible into consideration.

Why? The reason for this is mostly due to the fact that Plan G’s can enroll newer, younger (and hopefully, healthier) Medicare Beneficiaries into their plans. In contrast, Plan F’s will now have a shrinking pool of people to choose from as people age.

Plan F’s are not going away, as many millions of Medicare Beneficiaries still have them, but they may have steeper price increases each year – relative to other plans.

Conclusions and Actions

In summary, Medicare Plan G is a good replacement for Plan F, and offers the most comprehensive Medicare coverage available to people just now aging into Medicare.

Remember, Plan F is only available to people who already turned 65 before January 1, 2020. However, people in Plan F might benefit from seeing if they can get Medically underwritten into a Plan G as its premiums might be cheaper. In addition, Plan G’s premiums will most likely raise at a slower pace than Plan F’s as G can enroll new people.

The post What is Medicare Plan G? appeared first on Medicare Life Health.