Medicare Part A, B, C & D Coverage for Pain Management

While individuals may be open to trying alternative therapies to control their pain, which ones they ultimately choose is largely influenced by their insurance coverage. Original Medicare, Medicare Advantage, and prescription drug plans cover many treatments and services used in pain management, but which benefit the coverage falls under will depend on how the treatment is given or administered. Here is an overview of the parts of Medicare that help pay for pain management and what therapies are included.

Medicare Part A

Part A provides hospital insurance. It pays for eligible hospital inpatient, home health, hospice, and skilled nursing facility care. Patients may receive pain management if they’re an inpatient at a hospital or long-term care facility for reasons such as trauma or major injury, surgery, or treatment of a serious illness (e.g., cancer). While they’re admitted to the hospital, their pain may need to be managed by several different therapies or services such as medications (both narcotic and non-narcotic), occupational therapy (OT), physical therapy (PT), or spinal injections.

To be eligible for coverage, the individual must be enrolled in either an Original Medicare plan or a Medicare Part C (Medicare Advantage) plan. A doctor must deem their hospital stay medically necessary and the hospital must participate in Medicare.

Medicare Part B

Part B provides medical insurance, which helps pay for outpatient services, such as those to diagnose and treat medical conditions, as well as preventive care. Physicians may recommend several different therapies to help manage pain. Outpatient services covered under Part B for pain management include:

Medication: Doctors may order prescription medications or over-the-counter (OTC) drugs to help control pain. In some instances, prescribed drugs may be covered under Part B, for example, when a doctor is required to administer the medication in their office. Most prescription coverage is provided by Medicare Part D, which pays for many types of pain-relieving prescription drugs, as well as a Medication Therapy Management (MTM)

Acupuncture: Research suggests that this form of traditional Chinese medicine, which involves the stimulation of specific points on the body, usually through the insertion of thin needles into the skin, may help low back pain. Part B covers up to 12 visits in 90 days for chronic low back pain and an additional eight sessions if the patient is improving.
Physical therapy: Used for both acute and chronic pain issues to improve strength or correct how a person uses their body, PT is a rehabilitative process that may include techniques, such as heat and cold, exercise, massage, and electrical stimulation, to improve functioning and manage pain.
Occupational therapy: With OT, a therapist evaluates how pain limits a person’s activities and assists them with durable medical equipment and pain management strategies. OT helps patients get back to their normal daily activities; ones that they may not be able to do while in pain. It must be medically necessary and certified as such by the provider.
Chiropractic spinal manipulation: Data suggest chiropractic care, which involves manipulation or adjustment of the spine and other parts of the body, is as effective at treating lower back pain as Part B covers manual manipulation of the spine to correct subluxation only. No other tests or services are covered.
Behavioral health integration services: Sometimes, people with chronic pain also have problems with anxiety and depression. Cognitive behavioral therapy is a form of psychotherapy that focuses on helping patients change their thinking patterns to change unhealthy behavior or moods. Medicare covers behavioral health services, as well as individual and group therapy, if certain conditions are met.
Alcohol use disorder screening and counseling: Chronic pain can lead to substance abuse. Alcohol use can increase in those suffering from chronic pain and may lead to various health Part B covers one alcohol misuse screening and up to four brief counseling sessions a year.
Depression screening: Chronic pain can trigger depression and depression can make pain worse. Detection and intervention are key. Part B covers one screening per year with doctors who can order treatment or give a referral.

Other forms of outpatient pain management also covered under Part B include outpatient injections (i.e., steroid injections, epidural injections), transcutaneous electrical nerve stimulation (TENS) for pain after a surgical procedure, and autogenous epidural blood graft (blood patch) for headaches after an epidural or spinal tap. Note that before these services and procedures are covered, a Medicare-enrolled doctor must certify that they are medically necessary to treat the patient’s condition.

Medicare Part C

Medicare Advantage Plans, also known as Part C or MA plans, are an “all in one” alternative to Original Medicare. They are offered by Medicare-approved private insurance companies. These bundled plans include Part A and Part B and usually Part D. Some Part C plans offer additional benefits, which may include additional pain management services.

Most MA plans offer coverage for things Original Medicare doesn’t pay for, such as vision, hearing, dental, and fitness programs (gym memberships or discounts). Plans can be tailored for individuals who would like to choose to cover even more benefits. For example, some plans may offer coverage for services like transportation to doc- tor visits, OTC drugs, and services that promote health and wellness. Check with plan providers to explore available coverage options.

Medicare Part D

Part D provides prescription drug coverage that will help pay for medications and programs to manage them. MTM programs are covered and can offer help navigating complex health needs. Through MTM, patients will get a comprehensive review of their medications, explanations of why they are taking them and potential side effects, and analysis of whether their costs can be lowered.

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 type of pain medication a person’s doctor can order. Costs will vary from plan to plan, as will the coverage amount for different drugs. Both Part D and some MA plans cover many of the medicines commonly prescribed for pain management, which include but are not limited to:

Narcotic medications, such as hydrocodone (Vicodin®), oxycodone (OxyContin), morphine, codeine, and fentanyl
Neuroleptic medications, such as gabapentin, that depress nerve function and relieve nerve pain
Anti-inflammatory medications, such as celecoxib (Celebrex®)

There are several OTC medications that may help manage pain, such as acetaminophen, ibuprofen, naproxen, and lidocaine patches, but Part D does not cover OTC medications; only prescription drugs. Some Part C plans may include an allowance for these medications. Check with each plan to verify coverage.

References:

https://www.medicare.gov/coverage/pain-management

https://www.hhs.gov/sites/default/files/pmtf-final-report-2019-05-23.pdf

https://www.cdc.gov/drugoverdose/data/index.html