Does Medicare Cover Chronic Diseases?
Last Updated : 11/11/20195 min read
Chances are high that you know someone with a chronic disease—or may have one yourself. Persistent, long-term conditions like diabetes, hypertension, and heart disease often require ongoing treatment and leave a significant impact on people’s everyday lives.
Here’s a chronic disease overview, including risk factors, prevention, and how Medicare coverage works if you have an ongoing condition that needs treatment.
What is a chronic disease?
The World Health Organization (WHO) defines a chronic disease as a condition that:
- Usually progresses slowly
- Isn’t passed from person to person (noncommunicable)
- Persists over a long period
However, a National Institutes of Health paper rightly notes there is a lot of variation among the medical community when it comes to defining what a chronic disease is and what conditions fall under its umbrella. For example, according to the WHO, chronic diseases can be broken down into four types: cancers, diabetes, chronic respiratory diseases, and cardiovascular diseases. However, the Centers for Medicare & Medicaid Services (CMS) lists 15 chronic diseases that a Special Needs Plan may cover, including mental illnesses; neurological conditions; and transmittable diseases like HIV that don’t fit under the WHO’s categorization of a chronic disease.
There’s also disagreement over how long a chronic disease must persist to be considered “chronic”: the U.S. National Center for Health Statistics defines a chronic disease as a condition that lasts three months or more, while others define it as a condition that lasts for a year or more.
Despite confusion over definitions, the following conditions are usually considered to be chronic diseases by CMS:
- Heart failure and cardiovascular disorders
- Arthritis and other autoimmune disorders
- Asthma and other chronic lung disorders
- Mental illnesses like major depression
- Neurological disorders such as epilepsy or multiple sclerosis
- End-stage liver disease
- End-stage renal disease
- Hemophilia and other hematologic disorders
- Chronic alcohol and drug dependence
Chronic disease impact, risk factors, and prevention
Chronic diseases in the United States have a staggering impact when it comes to the number of people affected, death toll, and economic costs. According to the Centers for Disease Control (CDC):
- 7 of 10 deaths ever year are due to a chronic disease.
- 86% of health-care costs in the U.S. come from treating people with chronic diseases.
- Half of all U.S. adults have at least one chronic disease.
- One in four adults have two or more chronic diseases.
According to the CDC, many chronic diseases have common risk factors, such as smoking, obesity, and high blood pressure. You may be able to lower your risk for getting a chronic disease with lifestyle changes, such as:
- Reducing your alcohol intake.
- Eating a diet high in fruits and vegetables.
- Staying physically active.
- Not smoking.
- Maintaining a healthy weight.
Does Medicare cover chronic diseases?
If you have a chronic disease, such as diabetes or arthritis, you may wonder how Medicare coverage works. Medicare Part A generally covers inpatient hospital and skilled nursing facility services if your condition requires hospitalization, while Medicare Part B covers ongoing outpatient care, such as doctor visits, lab tests, screenings, and durable medical equipment such as wheelchairs.
Medicare also covers chronic care management services to help people with two or more chronic diseases expected to persist for at least a year. If you’re eligible, a health-care professional will create a plan of care that fits your health goals and work with you to meet them. You’ll also get:
- Coordinated care between your providers (such as doctors, pharmacies, and hospitals)
- Phone calls between appointments to help you stay on track with managing your chronic diseases
- 24/7 emergency access to a health-care professional
- A minimum of 20 minutes per month of services to manage your chronic diseases
Medicare covers other services to help you manage your chronic disease(s), including:
- Nutritional therapy services for diabetes or kidney disease patients
- Yearly eye exams to check for diabetic retinopathy if you have diabetes (note that routine eye exams aren’t otherwise normally covered)
- Cardiac rehabilitation programs for people with qualifying heart conditions
- Obesity screenings and counseling services
- Mental health care, including therapy services
Certain types of Medicare Advantage plans, known as Special Needs Plans (SNPs), have benefits tailored for people with certain chronic diseases, such as diabetes, dementia, and more. Special Needs Plans may include specialized formularies, provider networks, and coordination services to help you manage your chronic disease. You can see this link for a full list of conditions that a Special Needs Plan may cover. Note that not all plans are available in every location, so research plan options in your area if you have a chronic disease and are interested in a SNP.
You may be able to qualify for Medicare Coverage under 65 if your chronic disease is considered a disability by the Social Security Administration.
If you need help finding Medicare plan options to manage your chronic disease(s), I can help. Use the links below to schedule a one-on-one phone call or receive an email from me with plan information. Or, to start looking on your own time, click the Compare Plans button.