Does Medicare Cover Sepsis?

Last Updated : 09/10/20184 min read

Sepsis, which is potentially fatal, is the body’s extreme response to infection. Sepsis causes system-wide inflammation injuring tissues and organs, according to the Centers for Disease Control and Prevention (CDC). Sepsis may progress to septic shock, causing the blood pressure to drop dramatically which may lead to death, according to the Mayo Clinic.

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Age is a risk factor for sepsis. While people aged 65 years and older make up about 12% of the American population, they make up 65% of sepsis cases in the hospitals, according to a 2006 study reported by the Sepsis Alliance. People with chronic medical conditions, such as diabetes, lung disease, cancer, and kidney disease and those with weakened immune systems are considered at higher risk of an infection turning into sepsis than others, according to the CDC.

What causes sepsis?

The Centers for Disease Control and Prevention (CDC) explains that sepsis happens when an infection you already have – in your skin, lungs, urinary tract or somewhere else – triggers a reaction throughout your body.

What are the symptoms of sepsis?

Often people with sepsis appear confused or disoriented. Other symptoms include fever, chills, shortness of breath, low body temperature, low blood pressure, rapid pulse, and extreme pain or discomfort, according to the CDC.

How is Sepsis Treated?  

Time is of the essence when you or your doctor suspects an infection has progressed to sepsis.  Aggressive treatment boosts your chance of survival according to the Mayo Clinic. Sepsis is almost always treated in the hospital. People with severe sepsis require close monitoring and treatment in a hospital intensive care unit. According to the Mayo Clinic, treatment typically includes IV fluids and antibiotics. Other medications, such as those to raise blood pressure, insulin, and painkillers may be needed. Machines used to monitor body functions such as heart rate and blood pressure are common in the treatment of sepsis. In cases of severe sepsis or sepsis shock, machines to support body functions, such as a ventilator to help the patient breathe or dialysis for kidney failure, are common.  Surgery may be necessary to remove the infection or abscess.

Is treatment for Sepsis covered by Medicare?  

Yes, Medicare generally covers medically necessary treatment for sepsis. Medicare Part A usually covers inpatient hospital services, including semi-private rooms, meals, general nursing, and medications as part of your inpatient treatment, as well as other hospital services and supplies. Because sepsis is treated in an inpatient hospital setting, Medicare Part A is likely to pay its portion of medical expenses incurred at a Medicare participating facility. You would be responsible for paying the Medicare Part A deductible ($1,340 in 2018) and coinsurance.

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If you have a Medicare Supplement plan, it may help you with some of these expenses related to your Medicare cost-share. Your cost share may be less if you are enrolled in a Medicare Advantage plan. Medicare Advantage is another way to get your Part A and Part B benefits through a private company. Medicare Advantage covers everything original Medicare covers with the exception of hospice care, which is still covered by Part A.

If you have been hospitalized a long time with sepsis, you may suffer from post-sepsis syndrome (PSS), which affects approximately 50% of survivors, according to the Sepsis Alliance. Your doctor may refer you to counseling, physical therapy, or neurorehabilitation, explains the Sepsis Alliance. Medicare Part B (outpatient insurance) may help you pay for medically necessary care you receive to treat PSS. Typically Medicare Part B covers 80% of the Medicare allowed amount after you have met your deductible. You are responsible for the Medicare Part B deductible and 20% of the Medicare allowed amount. Your out-of-pocket costs may differ if you have a Medicare Supplement plan working alongside your Medicare coverage or if you are enrolled in a Medicare Advantage plan.

Do you have further questions about Medicare coverage and sepsis? Would you like help finding Medicare Advantage plans or Medicare Supplement plans that may be of interest to you in meeting your health insurance goals? I would be happy to help you.

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