Osteoporosis, a condition that causes bones to become porous and weak, significantly increases the risk of fractures, especially in older adults. The condition is often referred to as a “silent disease” because bone loss occurs without symptoms until a fracture happens. Because of the high prevalence of osteoporosis in the Medicare-eligible population, the program provides comprehensive coverage for diagnosis, treatment, and recovery services. Coverage depends on the specific part of Medicare—Part A, Part B, or Part D—and the setting in which the care is provided.
Coverage for Screening and Outpatient Treatment
Medicare Part B covers many of the diagnostic and outpatient services necessary for managing osteoporosis. This includes bone mass measurements, such as Dual-Energy X-ray Absorptiometry (DEXA) scans, which are the standard for measuring bone mineral density. Part B covers one bone mass measurement test every two years for individuals who meet certain criteria. These criteria include a diagnosis of low estrogen, X-ray evidence of osteoporosis, or the need for monitoring ongoing osteoporosis drug therapy.
Part B also covers specific drug treatments that must be administered by a healthcare professional in a doctor’s office or clinic. These include injectable or infusible medications, such as denosumab (Prolia) or zoledronic acid (Reclast), which are not self-administered. After meeting the Part B deductible, beneficiaries typically pay a 20% coinsurance for the Medicare-approved amount of these drugs and the associated administration services. In certain situations, a home health nurse may administer the injection at home if the patient qualifies for home health services.
Prescription Drug Coverage
The coverage for osteoporosis medications is split between Medicare Part B and Medicare Part D, depending on how the drug is taken. Medications that are self-administered, typically oral bisphosphonates like alendronate (Fosamax), are covered under Medicare Part D, the prescription drug benefit. Part D plans are offered by private insurance companies and utilize a formulary, which is a list of covered drugs organized into tiers that determine patient cost-sharing.
Beneficiaries must enroll in a standalone Part D plan or a Medicare Advantage plan that includes prescription drug coverage to access these benefits. The specific cost-sharing for oral osteoporosis drugs, including deductibles, copayments, and coinsurance, is determined by the individual Part D plan. It is important for the patient to check their plan’s formulary to confirm coverage for a specific oral medication. The cost of these medications may be subject to various phases of the Part D benefit, though recent changes have capped annual out-of-pocket costs for prescription drugs.
Understanding Inpatient and Post-Fracture Care
Medicare Part A, known as Hospital Insurance, covers the acute care services often required following a severe osteoporosis-related complication, such as a hip fracture. Part A covers the costs associated with an inpatient hospital stay, including surgery for fracture repair, necessary medications, and other services rendered during the hospitalization. This coverage begins after the patient meets the Part A deductible for a benefit period.
Part A also covers short-term stays in a Skilled Nursing Facility (SNF) for rehabilitation immediately following a qualifying three-day inpatient hospital stay. SNF coverage includes skilled nursing care, physical therapy, occupational therapy, and other services necessary for recovery from the fracture. Medicare fully covers the first 20 days of a SNF stay, but a daily copayment applies for days 21 through 100.
How Medicare Advantage Plans Handle Treatment
Medicare Advantage plans (Part C) provide an alternative way for beneficiaries to receive their Medicare benefits through a private insurance company. By law, these plans must cover all the same services as Original Medicare Parts A and B, including osteoporosis screenings, outpatient treatments, and inpatient fracture care. Most Medicare Advantage plans also include prescription drug coverage (MAPD), consolidating the Part D benefit into a single plan.
While the required services are the same, Medicare Advantage plans often have different rules and cost structures than Original Medicare. These plans may utilize copayments instead of coinsurance, and beneficiaries may need to use in-network providers to receive the lowest out-of-pocket costs. The plans can also offer additional benefits not covered by Original Medicare, such as gym memberships or transportation, which support the overall health management of an individual with osteoporosis.