How Health Care Reform Affects Your Pain Treatment

Medicare Part B (Medical Insurance) helps pay for these services that may help you manage your pain and related issues:

Pain management

Medicare Part B (Medical Insurance) helps pay for these services that may help you manage your pain and related issues:

• Acupuncture for chronic low back pain
• Alcohol misuse screenings & counseling
• Behavioral health integration services
• Chiropractic services
• Depression screenings
• Occupational therapy
• Physical therapy

• Medication Therapy Management programs for complex health needs.
• Opioid pain medication. Prescription opioids, like hydrocodone (Vicodin®), oxycodone (OxyContin®), morphine, codeine, and fentanyl can be used to help relieve severe pain. Some Medicare plans have certain coverage rules to help you use opioids safely. Get more information on drug plan coverage rules.

Your costs in Original Medicare

• For most pain management services, you pay 20% of the Medicare-Approved Amount for visits to your doctor or other health care provider to diagnose or treat your condition. The Part B deductible [glossary] applies.
• If you get your services in a hospital outpatient clinic or hospital outpatient department, you may have to pay an additional copayment or coinsurance amount to the hospital.
• You pay nothing for a yearly depression screening if your doctor or health care provider accepts assignment.

Note

To find out how much your test, item, or service will cost, talk to your doctor or health care provider. The specific amount you’ll owe may depend on several things, like:

• Other insurance you may have
• How much your doctor charges
• If your doctor accepts assignment
• The type of facility
• Where you get your test, item, or service

What it is

There are many ways to manage pain safely and effectively. While prescription pain medications covered under Medicare prescription drug coverage (Part D) may be effective at treating certain types of pain, especially during short-term use, you might be able to take other medications or do other things to help effectively manage your pain with less risk long term. Talk with your doctor about all your pain treatment options.

Things to know

There may be other ways to manage your pain. Your doctor may recommend treatment options that Medicare doesn’t cover, like massage therapy.

If this happens, or if your doctor or other health care provider recommends you get services more often than Medicare covers, you may have to pay some or all of the costs. Ask questions so you understand why your doctor is recommending certain services and if Medicare will pay for them.

Related resources

• Pain management options and best practices (Health & Human Services)
• Know your options: nonopioid treatment for chronic pain (Centers for Disease Control and Prevention (CDC))
• Prescription pain medications: know the options, get the facts (Substance Abuse and Mental Health Services Administration)
• Promoting safer and more effective pain management (CDC)

How Health Care Reform Affects Your Pain Treatment

If you have chronic pain, the Affordable Care Act requires your health plan to offer certain services and benefits that can help you.* For instance, your plan must cover prescription drugs. You will also have better access to pain counseling through your family doctor.

But some questions remain. Whether you will be able to use some treatments for pain may still depend on what state you live in or on your particular health plan. Your insurance may not have to cover acupuncture or chiropractic care, for example. This may depend on where you live. Also, pain clinics are not required to be part of your plan’s network, although some plans may include them.

Pain Management Benefits

If you bought a health plan through your state’s Marketplace, on the individual market, or have insurance through your small employer, your health plan must cover a core package of benefits under the Affordable Care Act called essential health benefits. You may still have to meet your deductible first and pay a portion of the cost, except for some preventive services. While health plans offered by large employers are not required to include these essential health benefits, almost all do. The pain management benefits include:

• Prescription drug coverage
• Chronic disease management
• Emergency care
• Hospital care
• Mental health services

If you have Medicare, your plan includes the essential health benefits. So does Medicaid if you qualified due to your state’s expansion of Medicaid.

Pain Treatment and Counseling

Most of your pain management care should come from your family doctor. There are also specialists in pain clinics that focus on people with more complex cases. Check with your insurance company or employer to see if these specialists are included in your plan.

Depression and Mental Health Treatment

You might feel depressed or anxious because of your chronic pain. You can get free screening for depression under the new law. You also can get mental health treatment for depression, anxiety, and other mental health conditions.

Alternative Medicine

You might be able to have acupuncture or see a chiropractor for your pain. This depends on where you live and the specifics of your plan. That’s because states can choose whether to include these services as part of the essential health benefits package.

Most states include chiropractic care as an essential health benefit. Only a handful of states – California, Hawaii, Oklahoma, Oregon, and Utah – do not.

On the other hand, very few states include acupuncture. Only Alaska, California, Maryland, New Mexico, and Washington include acupuncture as an essential health benefit. Other states may follow.

Remember, if you get your health plan through your employer and your employer has more than 50 employees, your employer gets to choose what benefits to include.

Medicare provides very limited coverage of chiropractic care. It does not cover acupuncture.

Savings on Drug Costs for Seniors

If you’re on Medicare and take medicine for chronic pain, you may be pleased to know that the donut hole — the gap in Medicare coverage for prescription drugs — has changed significantly. Now you pay just 25% of the cost of your brand-name and generic medications. See What Medicare Costs, Part D to get the details.

*Grandfathered health plans — those that have been in effect since before the ACA passed and have not substantially changed — as well as short-term health plans — those that provide coverage for less than one year — are not required to provide the essential health benefits.

Show Sources

American Society of Anesthesiologists: “Pain Medicine.”

Institute of Medicine: “Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research.”

U.S. Preventive Services Task Force: “USPSTF A and B Recommendations.”

Robert Wood Johnson Foundation: “Chronic Disease Management.”

Kaiser Family Foundation: “Health Law Boosts Status Of Alternative Medicine — At Least On Paper.”

American Chiropractic Association: “A Blueprint for Relieving Pain.”

Centers for Medicare and Medicaid Services: “Acupuncture,” “Chiropractic Services.”

Community Catalyst and the Center for Health Insurance Studies, Georgetown University Health Policy Institute: “Essential Benefit Package.”

Bastyr University: “Health Care Law Creates Openings for CAM Fields.”

Medicare.gov: “Closing the Coverage Gap – Medicare Prescription Drugs Are Becoming More Affordable.”

American Cancer Society: “Health Insurance and Financial Assistance for the Cancer Patient.”