The Medicare insurance program offers comprehensive coverage for a wide variety of health services. But understanding which services are covered and for how much can be difficult to decipher. This is especially true for more specific conditions like sporting injuries. So, does Medicare cover sporting injuries? It can, but it depends on a few different factors.

How Medicare Pays for Services

Two parts act as the foundation for your Medicare coverage: Medicare Part A and Part B. Part A helps cover your inpatient hospital needs like room and board, skilled nursing facility stays, hospice care, and more. Part B handles your outpatient care, including surgeries, doctor’s visits, lab work, and more.

Therefore, the care you receive for a sporting injury will likely fall under Medicare Part B, especially if you need Medicare physical therapy coverage. Now, Part B has a specific payment structure that is important to understand. If Medicare approves a service, Part B will pay 80% of the bill, which means you are responsible for the leftover 20%. Fortunately, Medicare Supplement plans can step in to help you.

Medicare Supplement Plans

Medicare Supplement plans, also known as Medigap plans, help cover your 20%. There are ten different Medigap plans available to beneficiaries. Depending on the plan you choose, it can cover all 20% after meeting the Part B deductible. For example, Medigap Plan G covers all Medicare-approved services after you’ve paid the Part B deductible for the year, which is $233.

There is one thing to keep in mind. Medigap plans will only help pay for a service if Medicare does. So, if Medicare denies you coverage, your Medigap plan will also reject it.

How Medicare Covers Sports Injuries

Medicare chooses to cover services based on its guidelines. More specifically, they decide to cover medically necessary services. Well, what does this mean? In other words, Medicare covers medical services needed to treat, monitor, or diagnose a health condition. Medicare can cover some preventative services but typically will not cover routine services.

So, if your sports injury requires medical treatment and those services are considered medically necessary, Medicare should provide coverage. When your healthcare provider submits a claim to Medicare, they should document the services as medically necessary in this case.

What About Medicare Advantage Plans?

If you have an Advantage plan, you may wonder if coverage works the same way. When you have an Advantage plan, you receive health benefits through that private plan, not the federal government. Although private carriers run these plans, they are required to offer the same benefits as Part A and Part B through Medicare.

The difference with an Advantage plan is that your cost-sharing may be different than if you had Medicare and a Medigap plan. Each Advantage plan is different in what it charges for specific services. You should be able to refer to your plan’s Summary of Benefits for specific expenses.

What About Medicare Part D?

Medicare Part D is coverage for your retail prescription drugs. If your provider prescribes you medication to help treat your injury, your Part D plan can help cover this. However, each Part D plan is different in which medications it covers and for how much. So, you’ll want to check with your plan to see which medications it covers.

Also, keep in mind that some medications can fall under Part B if administered to you by a healthcare professional in an outpatient setting.

Summary

Medicare, specifically Part B, can help cover a wide range of outpatient services that help treat sports injuries, including physical therapy. The key here is to remember that Medicare typically only covers medically necessary services to treat, monitor, or diagnose a health condition.

The exact costs for services depend on different factors, including which Medicare plans you have, medical necessity, your health condition, coding, and more