Navigating health insurance systems in the U.S. often proves a challenge at the best of times. Yet, despite any prior coverage, your health insurance will change once you turn 65. Medicare, the federal government’s health insurance, requires people over 65 to enroll in one or more of its insurance plans. Going by this, you must know about medicare coverage during menopause and what to expect.
Most women at 65 have either gone through perimenopause and entered postmenopause or are in the midst of the menopause transition. With fewer protective hormones like estrogen, however, a woman’s body becomes more at risk for temporary, menopause-related symptoms and longer-term conditions that may require prescription medication or ongoing treatment.
Does Medicare offer coverage for women undergoing perimenopause or postmenopause, and what treatment options are or aren’t available under Medicare?
What is Medicare?
Medicare is an umbrella term that refers to the different types of federal healthcare coverage people receive after they turn 65. Some people receive Medicare before turning 65 if they also receive Social Security or disability benefits or have end-stage renal (kidney) disease or ALS. However, most people must enroll in one or more types of Medicare coverage to start receiving benefits.
There are four main types of Medicare coverage:
Medicare Part A covers hospitalization and inpatient treatments.
Medicare Part B covers medical appointments and outpatient treatments, like immunizations or lab work. Together, Medicare Parts A and B are called “Original Medicare.”
Medicare Part C (Medicare Advantage) isn’t technically a type of federal insurance but an option to choose between private health insurance plans. Advantage plans must cover benefits similar to Parts A and B and may include prescription drug coverage.
What are some exceptions?
Medicare Part D covers prescription drug costs, which is where medicare coverage for menopause treatments often come into play. What must you expect with this type of coverage? Private insurance companies provide Medicare Part D coverage, and, like Part C, you can compare plans to find one that best fits your needs.
Though Medicare Part A is often free to people who receive Social Security benefits or paid ten or more years of Medicare taxes through an employer, others may need to pay a monthly premium.
Medicare Part B costs an average of $164.90 per month. You can wait to enroll in Medicare Part B if you are under an employer’s health insurance plan. When you are no longer under your employer’s plan, you must enroll in Part B to receive full Medicare coverage and avoid paying late filing penalties.
Payment assistance options are available for people unable to pay Medicare costs out of pocket through programs like State Medical Assistance (Medicaid). You can also add Medigap coverage to Original Medicare, which is “extra insurance you can buy from a private health insurance company to help pay your share of out-of-pocket costs.”
What treatments does Medicare cover during menopause?
Here’s how Medicare coverage translates to treatment for menopause-related symptoms and conditions.
If you have Original Medicare (Part A and B), Medicare Part A covers any inpatient treatment related to menopause, such as a hospital stay or medication received during your stay.
Medicare Part B covers menopause-related treatments performed in an office setting, such as labs required to test your hormone levels, other blood work, and consultations for managing your premenopausal or postmenopausal symptoms.
Does Medicare coverage during menopause include hormone replacement therapy (HRT)?
HRT remains the most popular menopause treatment and requires a prescription from a healthcare provider. The two primary types of HRT are systemic, which includes estrogen and progesterone (or just estrogen if a woman no longer has a uterus), and topical estrogen therapy, often applied directly to the vaginal tissue as a cream or lotion. Both come in various forms, such as pills, patches, creams, and rings.
Original Medicare alone does not cover prescriptions like HRT. You must either pay out of pocket for HRT or enroll in Medicare Part D to receive partial or complete coverage.
Or, if you choose to enroll in Medicare Part C (Medicare Advantage), you may find that some or all your HRT costs are covered under your plan. Even so, with either Medicare Part C or D, depending on your specific health plan, you may need to pay a deductible, copayment, or coinsurance.
If you do want to add Part D to Original Medicare or enroll in a Medicare Advantage plan, check the plan’s formulary first. A formulary refers to a list of prescription drugs covered by an insurance plan. Even within Parts C and D, some plan options may cover certain HRT types and not others.
Does Medicare cover other treatment options for menopause?
What if you choose a menopause treatment option other than HRT? If it’s a prescribed medication, you may encounter the same coverage challenges.
Most insurance companies do not cover bioidentical hormone pellet therapy, an experimental type of hormone therapy that differs from HRT. Supplements and non-hormonal treatment options are often not covered under Medicare. Newer menopause treatments also vary in health insurance coverage as some do not yet have assigned billing codes.
Can you pay out of pocket for menopause treatments, even with Medicare?
If you’re over 65, you must enroll in Medicare Parts A and B or Part C. However, if you choose to enroll only in Part A and B, your healthcare provider can still prescribe medication like HRT, but you will likely need to pay out of pocket.
To lower your costs, ask the pharmacy for the cash price of a prescription drug, which tends to be less expensive. It can also be a good idea to call different pharmacies ahead of time to compare prices.
You can also search for over-the-counter menopause treatment options, like FemmePharma’s supplements and vaginal moisturizers, that may provide sufficient symptom relief.
One of the best things to do, however, is talk with a Medicare insurance broker. You do not pay to speak with a broker. They can walk you through all your options and, based on your financial status and health history, help you determine which Medicare type fits your needs. If you require HRT for your menopause symptoms, for instance, they can help you identify an affordable plan that includes coverage for HRT.
Navigating Medicare options for menopause may feel like a challenge at first, but in time and with guidance, you can learn to master its ins and outs. Remember to be patient with yourself, read coverage descriptions carefully, and adjust as needed each year during open enrollment.