Transcript (Erectile Dysfunction and Medicare)

Introduction
Erectile dysfunction, often called ED, is common and treatable. ED can feel private, but it is a medical issue. It can also point to other health concerns. Many men in the United States experience ED. Research shows that 60% of men over 60 may have ED. By age 70, about 70% of men report some erectile dysfunction. [National Library of Medicine]

Medicare can help with prevention, diagnosis, treatment, follow-up, and medications. Before we get into ED coverage, it helps to look at what Medicare covers overall. Part A covers medically necessary inpatient hospital stays and skilled nursing facility care. It also covers hospice and some home health services. Part B includes doctor visits, preventive services, durable medical equipment, and outpatient care. Part D generally covers prescription drugs you get from a pharmacy.

Medicare A, B, C, and D can include co-insurance, co-pays, and deductibles.

In this video, we’ll walk through erectile dysfunction prevention, diagnosis, treatment, follow-up, and medications.

Prevention
Among men over 65, ED is often linked with other health issues. The issues could stem from heart or circulation problems, vascular conditions, nerve-related issues, hormones, medications, or psychological factors.

Medicare may cover preventive services tied to related risks. These may include diabetes screening, cardiovascular risk counseling, and depression screening. Medicare Part B covers most preventive services, including a Yearly Wellness visit. Those visits may support an ED prevention plan.

Diagnosis
ED is usually diagnosed through a conversation with a doctor. The doctor may ask about symptoms, medications, health history, and lifestyle. Blood or urine tests may check diabetes, cholesterol, hormone levels, or other concerns. Some men may need to see a urologist for more testing.

Medicare Part B covers many diagnostic tests, doctor visits, and outpatient care when ordered to evaluate ED or related conditions, subject to a deductible and 20% coinsurance.

Treatment

ED treatment depends on the cause. Some men improve with lifestyle changes, counseling, or medication changes. Common treatments include oral medications, injections, urethral medication, hormone treatment, vacuum devices, or penile implants. Medicare may cover some medically necessary ED care.

CMS has a national coverage determination for Diagnosis and Treatment of Impotence [also called NCD 230.4]. It states that program payment may be made for diagnosis and treatment of sexual impotence when appropriate.

Follow-Up
Follow-up care is important for managing ED and monitoring side effects. Some men only need follow-up visits and medication adjustments. Others may need monitoring after injections, hormone therapy, or surgery. Counseling may also help when ED affects confidence or relationships. Medicare often covers necessary ED follow-ups when related to other health problems.

Medications
Medicare Part D rarely covers drugs used for sexual or erectile dysfunction. An exception might exist if the drug is also approved for a different condition.

Prescription drug coverage varies by plan rules, tiers, formulary, and pharmacy network. A formulary is a drug list covered by your Part D plan. A drug may require prior authorization, step therapy and quantity limits. Part B often covers outpatient drugs given in medical settings. In most cases, this involves drugs given via injection or infusion, and vaccines for prevention.

Medicare Advantage
With Medicare Advantage, additional rules come into play. All plans must include Medicare services; however, the guidelines can change. Network use, referrals, and prior authorization may affect access. Medicare Advantage plan rules can also affect costs and timing. Some plans may offer extra support for ED treatment. These services can vary by plan and location.

Final Thoughts

Erectile dysfunction is common, treatable, and worth discussing. It may be connected to blood flow, nerves, hormones, medications, or mental health. Medicare may help cover diagnosis and some medically necessary treatment. But ED medications are usually not covered when used for ED. The best next step is a direct conversation with a doctor. A private concern may lead to better answers, better care, and better overall health.