Multiple sclerosis (MS) is a chronic neurological condition that affects nearly 1 million adults in the United States. If you or a loved one has MS and are eligible for Medicare, many of your costs will be covered.
Medicare provides coverage for medications, physical and occupational therapy, hospital stays, doctorsâ€™ visits, surgeries you might need, and medical equipment. Your costs and coverage will depend on the type of Medicare plan youâ€™re enrolled in and what services are medically necessary for your situation.
What parts of Medicare cover MS treatments?
As you may know, Medicare has multiple parts (A, B, C, and D) that provide different aspects of medical coverage. But it can be confusing to try and figure out what each part covers â€” especially if youâ€™re treating a chronic condition like MS.
Knowing what each part will cover for your MS treatment can help you know what to expect as you manage your health.
Medicare Part A is hospital insurance. It covers inpatient stays in hospitals and hospice care. It also provides limited skilled care in your home and short stays at skilled nursing facilities.
Part A covers any treatments you receive while admitted to a facility, including therapies and medications.
Medicare Part B is medical insurance. Together with Part A, it makes up what is known as original Medicare.
Part B covers a wide range of services you might need while managing MS, including:
- doctorsâ€™ visits
- physical therapy
- occupational therapy
- speech therapy
- counseling services
- medical equipment to use at home
- lab tests MRIs
- medications you receive at a doctorâ€™s office
Medicare Part C is also known as Medicare Advantage. When you have Part C, you buy a plan from a private insurance company that contracts with Medicare.
Your Medicare Advantage plan takes the place of original Medicare (parts A and B) and is required to cover all the same services as original Medicare.
Some plans cover additional services as well. For example, your Part C plan might also cover prescription drugs.
Most plans work with a network of providers. To receive full coverage, youâ€™ll need to use pharmacies, doctors, and other providers within the planâ€™s network.
Medicare Part D provides coverage for prescription drugs, including medications you might take to manage your MS.
Original Medicare doesnâ€™t cover medications, unless you receive them in a facility or at a doctorâ€™s office. So, you can purchase a Part D plan to supplement your original Medicare coverage.
Part D plans have what is known as a formulary. This is a list of medications the plan covers. If there are two medications that can treat the same conditions, a formulary might cover only one of them. The cost of drugs on the formulary often depends on which pricing tier they fall under.
Medigap plans are designed to cover some of the out-of-pocket costs you pay with Medicare. These plans can save you some up-front costs, like:
What specific medications, services, and treatments for MS are covered?
Managing MS often requires a treatment plan with several parts. Medicare will help cover the cost of many of these treatments, as long as theyâ€™re considered medically necessary in your situation.
The FDA has approved multiple medications for MS. Depending on your symptoms and the progression of your MS, you might be prescribed medications with one of three aims:
- Slowing the disease course. These medications are used to slow down the progression of MS. You might take these medications as a pill, injection, or infusion. Common medications in this group include interferon beta-1a (Avonex, Rebif, Plegridy), interferon beta-1b (Betaseron, Extavia), glatiramer acetate (Copaxone), fingolimod (Gilenya), and ocrelizumab (Ocrevus).
- Treating relapses. Many MS relapses resolve on their own. During a severe relapse, your doctor might prescribe high-dose medications such as methylprednisolone (Solu-Medrol), prednisone (Deltasone), or ACTH (H.P. Acthar Gel) to help you manage it.
- Managing symptoms. Not everyone with MS has the same symptoms, so the medications you need will depend on your specific experience. Medications can help manage symptoms like loss of bladder control, bladder infections, loss of bowel control, depression, pain, fatigue, sexual problems, dizziness, and tremors.
Medicare coverage for any of these medications will depend on where you receive them.
For example, if you receive prednisone in the hospital during a relapse, it will be covered under Part A. If youâ€™re taking daily medications at home to manage your symptoms or slow the progression of your MS, youâ€™ll need a Part D or Part C plan for coverage.
Much like the medications you might take for symptoms, the services you need will depend on the progression, severity, and specific symptoms of your MS.
Depending on your needs, your doctor might recommend:
- Physical therapy. Medicare will cover any medically necessary physical therapy. This means that the therapy must be used to treat your symptoms. It could include therapy to reduce pain, improve balance, or build strength.
- Occupational therapy. Medicare will also cover any medically necessary occupational therapy. Occupational therapy can help you learn or relearn how to do everyday tasks, such as showering or eating, as your disease progresses.
- Speech therapy. You can get coverage for speech therapy for any symptoms that might be making it difficult for you to communicate, eat, or swallow.
- Mental health counseling. Depression and other mental health concerns are very common among people with MS. Medicare will cover visits with mental health professionals as part of your treatment plan.
Generally, Medicare will cover these services under Part B, unless you receive them while in inpatient care.
For example, if you receive physical therapy for your MS while staying in a skilled nursing facility, Part A would cover the cost. Because Medicare Advantage plans cover at least as much as original Medicare, these services are also covered by all Part C plans.
Part B will cover durable medical equipment (DME) you use in your home. This DME must be deemed medically necessary and includes a range of things you might need to manage your MS, including:
- mobility scooters
- raised toilet seats or portable toilets
- pressure-reducing support surfaces, such as cushions or mattresses
The following table summarizes how each of the treatments weâ€™ve discussed are covered by Medicare:
What isnâ€™t covered?
Medicare wonâ€™t cover everything you might need to treat your MS. Since the course of MS varies from person to person, you might run into some things that arenâ€™t covered. Common examples include:
- Experimental treatments. Medicare wonâ€™t cover any treatments that havenâ€™t been approved by the FDA for treating MS. For example, stem cell therapy is being studied as a treatment for MS, but it hasnâ€™t been approved by the FDA. Since itâ€™s not approved, Medicare wonâ€™t cover it.
- Long-term care. Medicare doesnâ€™t cover long-term care in nursing homes or other facilities. Part A covers short- term stays of up to 60 days, as long as theyâ€™re medically necessary. Medicare wonâ€™t pay for you to permanently stay in a nursing facility or have long-term help at home.
- At-home medications. Youâ€™ll need a Part D or Medicare Advantage plan to cover any at-home MS medications. Original Medicare doesnâ€™t cover medications unless you receive them at a hospital, doctorâ€™s office, or other healthcare facility.
What costs should I expect to pay?
Your costs for MS treatment will depend on the parts of Medicare you use and the therapies you receive.
Part A costs
Most people receive Part A without a monthly premium. But youâ€™ll need to pay a deductible before Part A coverage kicks in. In 2020, the Part A deductible is $1,408.
Once youâ€™ve paid the deductible, Medicare Part A will cover 100 percent of your costs during the first 60 days of inpatient treatment. On days 61 through 90, youâ€™ll pay $352 in coinsurance per day. After day 90, youâ€™ll pay $704 per day in coinsurance until youâ€™ve used up your 60 lifetime reserve days.
The deductible and coinsurance costs apply for each benefit period. A benefit period begins the day youâ€™re admitted as an inpatient and ends when you havenâ€™t received care for 60 days. You can have multiple benefit periods in a single year.
Part B costs
Youâ€™ll pay a monthly premium for Part B. In 2020, the Part B premium is $144.60.
Youâ€™ll also need to pay the Part B deductible of $198 before your coverage begins. After you meet your deductible, youâ€™ll be responsible for coinsurance, which is 20 percent of the Medicare-approved amount for most covered services.
Part C costs
Your Part C costs will depend on the plan you choose. Not all plans are available in all states. You can shop for a plan in your area on the Medicare website. The plan you choose will determine your deductibles, copays, coinsurance, and premiums. Check the plans in your area for specific prices and services covered.
Part D costs
Just like with Part C, your costs will depend on the plan you choose. The national base beneficiary premium for Part D is $32.74 in 2020. You might also have a deductible or copayments.
You can look for plans in your area using on the Medicare website. Check each planâ€™s formulary to make sure any medications you need are covered. To lower your costs, you can ask your doctor if itâ€™s possible to switch to the generic version of any expensive brand-name medications.
Youâ€™ll have to pay a premium for Medigap plans. These premiums tend to be more expensive than those for Medicare Advantage or Part D.
But Medigap plans can help lower your out-of-pocket costs significantly. Depending on the plan you choose, Medigap can cover your coinsurance amounts, Part A premium, and more.
So, if youâ€™re going to be using a lot of Medicare services when managing a condition like MS, a Medigap plan might save you money in the long run. You can compare plans in your area to see which ones fit your budget and healthcare needs.
What is MS?
MS is a condition that affects your central nervous system. Damage to your central nervous system affects communication between your brain, spinal cord, and the rest of your body.
The cause of MS is unknown, and symptoms vary among those affected. Itâ€™s typical to be diagnosed between 20 and 50 years old, but you can be diagnosed at any age.
MS can cause difficulty walking and with other movement, but most people donâ€™t end up with paralysis. In fact, two-thirds of people with MS are able to continue walking.
Although MS itself isnâ€™t what we usually think of as a fatal condition, your life expectancy may be 7 years less than people who donâ€™t have MS.
There are four distinct types of MS:
- Clinically isolated syndrome (CIS). CIS is a severe neurological episode that lasts at least 24 hours. Not everyone who has CIS will go on to have MS. Youâ€™re more likely to develop MS after CIS if you have a lesion on your brain thatâ€™s detected by an MRI.
- Relapsing-remitting MS (RRMS). RRMS is the most common type of MS. It affects 85 percent of people diagnosed with MS and involves clear cycles or relapses where MS worsens, followed by remission without disease progression.
- Secondary progressive MS (SPMS). A diagnosis of SPMS typically follows an RRMS diagnosis. In SPMS, the disease gets worse without relapse episodes. Occasional relapses and periods of stability might still occur.
- Primary progressive MS (PPMS). About 10 to 15 percent of people with MS have PPMS. In PPMS, there is a steady progression of symptoms with no relapse or remission periods.
Living with MS
The symptoms of MS vary from person to person, but can include:
- blurred vision
- poor coordination pain
- changes in speech
- low sexual desire
- difficulty swallowing
Treatment for your MS will depend on your symptoms, type, and overall health. You can combine different therapies with advice from your doctor for a full treatment plan.
MS is a chronic condition and management often involves therapies, doctorsâ€™ visits, tests, and medications. Medicare can help you pay for some of those costs.
Different parts of Medicare will cover different treatment options. For example, your Part A coverage will cover hospital stays, while your Part B coverage will cover doctorsâ€™ visits and medical equipment. Your Part D coverage will cover necessary medications to take at home.
If you have a Medicare Advantage plan, youâ€™ll receive coverage thatâ€™s equal to coverage under parts A, B, and D combined.
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