Does Medicare Cover Multiple Sclerosis?
Multiple sclerosis, or MS, is a widespread and oftentimes disabling neurological disease that affects about 400,000 people in the U.S. Each week, 200 people are diagnosed with MS, most of them women. Although it can occur at any age, it’s most often diagnosed in people between the ages of 20 and 40.
It’s almost impossible to predict how multiple sclerosis will affect a particular person. About 20% of MS patients have what doctors call a “benign” course of the disease. These individuals have few, less severe symptoms, and the disease progresses slowly. About 15% have the most aggressive form of MS, with steadily progressive, severe symptoms and few or no periods of remission.
As you’d imagine, treatment for multiple sclerosis is very costly. Of all chronic diseases and conditions, only congestive heart failure costs more to treat on a yearly basis. On average, medical treatment for a person with MS costs between $8,500 and $55,000 per year.
If you or someone you care for has multiple sclerosis, and you rely on Medicare for your health insurance, here’s what you need to know about your coverage.
Unfortunately, there is no specific “multiple sclerosis test.” If your doctor suspects MS after reviewing your symptoms and doing a physical exam, she will likely order one or more of the following tests to confirm the diagnosis:
● Blood tests. Although your doctor can’t diagnose MS from a blood test, she can rule out other conditions that might be causing your symptoms.
● Spinal tap. MS causes known abnormalities in spinal fluid that can be identified by a pathologist to confirm the disease.
● MRI of the brain or spinal cord. Multiple sclerosis can be diagnosed by the presence of sclerosis, or lesions, on these structures.
Medicare covers all medically necessary doctor visits and tests your doctor orders to diagnose multiple sclerosis. Part A provides inpatient hospital benefits and Part A covers outpatient medical. Most of the tests are done on an outpatient basis, which means they are covered by Part B.
Medicare Part B pays for 80% of covered services after you first pay an annual Part B deductible. This deductible is $183 in 2018.
You also pay the other 20% of the allowable charges if you have Original Medicare. There is no annual cap on how much you might spend for your share of Part B expenses. So, many individuals with Original Medicare also have a Medigap plan.
Most Medigap plans cover the 20% coinsurance under Part B that you would normally be responsible for. If Medicare approves a claim and pays its 80% share, your Medigap plan will cover its share, as well. This leaves you with little-to-no out-of-pocket for many services, depending on which Medigap plan you choose.
You can choose from 10 standardized plans in most states, and many of them also cover things like deductible and copays for hospital, outpatient and skilled nursing facilities.
You can find a list of plans and what each plan covers here.
There is no cure for MS; treatment focuses on managing the symptoms and preventing disease progression.
There are three types of MS:
● Relapsing-remitting MS (about 85% of all diagnoses). This type has well-defined periods of disease activity and worsening symptoms followed by periods of remission.
● About 50% of people with relapsing-remitting MS go on to develop a more aggressive form of the disease known as secondary-progressive MS within 10 years of diagnosis.
● Primary-progressive MS (about 15% of all cases). This type of multiple sclerosis steadily progresses without any periods of remission.
Treatment generally focuses on three areas: managing an active MS attack or flare-up, slowing the progression of the disease, and managing the signs and symptoms.
During an active MS flare-up, you may be given corticosteroids, either by mouth or IV, to reduce nerve inflammation.
If your symptoms are particularly severe, or aren’t responding to steroids, you may have plasma exchange, or plasmapheresis. This is an outpatient procedure that exchanges the liquid part of your blood, known as plasma, for plasma from a donor. You may also get a plasma substitute during plasma exchange.
Plasma exchange works by removing the proteins in your own plasma that cause MS attacks and replacing it with “clean” plasma from a donor or plasma substitute.
There are several prescription drugs used to slow the progression of the disease. If you have primary-progressive MS, the only FDA-approved medication is Ocrevus. This drug is usually given by IV infusion in an outpatient infusion center.
For relapsing-remitting types, there are several prescription drugs including beta interferons, Copaxone, Lemtrada, Gilenya, Aubagio, and Tysabri, among others. Some of these medications are given by IV infusion, some are injected under the skin or into the muscle, and some are taken by mouth.
Treatment to manage the symptoms of MS may include physical therapy to strengthen muscles and improve mobility, and prescription medications to relieve pain and reduce muscle spasms.
Multiple sclerosis medications given by injection or IV infusion in a doctor’s office or outpatient setting may be covered under Part B at 80%.
Medically necessary outpatient treatments such as plasma exchange are covered under Part B, too.
Part B also provides physical therapy that your doctor orders to help manage your MS symptoms. In prior years, there was an annual limit, or “therapy cap,” on the amount Medicare would pay towards physical and occupational therapy. These no longer apply in 2018, although Medicare may review your health records once your therapy bills reach $3,000 to make sure your treatment is medically necessary and qualifies for coverage.
Of course, if you are hospitalized for multiple sclerosis treatment, your care is covered under Part A at 100% for the first 60 days after you’ve met your Part A deductible. This deductible in 2018 is $1340.
Some individuals opt to get their Medicare coverage from a private insurance company instead of Original Medicare. These are called Medicare Advantage plans. If you have Medicare Advantage, your plan covers the same covered services asOriginal Medicare. Instead of 20% coinsurance amounts, however, you may pay a flat copayment amount for your care.Each plan varies and you should review your plan’s Summary of Benefits to see what your cost-sharing responsibility is for various services.
Oral medications you take at home are almost never covered under Part B. However, Medicare Part D is a voluntary prescription drug program that you can enroll in to help cover the costs of your retail outpatient medications.
If you have Medicare Part D coverage for prescription drugs, either as a stand-alone plan or as part of your Medicare Advantage plan, your multiple sclerosis medications are generally covered. Depending on your plan, you may have an annual deductible and/or copayment amounts when you fill a prescription. All plans have catastrophic coverage which helps to limit the total dollar amount that you can spend in any given year.
Some people experience mobility problems as their disease progresses. Your doctor may recommend a cane, walker, wheelchair, or other device to help you get around. You may also need equipment in the home such as a hospital bed, bedside commode, or other assistive devices.
Part B covers durable medical equipment (DME) at 80% of the allowable charges after you meet your Part B deductible. You may need to get your equipment from suppliers specially contracted with Medicare in order for your benefits to apply. It’s easy to find these providers on Medicare’s website using their Find a Supplier tool.
Danielle K. Roberts is the co-founder of Boomer Benefits, where she and her team help Baby Boomers navigate Medicare.