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Multiple Sclerosis and Medicare – What is Covered?

By Danielle Kunkle

Entering Medicare with a chronic health condition can cause some concern. Patients with illnesses like multiple sclerosis can often be reluctant to give up employer coverage to transition to Medicare because of uncertainty over how Medicare works and what it covers.

Fortunately, Medicare does not place any limits on pre-existing conditions and will provide sound coverage of any medically necessary treatments for MS and other health conditions.

Let’s look at how the parts of Medicare cover diagnosis and treatment of MS.

Two parts to traditional Medicare

Medicare offers coverage to people 65 and older and to people under 65 who have qualified for Social Security Disability Income benefits.

Medicare has two parts that cover inpatient and outpatient care. Part A covers inpatient hospital stays and skilled nursing while Part B covers outpatient medical, including visits to specialists, diagnostic imaging, physical therapy, durable medical equipment, and injected medications that are administered in a clinical setting.

Most treatment for MS falls under Part B because treatment is provided on an outpatient basis. This may include blood tests that your doctor runs when diagnosing your condition as well as things such as spinal taps or MRI imaging of your spinal cord or brain. Part B will also provide for any mobility equipment that may need, including canes, walkers, and wheelchairs.

Because several medications that treat MS are administered by your doctor in his office, Part B would be the part that pays toward these drugs.

Part A cost-sharing

Should you have an inpatient surgery or hospital stay related to MS or any other health condition, Part A pays for the first 60 days entirely after your first meet the hospital deductible. This deductible is set by Medicare each year and in 2019, it is $1,364. If a longer hospital stay is needed, Medicare covers some of the costs while you would pay a daily copay.

Part B Cost-sharing

Part B covers 80 percent of medically necessary outpatient care after you first satisfy a small annual deductible. In 2019, that deductible is $185. This deductible is also set by Medicare annually and typically sees a slight increase each year.

You are responsible for the other 20 percent of outpatient costs. For this reason, many beneficiaries enroll in either Medicare supplement coverage or Medicare Advantage coverage to help pay for these deductibles, coinsurance, and cost-sharing that you would otherwise be responsible for.

Supplemental coverage

Medicare has standardized Medicare Supplement plans into 10 plans so that you can easily compare them. One of the most popular plans is Medicare supplement Plan G. This plan pays for all of your cost-sharing except the Part B deductible. Once that deductible has been satisfied, you would have no out-of-pocket costs toward any Part A or B covered services for the rest of the year.

With these plans, you have freedom of access to see any provider nationwide that accepts Medicare. You do not have to choose a primary care doctor or get a referral to see a specialist.

People enrolling this type of coverage would add their outpatient drug coverage separately by enrolling in a Part D drug plan. These plans each have their own deductibles and copays that you will incur when using the coverage to fill medications. You can find plans that suit you by using Medicare’s Plan Finder Tool.

Medicare Advantage coverage

Some people choose to enroll in private Medicare Advantage coverage instead of original Medicare with a supplement. These plans have networks and some plans will require you to choose a primary care physician and get referrals from him or her before you can see a specialist. 

Advantage plans typically have lower premiums than Medicare supplement plans because you are agreeing to treat with the plan’s network to help keep costs down. You will pay copays and coinsurance for various medical services as you go along, but the plans do have an out-of-pocket limit to protect you from spending beyond a certain dollar limit each year.

Some Medicare Advantage plans include built-in Part D coverage.

With Medicare in place and the right supplemental or advantage plan that meets your needs and budget, you can expect good coverage for the treatment of MS.