Does Medicare Cover Multiple Sclerosis Treatment?

What parts of Medicare cover MS treatments?

The different parts of Medicare (parts A, B, C, and D) provide different aspects of medical coverage.

Knowing what each part covers for your MS treatment can help you know what to expect as you manage your condition.

Part A

Medicare Part A is hospital insurance. It covers inpatient stays in hospitals. 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.

Part B

Medicare Part B is medical insurance. Together with Part A, it makes up Original Medicare.

Part B covers a wide range of services you may need while managing MS, including:

• doctors’ appointments
• physical therapy
• occupational therapy
• speech therapy
• counseling services
• medical equipment to use at home
• lab tests
• MRIs
• medications you receive at a doctor’s office

Part C

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 may also cover prescription drugs.

Most plans work with a network of providers. To receive full coverage, you’ll need to use pharmacies, doctors, and other providers within the plan’s network.

Part D

Medicare Part D provides coverage for prescription drugs, including medications to manage MS.

Original Medicare doesn’t cover medications unless you receive them in a facility or at a doctor’s office. So, you can purchase a Part D plan to supplement your Original Medicare coverage.

Part D plans have what’s known as a formulary. This is a list of medications the plan covers. If there are two medications that can treat the same condition, a formulary may cover only one of them. The cost of drugs on the formulary often depends on which pricing tier they fall under.

Medigap

Medigap plans cover some of the out-of-pocket costs you pay with Medicare. These plans can save you some upfront costs, like:

• deductibles
• coinsurance
• copays

However, they do not cover services not covered by Medicare.

What specific medications, services, and treatments for MS are covered?

Managing MS often requires a treatment plan with several parts. Medicare typically covers the cost of many of these treatments, as long as they’re considered medically necessary in your situation.

Medications

The Food and Drug Administration (FDA) has approved multiple medications for MS. Depending on your symptoms and the progression of your MS, your doctor might prescribe medications with one of three goals:

• Slowing the disease course: These medications help slow the progression of MS. You might take them 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)
  • ocrelizumab (Ocrevus)
• Treating relapses: Many MS relapses resolve on their own. During a severe relapse, your doctor might prescribe high dose medications to help you manage it, such as:
  • methylprednisolone (Solu-Medrol)
  • prednisone (Deltasone)
  • ACTH (H.P. Acthar Gel)
• Managing symptoms: Not everyone with MS has the same symptoms, so the medications you need 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
  • tremors

Medicare coverage for these medications depends on where you receive them.

For example, if you receive prednisone in the hospital during a relapse, it’s covered under Part A. If you’re taking daily medications at home to manage your symptoms or slow the progression of your MS, you’ll need a Part D or Part C plan for coverage.

Services

Much like the medications you might take for symptoms, the services you need depend on the progression, severity, and specific symptoms of your MS.

Depending on your needs, your doctor might recommend:

• Physical therapy: Medicare covers medically necessary physical therapy. This means the therapy must be used to treat your symptoms. It could include therapy to reduce pain, improve balance, or build strength.
• Occupational therapy: Medicare also covers medically necessary occupational therapy. If needed, occupational therapy can help you learn or relearn how to perform everyday tasks, such as showering or eating, as MS progresses.
• Speech therapy: You can get coverage for speech and language 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 common among people with MS. Medicare covers visits with mental health professionals as part of your treatment plan.

Generally, Medicare covers 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 covers the cost. Because Medicare Advantage plans cover at least as much as Original Medicare, these services are also covered by all Part C plans.

Medical equipment

Part B covers durable medical equipment (DME) you use in your home. This DME must be deemed medically necessary. It can include a range of devices you may need to manage MS, including:

• canes
• walkers
• mobility scooters
• wheelchairs
• raised toilet seats or portable toilets
• pressure-reducing support surfaces, such as cushions or mattresses

The following table summarizes how each of the treatments discussed in this article are covered by Medicare:

What isn’t covered?

Medicare may not cover everything you need to treat your MS. Since the course of MS varies from person to person, you might run into some things that aren’t covered. Common examples include:

• Experimental treatments: Medicare does not cover any treatments that haven’t been approved by the FDA for treating MS. For example, researchers are studying stem cell therapy as a treatment for MS, but the FDA hasn’t approved it. Since it’s not approved, Medicare won’t cover it for MS.
• Long-term care: Medicare doesn’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 they’re medically necessary following a hospital stay. Medicare won’t pay for you to permanently stay in a nursing facility or have long-term help at home.
• At-home medications: You’ll need a Part D or Medicare Advantage plan to cover any at-home MS medications. Original Medicare doesn’t cover medications unless you receive them at a hospital, doctor’s office, or other healthcare facility.

What costs should I expect to pay?

Your costs for MS treatment depend on the parts of Medicare you use and the therapies you receive. Here’s a cost breakdown according to a Medicare fact sheet.

Part A costs

Most people receive Part A without a monthly premium. But you’ll need to pay a deductible before Part A coverage kicks in. In 2024, the Part A deductible is $1,632.

Once you’ve paid the deductible, Medicare Part A covers 100% of your costs during the first 60 days of inpatient treatment. On days 61 through 90, you’ll pay $408 in coinsurance per day. After day 90, you’ll pay $816 per day in coinsurance until you’ve used up your 60 lifetime reserve days.

The deductible and coinsurance costs apply for each benefit period. A benefit period begins the day you’re admitted as an inpatient and ends when you haven’t received care for 60 days. You can have multiple benefit periods in a single year.

Part B costs

You’ll pay a monthly premium for Part B. In 2024, the Part B premium is $174.70.

You’ll also need to pay the Part B deductible of $240 before your coverage begins. After you meet your deductible, you’ll be responsible for coinsurance, which is 20% of the Medicare-approved amount for most covered services.

Part C costs

Your Part C costs 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 determines your:

• deductibles
• copays
• coinsurance
• premiums

Check the plans in your area for specific prices and services covered.

Part D costs

As with Part C, your Part D costs depend on the plan you choose. Many people only pay their monthly premium, but you may also have a deductible or copayments.

You can look for plans in your area using the Medicare website. Check each plan’s formulary to make sure any medications you need are covered.

To lower your costs, you can ask your doctor if it’s possible to switch to the generic version of any expensive brand-name medications.

Medigap costs

You’ll have to pay a premium for Medigap plans, which 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.

If you’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.

The takeaway

MS is a chronic condition. Management often involves therapies, doctors’ 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, Part A covers hospital stays, while Part B covers doctors’ visits and medical equipment. Part D covers necessary medications to take at home.

If you have a Medicare Advantage plan, you’ll receive coverage that’s equal to coverage under parts A, B, and D combined.