Amyotrophic Lateral Sclerosis is a medical condition that attacks the neurons that affect your muscles. ALS disease has a few different names, but luckily Medicare covers the disease.
Lou Gehrig’s disease is one of the most common. Named after the New York Yankees Hall of Famer, he was diagnosed on his birthday in 1939. The condition caused him to retire on July 4, 1939.
Amyotrophic Lateral Sclerosis and Medicare Coverage
For most Americans, Medicare will be available once they turn 65. However, a few health conditions qualify individuals for Medicare before their 65th birthday. When diagnosed with ALS, your Medicare will start the first month you start your social security disability benefits.
There is a five-month waiting period when an ALS patient’s initial disability classification before your SSDI benefits start.
Medicare covers Americans aged 65 or older or under 65 with certain chronic health conditions. There are four parts of Medicare coverage. Combined Medicare Part A and Part B are called Original Medicare.
Part A Coverage for Amyotrophic Lateral Sclerosis
Medicare Part A. Coverage provides coverage for inpatient hospital stays, and services for Medicare Part A also extend to skilled nursing facilities, hospices, and inpatient surgeries and procedures.
Medicare Part A costs include a per-occurrence deductible and daily copays once you have been in the hospital for more than 60 days. If you’re in skilled nursing for more than 20 days, there will be a per-day copay for days 21-100
Part B Coverage for Amyotrophic Lateral Sclerosis
Medicare Part B covers outpatient services and procedures. These include doctor office visits, durable medical equipment, laboratory tests, diagnostic testing, and medications administered in a doctor’s office or outpatient setting.
Costs associated with Medicare Part B include a small annual deductible. Once you meet your deductible, you’re cost-share will consist of a 20% coinsurance and up to 15% excess charge.
Medicare Advantage Coverage for Amyotrophic Lateral Sclerosis
Medicare Part C is another way to receive your Original Medicare benefits. Part C is also known as Medicare Advantage plans. In addition to your Original Medicare benefits, Medicare Advantage plans typically include your Medicare prescription drug coverage for pharmacy prescriptions. They also have additional benefits that Original Medicare doesn’t provide.
Medicare Part C plans have their specific fee schedules. Most items are subject to a fixed copay. Some services such s durable medical equipment and drugs administered in a doctor’s office could have a 20% coinsurance. These Medicare Advantage plans must include a maximum out-of-pocket to limit the amount you pay for medical costs throughout the year.
Medicare Part D Coverage for Amyotrophic Lateral Sclerosis
Prescription drug coverage is obtained by enrolling in a Medicare Part D plan. They go hand in hand with Original Medicare and Medicare Supplement plans. They cover the prescriptions you receive from the pharmacy.
You must review the plan’s formulary to ensure that any prescription you need is covered by the plan you choose.
Private health insurance companies contracted with the federal program to administer Medicare Part C and Part D plans. The Centers for Medicare and Medicaid Services handles regulation and oversight.
Medicare Supplement Coverage for Amyotrophic Lateral Sclerosis
Medicare Supplement health coverage is additional insurance you can purchase to help cover your deductibles, copays, and coinsurance related to Original Medicare. These plans come in ten options and must have the same coverage regardless of which company you choose to enroll with.
Depending on your plan, you may have little to nothing out of pocket for your treatment. Since these plans are secondary to Medicare, you’re not required to get a referral for specialists and can see any doctor nationwide that accepts Medicare.
Medigap plans require medical underwriting for most cases. So if you’re diagnosed with ALS, your open enrollment period is the best time to enroll. Open Enrollment occurs when you start your Medicare. During this period, you can buy any Medigap policy without going through the underwriting process.
Diagnosis for Amyotrophic Lateral Sclerosis
Diagnosis of ALS can be difficult in its early stage because it has similar symptoms to other neurological diseases. A handful of tests are used to try and rule out other diseases that share symptoms with ALS. Some of the tests include:
EMGs is a test that inserts a needle electrode through your skin into different muscles. The test examines the electrical activity of your muscles both when they are contracting and resting.
Nerve Conduction Study
This test will measure the ability of your nerves to send impulses to different muscles throughout your body.
An MRI uses radio waves and a powerful magnetic field to produce detailed images of your brain and spinal cord.
Blood and Urine Tests
Testing samples of your blood and urine could help eliminate other potential causes of your symptoms.
A spinal tap uses a small needle to collect a sample of your spinal fluid from between two vertebrae in the lower back. This fluid is then tested in laboratory testing.
Your doctor may recommend a muscle biopsy and would use this to determine if you have a different muscular disease.
There are no cures for ALS, but many treatments can slow the progression, prevent complications, and help you live an independent life.
Medications are the most common treatment. The FDA approves only two prescription drugs for the treatment of ALS.
This prescription will fall under Medicare Part D. It’s an oral medication from the pharmacy. This drug can increase life expectancy by three to six months.
Part B will cover Edaravone. This drug is an IV infusion in a doctor’s office or another outpatient facility that helps to reduce the decline in daily living.
Beneficiaries with ALS may also be prescribed medications that ease other symptoms related to the disease.
Treatments for Amyotrophic Lateral Sclerosis
Several other treatments help lessen the symptoms and slow the progression of ALS. Medicare part B would cover these treatments unless you’re an inpatient in the hospital.
As your ALS progresses, you’ll start to have trouble breathing because your muscles weaken. You can choose to use a ventilator to help with breathing.
Physical therapy can help with pain, walking, and mobility. It can also assist with training to use bracing and equipment to help you stay independent.
OT can assist you in finding ways to stay independent as your hand and arm weakness increases. You can use adaptive equipment to help you perform daily activities like dressing, eating, bathing, and grooming. An occupational therapist can assist in modifying your residence to give more accessibility.
Speech therapy can teach techniques to help make speech more understandable. Therapists can also suggest and teach other methods of communication.
Nutritional support will work with you to ensure you’re eating foods that meet your dietary needs and are easy to swallow. Individuals with ALS may eventually need the use of a feeding tube.
Psychological and Social Support
A social worker can help with financial issues, insurance, getting equipment, and paying for necessary items. Psychologists, social workers, counselors, and others may provide emotional support.
Medicare Coverage for Home Health Care
Home health care services fall under Medicare Part B. Medicare beneficiaries must meet all home health care requirements before it’s covered.
The beneficiary’s doctor is required to create a care plan and deems it medically necessary that the beneficiary needs the services administered at home. The healthcare provider must frequently review the care plan.
They must have documentation from their doctor stating that they’re homebound and cannot leave their residence without assistance or excessive effort. To be approved and covered, the care plan for home health care must include specific services.
The Medicare beneficiary must need medically necessary therapy services such as occupational, physical, or speech pathology services. They also may need intermittent skilled nursing care.
Medicare Coverage for Durable Medical Equipment
There are several types of durable medical equipment needed to help ALS patients. Some of these include wheelchairs and ventilators. The part of the Medicare program that will cover this is Medicare Part B. Typically, if you’re on Original Medicare only or a Medicare Advantage plan, you’ll pay 20% of the cost of the equipment.
If you’re enrolled in a Medicare Supplement plan, the plan could pay this cost entirely. ALS is a declinable condition for Medicare Supplement health insurance. If you want to start a Medigap plan, you must enroll during your Open Enrollment Period.
Does Medicare cover ALS treatment?
Medicare covers ALS treatment. Your costs will vary depending on how you received your Medicare benefits and if you’ve enrolled in a Medicare Supplement.
How much does it cost to treat ALS?
Costs can vary based on the severity. There are different treatments, and the amount of treatment needed will increase are the ALS progressing. The ALS Worldwide organization estimates the average cost for care to be over 200,000 per year.
Does life insurance cover ALS?
If you previously had life insurance, your death benefit will be covered by your life insurance. The average life expectancy is two to five years. If you don’t have life insurance before diagnosis, you will be declined by most insurance carriers.
Some companies offer a guarantee issue policy that health qualification isn’t required. For these policies, you could apply and be approved for life insurance coverage.
Is there a limit to how many treatments Medicare will cover for ALS?
There is no limit on Medicare treatments for ALS. You should ensure that your plan covers the medications that you need.
What is the average life expectancy for people with ALS?
The average life expectancy for someone diagnosed with ALS is two to five years.
What is the difference between ALS and Lou Gehrig’s Disease?
Lou Gehrig’s disease is another name for Amyotrophic Lateral Sclerosis. These are the same medical condition.
Get Help Choosing a Supplemental Medicare Plan for Amyotrophic Lateral Sclerosis
ALS is a challenging disease to live with, and it’s essential to have coverage to help pay the cost to ensure you can live your life as fully as possible.
Let our licensed insurance agents remove the guesswork and do the heavy lifting for you. We’ll review your prescriptions and doctors and ensure we find the best options that cover your needs.
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