Multiple Sclerosis and Medicare Coverage
Key Takeaways
- Multiple sclerosis is a chronic neurological disorder that can affect your movement, vision, and more.
- Medicare coverage may help you access disease-modifying therapies and manage MS symptoms.
- Original Medicare from the federal government covers doctor’s office visits, hospital stays, durable medical equipment, and drugs administered in a medical setting.
- For coverage of MS medications taken at home, patients need a Medicare Part D or a Medicare Advantage prescription drug plan.
According to a 2019 estimate, nearly a million people in the U.S. live with multiple sclerosis (MS). In MS, your body’s immune system attacks the myelin sheath, the cover of proteins and fatty acids that protects your nerve cells, the messengers that connect the brain to the rest of your body. Lesions develop on your brain and spinal cord, resulting in inflammation and scarring that can cause a variety of debilitating symptoms.
To manage this chronic neurological disorder, you need a treatment plan for slowing the disease’s progression and addressing symptoms. Your health insurance can help you access the medical services and prescriptions that are essential to lead a better life with MS.
For most U.S. adults over 65, that insurance is either Original Medicare from the federal government or a Medicare Advantage plan from a private insurance carrier.
By learning about multiple sclerosis and Medicare, you can plan for a fuller, healthier future. Let’s look at some of the key choices you’ll make about your coverage and what they could mean for your MS treatment.
Multiple Sclerosis as You Age
We don’t know what causes MS, but people who have the condition usually start to experience episodes of symptoms in their 20s or 30s. While MS is unpredictable and every individual’s experience is unique, some of the most common symptoms are:
- Vision problems
- Muscle weakness
- Loss of balance and coordination
- Tingling and numbness
- Bladder control issues
- Dizziness
A first episode that lasts at least 24 hours may be diagnosed as clinically isolated syndrome (CIS), one of four MS disease courses. Treatment of CIS can slow down the progression into relapsing-remitting MS (RRMS), the type that is most commonly diagnosed. During the RRMS disease course, attacks of symptoms are followed by symptom-free periods of remission.
However, some people develop primary progressive multiple sclerosis instead (PPMS). This disease course gradually gets worse without the alternating periods of remission and relapse. On average, people with PPMS tend to begin experiencing these symptoms about 10 years later than people with RRMS.
In either disease course, MS can become increasingly debilitating as you grow older. RRMS may turn into secondary progressive MS (SPMS), which causes worse neurological function and greater disability over time without the periods of remission.
MS also combines with the effects of aging to make everyday life more difficult. For example, older women with MS may be at especially high risk for osteoporosis, in which their bones become less dense and more likely to break.
Though there’s no cure for MS, disease-modifying therapies slow its progression while symptom management and rehabilitation make it possible to maintain greater mobility and a higher quality of life. It’s important to understand how your health coverage will help you get the necessary care and support.
Managing Multiple Sclerosis on Medicare
The National Multiple Sclerosis Society estimates that over a quarter of people with MS are enrolled in Medicare. Most U.S. adults become eligible to enroll in Original Medicare from the federal government during their Initial Enrollment Period, which starts three months before the month you turn 65. However, if you receive Social Security disability benefits for at least 24 months, you can choose to enroll in Medicare before turning 65.
Original Medicare consists of Medicare Part A, which is hospital insurance, and Part B, which is medical insurance.
Medicare Part A
Medicare Part A covers your care if you need to be admitted to a hospital or another inpatient facility. After your costs reach the Part A deductible amount, Medicare will pay the expenses of a hospital stay for the first 60 days.
People with MS may need inpatient care, not only for relapses of symptoms, but for other emergencies like a medication side effect or a serious infection. For example, the University of Michigan Center for Disability Health and Wellness found that patients with MS are 65% more likely to be hospitalized because of pneumonia.
Medicare Part B
Medicare Part B covers outpatient treatment, including:
- Appointments with a neurologist and other doctors.
- Medically necessary physical, occupational, and speech therapy.
- Counseling to address the mental health challenges of life with MS.
- Medications administered in a doctor’s office, such as injections and IV infusions.
- Durable medical equipment like a cane, wheelchair, or motorized scooter to help you move around safely.
- Lab tests, such as blood tests to rule out other causes for potential MS symptoms.
- Magnetic resonance imaging (MRI), to find lesions on your brain or spinal cord.
Ready for a new Medicare Advantage plan?
Does Medicare Cover MS Drugs?
People with MS receive several different types of drugs as part of their disease-modifying therapy. Some of the most commonly used are:
- Beta interferons, which work like a protein that naturally occurs in your body to reduce inflammation. These drugs are administered by injection in people with relapsing-remitting MS to make flare-ups of symptoms less frequent and severe.
- Dimethyl fumarate, which is taken by mouth to reduce inflammation in relapsing-remitting or secondary progressive MS.
- Cladribine, which is taken by mouth in either very active cases of relapsing-remitting MS or for secondary progressive MS. It works by killing white blood cells to prevent them from attacking your myelin.
- Alemtuzumab, which also kills white blood cells but is taken as an infusion.
- Steroids to shorten a relapse by reducing inflammation.
- Muscle relaxants or sedatives to treat muscle spasms or stiffness.
- Antidepressants to address the mental health effects of living with MS.
Original Medicare covers medications taken in a doctor’s office or other medical settings. However, to help pay for most prescriptions you take at home, you need Medicare Part D prescription drug coverage. After joining Medicare Part and B, you can enroll in a Medicare Part D plan from a private insurance carrier.
You also have the option to switch to a Medicare Advantage plan. These are plans offered by private insurance carriers that substitute for Original Medicare and must at least match the coverage you’d have from Medicare Part A and B. Medicare Advantage plans may include Part D prescription drug coverage, plus other benefits that can help people with MS like routine dental, fitness classes, and transportation.
When considering a Medicare Advantage plan, keep in mind that you will need to visit healthcare providers and pharmacies in your plan’s network. Check whether the key members of your MS care team are in network.
Living with multiple sclerosis comes with many complications as you age. Exploring your healthcare coverage options can help you plan for the challenges ahead.
Sources
Multiple Sclerosis. NIH.
A new way to estimate neurologic disease prevalence in the United States. Neurology.
Osteoporosis. National MS Society.
Disease Modifying Therapies for MS. MS Society
Patients with Multiple Sclerosis More Likely to be Hospitalized for Preventable Causes. Michigan Medicine Center for Disability Health and Wellness.