Under 65 with ALS: What Are Your Medicare Coverage Options

Last Updated : 07/05/20184 min read

Amyotrophic Lateral Sclerosis (ALS) is also called Lou Gehrig’s disease after the baseball player who died of the condition in 1941. This 100% fatal disease can cause a person to lose the ability to eat, speak, move and breathe, according to the ALS Association.

Medicare Part A and Part B for ALS

Medicare generally treats ALS differently than most other disabilities.

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People with ALS automatically get Medicare Part A and Part B coverage the month their disability benefits start. People with other disabilities usually have to wait 24 months after getting disability benefits before getting Medicare Part A and Part B coverage.

Medicare Part A usually covers inpatient hospital care, skilled nursing facility care, nursing home care, hospice, and home health services. Medicare Part B covers things like outpatient doctor visits, durable medical equipment, ambulance services and mental health services and some prescription drugs administered by a health care professional. According to the Food and Drug Administration (FDA) the prescription drug Radicava (edaravone) is, as of May 2017, approved to treat ALS. Since Radicava is an intravenous infusion given by a health-care professional, Part B may cover it.

Neither Medicare Part A nor Medicare Part B have an out-of-pocket maximum. This means there is no limit to what you might pay out of pocket. That’s where a Medicare Supplement plan sold by a private insurance company comes in to help cover some of the health-care costs.

Medicare Supplement for ALS

Medicare Supplement (also called Medigap) might help cover health-care costs that Original Medicare (Part A and Part B) doesn’t cover, such as copayments, coinsurance and deductibles. However, federal law does not require private companies to sell Medicare Supplement polices to anyone under 65, including people with ALS.

According to the ALS Association, the average age that people develop ALS is 55. Only half of people affected with ALS live three or more years after diagnosis, meaning that many people with ALS are under 65. The good news is some states require that private insurance companies sell Medicare Supplement plans to Medicare beneficiaries under 65. Depending on where you live, you may have a choice of multiple Medicare Supplement plans or you may have no Medicare Supplement plans available to you at all. The private insurance company may charge you more for your plan than they would charge someone 65 or older. You can contact your state’s department of insurance to learn more.

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Medicare Advantage for ALS

Medicare Advantage, also called Medicare Part C, is another way to get your Part A and Part B benefits. Medicare Advantage plans are offered by private companies and must cover everything that Medicare Part A and Part B cover except for hospice care, which Part A still covers. The benefit of Medicare Advantage plans is they usually set out-of-pocket maximums and they may cover additional benefits that Medicare Part A and Part B don’t typically cover, such as routine vision, routine dental, and prescription drug coverage. If you have Medicare Part A and Part B you can usually enroll in a Medicare Advantage plan. There are enrollment restrictions for certain conditions, such as end-stage renal disease, but no restrictions for ALS.

Medicare Part D for ALS

Medicare Part A and Part B usually only cover prescription drugs in limited circumstances, such as the prescription drugs you receive as a hospital inpatient or the prescription drugs administered to you by a doctor. Your doctor may prescribe drugs to help with other symptoms of ALS, such as muscle cramps, fatigue, pain, depression, and sleep problems, according to the Mayo Clinic. For coverage of prescription drugs you take at home, you generally need Medicare Part D. You can get Part D coverage through a Medicare Advantage plan. You can also get a stand-alone Part D Prescription Plan from a private insurance company.

If you would like to know more about how to choose a Medicare options for ALS, please feel free to reach out to me. If you prefer, you can schedule a phone call or request an email by clicking on the buttons below. You can also find out about plan options in your area by clicking the Compare Plans button.

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The product and service descriptions, if any, provided on these Medicare.com Web pages are not intended to constitute offers to sell or solicitations in connection with any product or service. All products are not available in all areas and are subject to applicable laws, rules, and regulations.

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