Medicare Coverage and Parkinson’s

Medicare - Davis Phinney Foundation

Written by Danielle Kunkle Roberts, Forbes Finance Council member and co-owner of Boomer Benefits

No one plans to spend their retirement battling a chronic illness, yet people on Medicare are diagnosed with such illnesses all the time. Dealing with a progressive chronic condition like Parkinson’s can be particularly devastating and also expensive.

Parkinson’s affects more than one million people in the United States, and these individuals can expect to spend more than $2,500 on medications each year. Costs for surgery can surpass six figures.

It’s no surprise then that older Americans with Parkinson’s have substantially higher health care spending than individuals without it. Fortunately, though, as these people with Parkinson’s age into Medicare, they can set up their coverage to help cover many of the costs of treatment and medications.

Common Treatments for Parkinson’s

While total treatment plans will vary depending on symptoms, one of the hallmarks of treatment for Parkinson’s is dopaminergic medications. Prescriptions such as Carbidopa/Levodopa can help to restore lost dopamine in the brain.  

This medication comes in many different strengths and formulations so that treatment can be individualized to each person. It can also be used in combination with other prescriptions such as dopamine agonists and anticholinergic agents to produce better results. Physical therapy, as well as speech and occupational therapy, are often prescribed alongside medication to help with mobility, balance and speech.

Unfortunately, after a person with Parkinson’s has been taking Carbidopa/Levodopa for a period of time, the medication often becomes less effective than it was initially. If the beneficiary has done well on Carbidopa/Levodopa thus far, he or she may be a candidate for a type of therapeutic surgery referred to as Duopa infusion therapy.

This advanced surgical procedure allows for continuous delivery of a suspension form of Carbidopa and Levodopa via a portable pump over a 16-hour period. The continuous nature of delivery of medicine helps to treat motor fluctuations.

During the procedure, the surgeon creates a small hole, referred to as a stoma, in the wall of the stomach and implants a PEG-J tube that delivers the medicine in a gel form directly into the intestines. The person with Parkinson’s then connects a brand-new cassette of Duopa in the mornings to replace the supply of medication.

Another surgical option for Parkinson’s is Deep Brain Stimulation (DBS). DBS is a more intensive surgery but has been approved by the FDA for over 10 years now. During this procedure, a surgeon implants an electrode into a targeted area in the brain. This electrode is connected by a wire to a pacemaker-like device implanted under the skin in the chest.  

The device stimulates pulses through the wire directly into the brain, and this helps to control movement symptoms and tremors that are resistant to medications.  

All of these treatments are covered by Medicare.

How Medicare Covers these Treatments

Traditional Medicare has two parts. Part A supplies hospital coverage. It will pay for your inpatient stay in the hospital as well as up to a hundred days in a skilled nursing facility.  If someone with Parkinson’s pursues inpatient surgery like DBS, Part A pays for this.

Outpatient treatments are covered under Medicare Part B. While this includes expected things like doctor visits and lab work, Part B also covers more costly services such as outpatient surgery, CT scans, injectable medications, durable medical equipment and physical therapy. It will cover the cassettes used with a Duopa pump and any diagnostic imaging necessary before these types of procedures.

For nearly 50 years, Medicare had no coverage for outpatient retail medications. However, all of this changed in 2006 with the advent of Medicare Part D.  Part D is optional drug coverage for people who are eligible for Medicare and are enrolled in either Part A and/or Part B.

Part D is critical for any person living with Parkinson’s. Most Part D plans cover Carbidopa/Levodopa as well as other common medications used in the treatment of Parkinson’s. All Medicare beneficiaries will have an opportunity to enroll in Medicare Part D when they first become eligible for Medicare, and there are no pre-existing condition limitations.

Medicare Part D policies are provided by private insurance carriers. However, there are federal guidelines which all plans must meet. People with Parkinson’s can see which medications are covered by each Part D plan by reviewing the plan’s drug formulary.

There are often a dozen or more Medicare Part D plans available in each state. However, Medicare’s site has a Plan Finder Tool which will help you easily compare them to determine which one will be most cost-effective for you.

Planning for Your Medicare Cost-Sharing

We often meet new Medicare beneficiaries who are surprised to learn that Medicare is not free. In fact, it functions very similar to other employer group health insurance you may have had during your working years. These plans all have cost-sharing that you pay in the form of deductibles, co-pays and coinsurance. Medicare has the same.

Let’s break down some of the cost-sharing items you will incur on each Part of Medicare. This will help you estimate your personal expected expenditures under Medicare.

When you have an inpatient hospital stay, a Medicare Part A benefit period is triggered. The Part A deductible per benefit period is $1,364 this year. A deductible is an amount that you pay out of pocket before your Medicare benefits kick in.

After you have paid your deductible, Medicare Part A covers all the rest of your inpatient hospital expenses for the next two months or 60 days. You won’t incur any further co-pays unless you have a hospital stay that is longer than 60 consecutive days, and that is rare.

It’s important to mention that it’s possible to have more than one benefit period in a calendar year. This occurs when you leave the hospital and are out of the hospital for 60 straight days, which closes the benefit period. If you go back into the hospital again, a new benefit period will begin, and you will owe the Medicare Part A deductible again.

Medicare Part B also has cost-sharing, but it has only a small annual deductible of $185. Once you satisfy that deductible, which is $185 in 2019, Medicare begins to pay 80% of all of your covered Part B services.

Your share is the other 20%, which is known as your coinsurance. There is no cap on this 20%, which is why supplemental coverage is important, and we’ll discuss that below.

Lastly, Medicare Part D plans also have cost-sharing. Some plans may require a deductible of up to $415 in 2019, and all plans will require you to pay a co-pay or coinsurance for medications by tier. Using generic drugs will help to keep your expenses down, so use those whenever possible.

Supplementing Medicare’s Coverage

Since Medicare has these gaps in the coverage, insurance companies have designed policies to help cover them. There are two main ways to get this coverage, and these are Medigap plans and Medicare Advantage plans.

Medigap plans are policies which pay after Medicare first processes and approves your claim and pays its share. All Medicare beneficiaries are given a six-month open enrollment window when they activate Part B. During this window, you can sign up for any Medigap plan you want with no health questions asked. It does not matter if you have Parkinson’s or any other health condition, so it’s a great time to get coverage without fear that the insurance company will turn you down for the coverage.

Medigap plan gives you the freedom and flexibility to see any health care provider that accepts Medicare nationwide. Comprehensive plans like Plan F or Plan G have very predictable and minimal back-end spending. These plans do not include drug coverage, so you would sign up for a standalone Part D drug plan on the back end.

The other type of coverage we mentioned above is Medicare Advantage, which falls under Part C of Medicare. These are private plans that provide your Medicare benefits to you. These plans typically have networks, so you must check with your providers to see if they participate before you enroll.

Advantage plan members can get the best pricing by treating with in-network providers. These plans are popular because they have lower premiums than Medigap plans do, but it’s important to keep in mind that you’ll have co-pays and coinsurance as you go along. Frequent health care services can add up quickly; so, you’ll want to review the plan’s summary of benefits to estimate what kind of monthly out-of-pocket spending you might have for doctor appointments, lab-work, etc.

Get quotes for both types of plans in your area and check with your providers to see which plans they participate in if you are considering a Medicare Advantage plan.

It’s important to carefully review your options so that the coverage you ultimately choose is a good fit for your personal needs and budget.

Common Questions about Parkinson’s and Medicare

Does Medicare cover physical therapy for Parkinson’s?

In the past, getting physical therapy under Medicare has been difficult for people with Parkinson’s because Medicare used to require doctors and therapists to attest that the therapy would improve the person’s condition. For people with Parkinson’s, therapy is often performed simply to maintain their current level of health and mobility.

This has changed in recent years and now medical necessity can be attained without requiring improvement. Caps on therapy were also removed in 2018, which now allows people with Parkinson’s access to more therapy each year.

Can I get Medicare due to disability under age 65 if I have Parkinson’s?

Yes. People under age 65 who qualify for Social Security Disability (SSDI) are eligible for Medicare after 24 months of SSDI benefits have been paid.

Will Medicare pay for in-home assistance for Parkinson’s?

Medicare usually does not provide non-medical home services such as cooking or cleaning or personal care like bathing and dressing. Medicare generally will only cover in-home health care services if your Medicare doctor recommends intermittent skilled care in a face-to-face meeting with you.

You must be homebound and unable to leave your home without special equipment. You must also receive care from a home health agency that is certified by Medicare.

If you meet these qualifications, then Medicare may cover limited home health care services as well as in-home physical therapy, durable medical equipment and medical supplies provided by the home health agency.

Danielle Kunkle Roberts is a member of the Forbes Finance Council and is the co-owner of Boomer Benefits, where her team assists Medicare beneficiaries with their supplemental benefit options in 47 states.  

Do you have a question about Medicare that wasn’t answered?

Please share your question in the comment section, and we’ll do our best to get an answer for you.

Want to learn more about what’s happening with Part D Access? Read: Protecting access to treatments for Medicare patients with the most complex conditions.

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Comments (14)

How are speech therapy and physical therapy yearly benefits combined? What is the number of visits allowed yearly?

Hi Judy – This is something your insurance provider can answer. I recommend calling your insurance or Medicare representative and getting the details on your specific coverage.

If a PWP is hospitalized it isvery important to get clarification about whether that individual has been admitted, or just thete for 48 hours of observation. 9nce the observation period ends, unless medicalnecessity is established, the services are notcovered by part A or B Medicare. Unfortunately, I found out the hard way.

Thank you for sharing your experience, Debra. This is a good point that I don’t think many of us would know to think of or ask about. I’m sorry you had to learn this the hard way.

Does medicare cover Rock Steady Boxing?

It does not, James. It’s not considered PT. As it is, it is just in the bucket of any type of exercise class.

Is there a chronic need Medicare plan that will cover Parkinson’s disease?

Hi Pat – Thanks for reading. Here’s a good place to start. After that, I would check with your health care team/providers to see if they offer chronic care management services.

Will Medicare cover Dialectical Behavior Therapy for Parkinsons patients. My husband has more cognitive symptoms than physical symptoms.

Hi Janet, Medicare Part B does cover some mental health-related services with certain professionals; however, in order to find out your coverage, you will need to speak with your doctor and health care providers.

Hi! My husband is receiving PT ST and OT at a center and is getting benefit with it. They want him to sign an Advance Beneficiary Notification taking on responsibility if Medicare does not pay. given the above in your article, should we sign?

Hi Shanti – Thank you for reading. My recommendation is always to check with Medicare FIRST to make sure any service you receive is covered and get it in writing. Never sign anything until you have all of the information. You may also be able to work with your husband’s PT, ST and OT to help you navigate the benefits with Medicare.

My dad is in a SNF and starting Duopa the SNF isn’t billing Medicare at all right now because he is beyond Medicare covered time period. Will Medicare part B pay for his Duopa pump fee ?

Hi Dena – I recommend speaking with your Medicare representative as soon as possible. You definitely want to get the coverage in writing so there are no surprises. Also, have you spoke with the SNF about how they are providing it? If they aren’t billing Medicare, are they billing you? This can get really messy; so, please be sure to talk to all parties involved and get your coverage in writing as soon as possible.

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