Medicare Coverage for Amyotrophic Lateral Sclerosis (ALS) available when the service is medically necessary. ALS is a rare, progressive disease formally known as amyotrophic lateral sclerosis. Specifically, ALS is a neurodegenerative disease that destroys the nerve cells in a patient’s spinal cord and their brain.
The scientific name broken down means, (a) no (Myo) muscle (Trophic) nourishment. Referring to the lack of nourishment in a person’s muscles. Without proper or any nourishment, muscles waste away.
The term “Lateral” is referencing the affected areas of the spinal cord. These areas are where parts of the nerve cells send signals to control certain muscles. As time progresses, these areas begin to degenerate. This causes scarring, which is the hardening of an area; otherwise known as “Sclerosis”.
Motor neurons are a type of nerve cell, part of the body’s Nervous System. Healthy motor neurons trigger the contraction of muscles. ALS disease destroys these motor neurons. This causes muscle weakness.
Medicare Coverage for Amyotrophic Lateral Sclerosis
Individuals with ALS or kidney failure (ESRD) may receive health care benefits through Medicare. Patients with these chronic diseases may enroll in Medicare without any age restrictions. The 24-month period of disability before coverage starts doesn’t apply in these cases.
Original Medicare Parts A and B provide beneficiaries with coverage for health care services. They must be medically necessary for treating or maintaining a health condition. Part A covers most inpatient hospital services, while Part B covers outpatient services and diagnostic tests.
Diagnostic Testing for ALS
ALS affects the body’s motor skills, senses like sight, touch, hearing, taste, and smell are not affected by the disease directly. Although many ALS patients report no change in the muscle use of the eyes and bladder.
However, the disease eventually prevents patients from breathing on their own. As breathing muscles weaken, permanent breathing support and assistance will become necessary. Due to the different variables among ALS patients, the initial diagnosis and testing may be difficult.
Symptoms may start as painless or come in sequences or patterns as the disease progresses. Universally, weakening muscles and paralysis are chief complaints in ALS patients. Many comprehensive diagnostic tests include many separate procedures.
Covering the costs for patients with this disease may be paid for by Medicare. The ALS Association is a national non-profit organization leading the fight of Lou Gehrig’s Disease.
The goal is to improve the quality of life through extensive research for new treatments and a cure. Working with the Centers for Medicare and Medicaid Services to help those suffering from ALS.
Medicare Eligibility for ALS Patients
Benefits provide ALS or ESRD patients with the proper and necessary healthcare services through their Medicare health insurance plan or policy.
Social Security Disability benefits begin five months following a patient’s initial “disability” classification from their healthcare provider. Therefore, it’s important to submit applications to either Social Security or the railroad retirement board immediately after receiving this diagnosis.
Although, ALS and ESRD are the only qualifying disabilities this rule applies. Other disabling health conditions may require individuals to receive SSDI benefits for 24 months prior to becoming eligible.
Enrolling in Medicare Part D With ALS
Enrollees can choose an appropriate Medicare Part D plan as soon as they’re eligible for Medicare. Future members should enroll during their Initial Enrollment Period (IEP).
Each person’s 7-month window to enroll (IEP) is likely different because their 65th birthdate is likely not the same. This period starts 3 months prior to a person’s 65th birthday month, the month of, and ends 3 months after turning 65.
Due to the nature of Lou Gehrig’s disease, prescription drugs are necessary to maintain the patient’s quality of life and health condition. Part D Prescription Drug plans can help pay for these drugs or lessen the cost.
Does Medicare Cover Home Health Care for ALS Patients
In most cases, Part B covers the cost of many home health care services and benefits. Members must meet all the requirements before receiving coverage for care. All beneficiaries needing health care services at home must be under the care of a physician who they regularly visit.
Doctors or other health care providers must create a care plan for patients, such as those with ALS. A care plan should establish regular services a patient receives. Additionally, providers must regularly review care plans.
Beneficiaries must have certification from their healthcare provider stating that they’re bound to their home. Meaning, they can’t leave without extensive effort and/or assistance.
Intermittent skilled nursing care or therapy services must be medically necessary to qualify for coverage. Therapy includes physical, occupational and speech-language pathology services.
Intermittent care is for less than 7 days a week or less than 8 hours a day. Care may be for up to 21 days or less. Although, beneficiaries must use a home health care company that Medicare approves for it to cover the costs of services.
Medicare Costs of Home Health Care for ALS Families
Part B pays for health care services in a beneficiary’s home. However, individuals must be eligible for services, meeting all Medicare’s requirements. Health care providers must certify the medical need for home health care coverage.
The costs of services for ALS families depend on what plan the beneficiary has and what it pays for. Original Medicare beneficiaries are responsible to pay premiums, deductibles, and copayments and coinsurance costs for most services. Enrollees must join a separate plan for any prescription drug coverage, many Part D Prescription Drug policies are available.
Beneficiaries under Medicare Advantage plans must use providers within the plan’s network. Referrals for specialist visits may also be a requirement under many MA policies. Members may also have similar out-of-pocket expenses like premiums, deductibles, and copays/coinsurance costs.
Medicare Coverage for Disabilities: Amyotrophic Lateral Sclerosis
Lou Gehrig’s disease or Amyotrophic Later Sclerosis patients are the exceptions to waiting periods for those under 65 with disabilities for Medicare coverage. Once SSDI benefits begin, Medicare eligibility begins automatically.
Patients with other disabling health conditions should complete and submit disability applications. Social Security requires an application before issuing SSDI benefits. The Railroad Retirement Board requires patients to submit applications for any railroad disability annuity benefits.
Social Security Disability requires a 24-month period of receiving benefits before Medicare coverage starts. ALS patients don’t have to collect these benefits for two years; they’re automatically eligible for coverage once classified as “disabled” for 5 months.
Ice Bucket Challenge
In 2014 the ALC Ice Bucket Challenge went viral on the internet. Videos of people dumping buckets of ice and water over their heads flooded social media platforms.
The ALS association used the funds that came from the Ice Bucket Challenge towards more research for developing treatments and finding a cure. From 2014-2018 the Association devoted almost $90 million funding research across the globe.
Since the challenge, The ALS Association has expanded its network of scientists. The network of clinical providers has also grown. In 2014, there were 100 Certified Treatment Centers of Excellence, Recognized Treatment Centers and Affiliated Clinics to 156 centers as of today.
Get Help Finding Medicare Coverage for Amyotrophic Lateral Sclerosis
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