Medicare Coverage for Epilepsy is a concern for many Americans. Over 570,000 adults over the age of 65 are living with epilepsy in the United States as of today. As the baby boomer generation nears retirement age, that number is on the rise.
Likewise, people under the age of 65 with epilepsy are Medicare eligible due to their condition.
The World Health Organization notes epilepsy as the most common serious brain disorder. Mentioning epilepsy doesn’t discriminate, favoring no rage, age, social class, national or geographical limitations.
According to the U.S. Centers for Disease Control and Prevention (CDC), 3.4 million people in the U.S. suffer from epilepsy. This is the underlying cause of why the brain produces seizures.
Seizures are abnormal sudden bursts of electrical energy. This energy disrupts brain functions, causing patients to have seizures.
The federally funded health insurance program provides coverage for Americans under the age of 65 living with an epilepsy diagnosis. Medicare is made up of 4 different parts, each covering specific aspects of health-care services.
Part A covers inpatient and hospital services, Part B includes certain doctors’ visits, outpatient services, medical supplies and preventative care.
However, Part C is known as Medicare Advantage and is an alternative option for Original Medicare. However, advantage plans include the benefits of Parts A and B and most plans include Part D prescription drug coverage. Members like Advantage plans because they get all their healthcare from one carrier.
Medicare Coverage for Epilepsy
The Epilepsy Foundation acts as a voice for beneficiaries suffering from the disability. This foundation is the nation’s leading voluntary health organization. Estimations predict that 1 in 26 Americans develop epilepsy at some point in their life.
The most popular form of treatment for controlling and limiting seizures is with epilepsy medications. Although, epilepsy treatment needs may vary from one person to another; no one medication works for all individuals.
Evaluating this condition must be done carefully by the patient and the healthcare provider. This condition is complex and specific to the individual. Due to this, treatment options and a full range of access to services is vital for improvement.
More than 3 million Americans suffering from Epilepsy find a voice within this foundation. However, in 2018 new proposals for coverage create concern among the foundation.
Although, as of late any changes made to the program must be to benefit the consumer rather than the program.
Medicare Part D and the Six Protected Classes
Coverage includes the six classes under Medicare Part D. The policy of classes ensures a higher level of protection for six different classes of medications.
Classes include anticonvulsants for epilepsy. Although there’s no substitution for the medication’s providers use in treating epilepsy, patients respond in a different way to available treatments.
Individuals living with epilepsy want full access to all the therapy options available (including the specialists who can prescribe them). Many beneficiaries suffering from epilepsy aren’t fond of switching medications or altering their treatment plans.
Reason being these changes can induce breakthrough seizures. The problem – breakthrough seizures may increase complications and/or the costs of service. In severe cases, this can cause death.
Fortunately, in May 2019 the Centers for Medicare & Medicaid Services (CMS) gave the existing Medicare Six Protected Classes policy validation. The Part D rule was finalized, giving more importance to the policy for individuals with complex acute as well as chronic health conditions. Epilepsy was among these conditions.
Patients with such conditions must have the opportunity to seek the entire range of medications available to treat or manage their condition and maintain a decent quality of life.
Medicare Part D Low-Income Subsidy (LIS)
The Medicare Part D Low-Income Subsidy (LIS) is otherwise known as the Extra Help program. Both help low-income beneficiaries afford the costs of prescription medications.
Millions of Americans with Medicare coverage rely on the LIS program to get the medications they need. Including over 6 million individuals that are eligible for both Medicare and Medicaid programs.
Coverage denial because of Epilepsy
Coverage for a health insurance plan may not be denied due to a pre-existing condition. Although, some plans may use medical underwriting to determine acceptance of coverage or the cost.
Medical underwriting is a process many insurance companies use to determine coverage or the cost of services due to an individual’s health condition.
However, this process is illegal during any Medicare beneficiary’s Initial Enrollment Period (IEP). During an individual’s IEP, carriers may not use medical underwriting to determine the cost of acceptance of an insurance plan.
Get Extra Medicare Coverage for Epilepsy
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If you still have questions or concerns about coverage and epilepsy, contact your local agent today. Here at MedicareFAQ, all we know is Medicare. We can provide quotes, compare plan options and answer any questions you may have.
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Suffering from a disability or condition is always challenging, your health insurance coverage doesn’t need to be. Let us do the hard work for you and help you find the best plan for your budget and health needs.