- 1 What is Parkinson’s Disease?
- 2 Diagnosis and Treatment for Parkinson’s Disease
- 3 Prescription Treatment
- 4 Surgical Treatment
- 5 Does Medicare Cover Parkinson’s Diagnosis and Treatment?
- 6 What Part of Medicare Covers the Necessary Prescriptions?
- 7 What Will You Pay Out-Of-Pocket?
- 8 What Doesn’t Medicare Cover?
- 9 Plans That Help with Costs
- 10 How to Choose the Right Plan
Parkinson’s disease (PD) is a disorder that impairs the substantia nigra. The substantia nigra is located in the center of the brain near the bottom outer edge. Within the substantia nigra are neurons that produce dopamine. When the dopamine production is diminished, it results in Parkinson’s.
PD is different for everyone. The level of severity and the symptoms vary from person to person. The most common symptoms are non-motor symptoms. Some examples of non-motor symptoms are
- Sleep disorders
- Reduced sense of smell
- Cognitive impairment
Another type of symptom people with PD can develop are motor symptoms. Those include symptoms such as
- Slowness of movement
- Rigid limbs
- Balance problems
Doctors use scales to diagnose the different stages of Parkinson’s disease. One of the most commonly used scale is the Hoehn and Yahr scale. This scale ranks PD in five stages. Stage one is the mildest form of PD and stage five is the most advanced.
Originally discovered in 1817, PD is a disease in which the cause still remains unknown. Like many diseases, there is no cure for Parkinson’s. Although PD isn’t fatal, this disease can cause deadly complications, making PD the 14th leading cause of death in the United States.
Diagnosis and Treatment for Parkinson’s Disease
As of today, there is no specific test to confirm the diagnosis of PD. Your neurologist concludes that it is PD by examining your medical history, performing diagnostic tests, and determining if you have at least two of the four motor symptoms listed above.
Parkinson’s is irreversible, but the symptoms can be managed. Luckily, there are multiple treatments to help manage Parkinson’s. Treatment plans include prescription medications, surgery, physical therapy, over the counter remedies, and general health and wellness initiatives.
Although each person with PD requires a different treatment plan. Nearly all patients will need dopaminergic medications. This type of medication helps to either replace or mimic the dopamine neurons that PD patients lack. The most effective dopaminergic medication is levodopa.
Levodopa converts to dopamine and then is transferred to the brain. Levodopa is usually combined with carbidopa. This combination allows there to be less nausea and vomiting, which are two common side effects of levodopa.
The form of dopaminergic medication that mimics dopamine are dopamine agonists. When this form of medication is taken, the brain is convinced it is receiving dopamine.
Medications that decrease tremors and extend the effect of levodopa are also available.
Doctors withhold surgery treatment for people with PD that have received treatment for symptoms but are still suffering profoundly. Surgery usually just helps to further improve symptoms that improved while taking levodopa.
Right now, there are only two main types of surgeries for PD patients. These are deep brain stimulation (DBS) and Duopa therapy.
DBS is the process of implanting a pacemaker that connects to your brain so that it sends electrical impulses to the brain nuclei. This surgery is meant to lessen PD symptoms.
Duopa therapy is a less invasive surgery that provides an alternative method of receiving the levodopa/carbidopa combination in gel form. The first step in Duopa therapy is the surgery itself. The surgeon will make a stoma (small hole) in your stomach wall so that a tube can be placed in your intestine. A Duopa pump is connected to the tube and pumps the gel medication directly into the intestine.
The rule of thumb with Medicare is that Medicare covers anything that is considered to be medically necessary. Therefore, Medicare covers many things needed for the diagnosis and treatment of Parkinson’s disease.
With that said, there are a few things that some would consider medically necessary that Medicare does not. We will discuss this in greater detail later in the guide.
Original Medicare is broken up into two parts, Part A and Part B. Each part of Original Medicare oversees a certain part of the beneficiary’s medical expenses. Part A mainly covers your inpatient hospital care while Part B covers your outpatient care.
Parkinson’s Coverage Under Part A
While Part A covers much of your inpatient hospital stay, it does not cover surgeries. Thus, deep brain stimulation for the treatment of idiopathic Parkinson’s and the surgery for Duopa therapy would be most likely be covered by Medicare Part B instead.
However, many PD patients might need skilled nursing care after undergoing one of these procedures. In that case, Medicare Part A covers the first twenty days in a skilled nursing facility (SNF) at no cost to you. You also receive an additional 80 days in which you will owe a daily copay for your SNF care.
Part A also covers hospice services and blood transfusions if needed.
Parkinson’s Coverage Under Part B
Medicare Part B covers nearly everything else. The items that PD patients might need that would be covered by Part B are
- Diagnostic testing
- Doctor visits
- Physical therapy (PT)
- Occupational therapy (OT)
- Durable medical equipment (DME)
- Mental health services
Again, in order for these items to be covered, they must be deemed medically necessary and ordered by your doctor. Your Duopa pump would be considered durable medical equipment and would be covered by Part B.
Part B also covers medications administered to you while in the hospital. Medications administered by way of IV for example.
What Part of Medicare Covers the Necessary Prescriptions?
Medicare has a specific part that covers your retail prescription drugs. Medicare Part D is an important part of a PD patient’s life. Part D is a voluntary part of Medicare. However, without this, you will pay full price for your necessary prescriptions.
Even though Part D is optional, Medicare will assess a late penalty if you do not enroll within the allotted initial election period unless you have other creditable coverage for delaying enrollment.
Each Part D drug plan has a drug formulary that lists all the medications that that specific plan will cover. We cannot stress this enough: check the drug plan’s formulary before committing to the plan. Thankfully, most Medicare Part D drug plans cover levodopa.
However, if you receive your levodopa in the gel version through a pump, that medication would be covered under Part B.
What Will You Pay Out-Of-Pocket?
Each part of Medicare has set deductibles and copays that the beneficiary must pay. These amounts change from year to year, so it’s important to note that the numbers mentioned below are based on 2018 set amounts.
If you have worked at least 10 years in the United States, you will receive Part A at no cost. You’ve paid taxes to pre-pay for these benefits. You are, however, still responsible for some cost-sharing as you use the benefits.
Part A is measured in benefit periods. This period is how Medicare measures your inpatient time spent in the hospital and a skilled nursing facility.
Medicare Part A’s deductible is $1340 for an inpatient stay at the hospital. This deductible covers your room and board for the first 60 days in the hospital. If you are released from the hospital on day 21, then return for another stay on day 45, you are still within your benefit period. Therefore, you won’t pay another deductible. However, if you leave the hospital and are out for 60 days, then the benefit period closes. Should you re-enter the hospital that same year, you will pay the Part A deductible again.
If you stay in the hospital for more than 60 days consecutively, that’s when begin paying daily copays. For days 61-90 you will pay $335 per day. If you continue your stay past three months, days 91-150 have a $670 per day copay. All costs past 150 days are your responsibility.
Medicare Part B on the other hand has a monthly premium. The average monthly premium for Part B is $134. Some individuals with higher incomes pay more.
Part B will cover 80% of medically necessary Part B items while you pay the 20%. However, before Medicare will pay anything, you must first meet the Part B deductible. Part B’s deductible is $183 in 2018 and may change from year to year.
You should know that there are no caps for out-of-pocket spending for Medicare Part A or Part B. If you don’t have a Medigap plan or Medicare Advantage plan (explained below), you could face some serious medical spending.
Medicare Part D’s national average monthly premium is $35. However, each plan sets its own monthly premium.
Just like Part A and Part B, your drug plan will also have a deductible and set copays for you to pay. Every drug plan is different in how much they charge their policyholders, but their deductible cannot be higher than $405.
Copays for Part D are based on which tier the medication is. For instance, a tier 4 medication would cost more than a tier 2 medication.
What Doesn’t Medicare Cover?
Earlier we mentioned that there might be things that people feel are medically necessary but aren’t covered.
Very often, PD patients need assistance at home with activities of daily living (ADL). Unfortunately, Medicare does not cover home health care if help with ADL is the only form of care you need.
Examples of activities of daily living are
- Getting dressed
- Using the bathroom
Medicare will only cover help with ADL if you are receiving skilled care and also needs help with ADL. Otherwise, you should be prepared to pay for these long-term care expenses on your own.
Plans That Help with Costs
As you can imagine, costs for managing Parkinson’s can amount to a very large sum. Fortunately, Medicare has options to help cover some of those costs for you.
One type of plan you can apply for is a Medigap plan. Medigap plans get their name because they cover the gaps within Medicare. For example, Medigap Plan G covers your Part A deductible and copays, as well as your Part B copays.
Monthly premiums for these plans are based on a number of things such as location, age, gender, and tobacco use. Just like other parts of Medicare, these monthly premiums can increase annually due to the rising costs of healthcare in America.
The best time to enroll in a Medigap plan is during your Open Enrollment Period (OEP). Your OEP lasts for the 6 months directly following your Part B effective date. You should enroll in a Medigap plan during this time because you won’t have to go through medical underwriting.
If you miss this period, you will have to answer health questions and could get turned down for your medical condition in most states.
Medicare Advantage Plans
Medicare Advantage plans can be a more affordable option for some individuals. With lower monthly premiums, Medicare Advantage plans are popular with today’s Medicare beneficiaries. Many plans include Part D drug plans and other helpful benefits like dental, vision, and hearing.
Medicare Advantage plans pay instead of your Original Medicare. To qualify for one, you must be enrolled in both Medicare Parts A and B and live in the plan’s service area. Though premiums may be lower than Medigap plans, you will still have to pay copays and meet deductibles set by the plan.
One thing to keep in mind when considering a Medicare Advantage plan is that they usually have networks. If you were to go out of network to see a doctor, you may not be covered on some plans. On others, you would have to pay more than what you would if you stayed within the network.
How to Choose the Right Plan
A good practice when trying to choose the best plan for you is to do just that, choose the best plan for YOU. Many people think that because their neighbor has a Medicare Advantage plan that that’s what they should get too.
Think about your specific situation and make a pros and cons list for each type of plan. If having a comprehensive Medigap plan will help you would sleep better at night, then it may be well worth the extra premium.