- Medicare provides coverage for epilepsy.
- Epilepsy is a chronic condition that might make you eligible for Medicare before you’re 65 years old.
- Medicare coverage includes the tests your doctor needs to diagnosis your epilepsy.
- Medicare will also cover medications and treatments for epilepsy, including surgery.
Epilepsy is a chronic condition that causes you to have unpredictable seizures. Medicare provides coverage for the care you need to manage your epilepsy.
Epilepsy is managed with medications, devices, brain treatments, and surgeries. You can get coverage for all of these options using Medicare. It’ll also provide coverage for the tests needed to diagnose epilepsy.
Read on to learn what Medicare coverage for epilepsy includes, when it applies, and which plans might be best for you.
When does Medicare cover epilepsy?
You can get coverage for epilepsy through Medicare as long as you’re eligible for Medicare.
In some cases, you’ll already be eligible because you’re 65 years old or over. In other cases, your epilepsy diagnosis might cause you to become eligible for Medicare regardless of your age.
That’s because Medicare covers people under age 65 who have a disability and who receive Social Security Disability Insurance (SSDI). An epilepsy diagnosis might qualify you to receive SSDI. You’ll automatically be enrolled in Medicare after 24 months of receiving SSDI.
However, you’ll need to apply for SSDI to get started. Medicare doesn’t make this decision. Instead, Social Security will review your case and determine if you’re eligible for benefits.
Social Security disability benefits are determined on a case-by-case basis. This means your epilepsy diagnosis won’t automatically qualify you. You’ll need to meet the standards set by Social Security for benefits.
These standards include:
- Your epilepsy must prevent you from working and earning more than $1,260 per month.
- Your epilepsy must be expected to severely limit your ability to work for at least 1 year.
Social Security will examine your medical records and determine whether your epilepsy prevents you from working. You’ll get a determination after the review process.
If Social Security determines that you’re eligible, your SSDI benefits will begin. From there, you’ll have a 2-year waiting period before your Medicare coverage begins. After those 24 months of SSDI benefits, you’ll be automatically enrolled in Medicare.
Your epilepsy care and treatments will be covered once you become eligible for Medicare, either because you’re 65 years old or because you’ve received 24 months of SSDI benefits.
No matter how you become eligible, you’ll receive a Medicare card in the mail along with welcome information. You can then start using your Medicare plan to get coverage for your epilepsy.
What is epilepsy?
Epilepsy is a chronic condition that affects people of all ages. The Centers for Disease Control and Prevention (CDC) reports that as of 2015,
Epilepsy is a permanent condition that affects people who have it in different ways.
Some people might have severe and frequent seizures, while seizures might be a lot rarer for others. These seizures are often unpredictable and can lead to other health conditions.
Seizures in epilepsy aren’t provoked by anything. This means they’re not being caused by an outside factor, like a blood sugar crash or alcohol withdrawal. You can be diagnosed with epilepsy after two such seizures.
The cause of seizures in epilepsy varies. Often there’s no known cause. In other cases, they’re caused by conditions like:
- traumatic brain injury
- brain tumor
- infection of your central nervous system
Some seizures might be quick, whereas others might be lasting and cause damage to your brain and other body systems. Since seizures are unpredictable, epilepsy might make it unsafe for you to drive, work, or live alone.
It can be dangerous to drive or do other activities if your seizures aren’t well controlled. Epilepsy can be considered a disability because it impacts your daily life.
Common effects of epilepsy on your daily life might include:
- Needing to modify your home for safety. You might need to make modifications to make your home safe in case you have a seizure.
- Trouble sleeping. Many people with epilepsy have trouble sleeping. A lack of sleep can also aggravate or trigger seizures.
- Trouble with memory. Seizures can cause you to have trouble with memory and other cognitive functions.
- Mood disorders. People with epilepsy are likely to have mood disorders like anxiety and depression. Some people report changes in their mood right before or after a seizure.
- Headaches. Headaches are a common complaint for people with epilepsy. Headaches often worsen before or after a seizure.
Managing your epilepsy is often an effort among you, your doctor, and your friends and family. Your doctor might prescribe medications, diet plans, and other treatments to help control your seizures.
If that doesn’t help, your doctor might suggest trying other options, including surgery.
Does Medicare cover diagnosing epilepsy?
Medicare will cover you during the epilepsy diagnosis process. In general, Medicare covers services it considers medically necessary.
Medically necessary services include services to diagnose, prevent, or treat conditions. So, your diagnostic testing for epilepsy will be covered.
Some tests you might have include:
- Electroencephalogram (EEG) and high-density EEGs. An EEG is a test that measures the activity in your brain. It’s done by putting electrodes on your scalp and measuring your brain waves.
- Imaging tests. Your doctor might order imaging tests — like CT scans, MRI scans, fMRI scans, PET scans, SPECTs, and others — to get a closer look at your brain to try and pinpoint the cause of your seizures.
- Neuropsychological tests. Neuropsychological tests are done to measure how your brain reacts to certain stimuli or tasks.
- Statistical parametric mapping (SPM), Curry analysis, and Magnetoencephalography (MEG). These tests are used to locate the exact part of your brain that the seizures are affecting.
Medicare will cover all of these tests as long as you have them done by a provider that participates in Medicare.
In some cases, Medicare might need more information from your doctor about why the test is being ordered before approving it for coverage. However, as long as your doctor verifies the test is being done to see if you can be diagnosed with epilepsy, Medicare will cover it.
What epilepsy treatments does Medicare cover?
Medicare will cover a variety of treatments you might need for epilepsy. The treatments you need will depend on how your epilepsy affects you and how severe your seizures are.
Common epilepsy treatments include:
- Medications. Epilepsy is normally treated with a class of drugs called anticonvulsants. Anticonvulsants are one of the six protected drug classes under Medicare that all Part D plans must cover. However, your plan might cover only certain anticonvulsants or only the generic form, so it’s important to check.
- Deep brain stimulation. During deep brain stimulation, doctors put electrodes in your brain to help reduce your seizures. Medicare will pay for this treatment if you’ve been taking anticonvulsants but are still having seizures.
- Epilepsy surgery. Epilepsy surgery is an option for people whose condition isn’t helped by medications or other treatments. During the surgery, doctors remove the part of your brain associated with your seizures. Medicare will pay for this surgery if it’s necessary because your epilepsy can’t be treated by other methods.
- Vagus nerve stimulation (VNS) and responsive neurostimulation (RNS). VNS and RNS are accomplished by a device, similar to a pacemaker, that doctors implant in your chest. The device sends signals up your spinal cord to stop your seizures. Medicare will pay for a VNS or RNS device if other treatments, including surgery, haven’t worked or if surgery isn’t an option for you.
- Nutritional services. Some people find that their epilepsy is helped by following a ketogenic diet. This is a diet that consists of low carbohydrates but high fat and protein content. Medicare doesn’t pay for any specific nutritional services for epilepsy, but it will cover your visits to doctors and other specialists who can help you develop a ketogenic diet plan for your epilepsy.
- Alternative therapies. Alternative therapies include things like chiropractic services and acupuncture. Original Medicare (Part A and Part B) never covers these therapies. However, some Medicare Advantage (Part C) plans do cover them.
Keep in mind that Medicare won’t pay for more invasive treatments if other options can be used.
Medication is effective at controlling seizures for about 7 out of 10 people with epilepsy, according to the Epilepsy Foundation. So, your doctor will start there.
If medications don’t work, Medicare will cover additional treatments. However, Medicare might ask for documentation from your doctor that you’ve tried medications and are still having uncontrolled seizures before approving coverage for other treatment options.
Which Medicare plans may be best for you if you have epilepsy?
You can use multiple parts of Medicare to get coverage for your epilepsy. The right combination of parts for you will depend on your budget and any other health conditions you might have.
You’ll definitely need certain services to be covered, though, so it’s important to have Medicare parts that include them. The coverage you’ll need includes:
- Prescription drug coverage. You’ll need to have coverage for your anticonvulsant medication and any other medications being used to treat your epilepsy. This means you’ll need a Medicare Part D (prescription drug coverage) plan or a Medicare Advantage (Medicare Part C) plan that includes Part D coverage. Original Medicare (parts A and B) doesn’t cover prescriptions, so you’ll need a Part D or Advantage plan.
- Doctor visit coverage. You might need to visit the doctor often when you’re being treated for epilepsy. You can get coverage for these visits through Medicare Part B if you have original Medicare. You can also get coverage through your Medicare Advantage plan.
- Outpatient care coverage. You might receive treatments for your epilepsy in a doctor’s office or other outpatient care setting. Medicare Part B or a Medicare Advantage plan will cover this care.
- Inpatient care coverage. There might be times when you need to stay in the hospital for epilepsy treatment, such as if you need surgery. If you have original Medicare, you can get coverage using Medicare Part A. You can also use a Medicare Advantage plan to get coverage.
Your costs will vary, depending on the service and on your plan. When you use Medicare Part D or Medicare Advantage, your costs for copayments, coinsurance, and deductibles will be set by the plan.
Costs are more consistent when you use original Medicare but will still depend on the service you receive. For example, Medicare will pay 80 percent of the cost of all services covered under Part B, and you’ll pay the other 20 percent.
However, if you need to stay in the hospital and use Part A, you’ll have a deductible. Once you meet that deductible, your stay will be completely covered for the first 60 days. That deductible is $1,484 in 2021.
You can use Medigap to cut down on some of these costs. Medigap plans, also known as Medicare supplement plans, are designed to cover the out-of-pocket costs of original Medicare.
A Medigap plan won’t pay for additional services that Medicare doesn’t cover; however, it will pay for things like your 20 percent coinsurance when you use Part B.
Tips for choosing a Medicare plan if you have epilepsy
- Search for a Chronic Condition Special Needs Plan (C-SNP) in your area that includes epilepsy.
- Check to see what medications are covered by Medicare Part D or Medicare Advantage plans in your area.
- See if any local Medicare Advantage plans include coverage for services beyond the ones original Medicare covers.
- Make sure your doctor is part of the network of providers for any Medicare Advantage plan you’re considering.
- Consider a Medigap plan if your epilepsy treatment requires a lot of doctor visits and treatments.
- Compare the costs of a Medicare Advantage or Medigap plan to the cost of using original Medicare to see what best fits your budget.
Help for Medicare if you have a chronic condition, including epilepsy
Medicare has plans known as Special Needs Plans (SNPs) for people in certain situations. A type of SNP called a C-SNP can help people with epilepsy.
C-SNPs are a type of Medicare Advantage plan. They offer additional services to people with chronic conditions. These services might include:
- lower medication copayments
- extra hospital coverage
- specialty care coverage
- nutrition coverage
Since C-SNPs are Medicare Advantage plans, the plans available to you will depend on where you live. You might not have a C-SNP that includes people with epilepsy in your area.
You can search using the Medicare website to see what options you might have. If there’s one available to you, a C-SNP can help you manage your epilepsy and possibly lower your cost.
- You can get coverage for epilepsy using Medicare.
- Epilepsy can also be a qualifying condition for SSDI and can make you eligible for Medicare before age 65.
- Medicare will help cover the tests needed for your doctor to diagnose epilepsy and the treatments you need to manage your condition.
- It’s important to purchase a part of Medicare that includes prescription drug coverage since anticonvulsant medications are a primary treatment for epilepsy.
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