How Does Medicare Cover Migraine?

How Does Medicare Cover Migraine?

Migraine affects nearly 40 million people in the United States. Though it most commonly affects those aged 18-44, there are many who still live with the disease throughout the later part of their lives. Migraine symptoms can cause falls, vision issues and more, especially for older adults.  

Healthcare costs are 70% higher for a family that includes a person with migraine; however, many of these costs can be covered for older adults under Medicare. Continue reading for the different options available to migraine patients covered by Medicare.

Migraine symptoms

Symptoms vary depending on the type of migraine and can include nausea, dizziness, blurred vision, sensitivity to light and sound, pain on one or both sides of the head and confusion. Symptoms last for up to 72 hours, and for some, symptoms can last for days. People who have chronic migraine experience at least 15 days of migraine symptoms in a month. 

Depending on the treatment prescribed, Medicare may require the doctor to document migraine symptoms. If the doctor can prove the procedure or treatment is medically necessary to treat chronic migraine and follows Medicare’s requirements, Medicare should cover the treatment.

Migraine treatments covered by Medicare Part B

Medicare Part B covers outpatient medical services such as doctor appointments, injections provided by medical professionals, durable medical equipment, lab work, and x-rays. Botox is one treatment that has been FDA approved to treat chronic migraine and is covered by Part B. 

Medicare may require the doctor to perform diagnostic tests to confirm a migraine diagnosis before Botox is covered. Part B covers medically necessary diagnostics the same way it covers treatment, with a deductible and 20% coinsurance cost-sharing.

How Botox treats chronic migraine

Botox is a neurotoxin that can reduce muscle contractions. Doctors inject Botox near pain fibers in the forehead and neck. The Botox then enters the nerves and blocks certain chemicals that cause migraine pain.

According to Dr. Andrew Blumenfeld from The Headache Center of Southern California, most patients need about 2-3 treatments before they see maximum results. Treatments must be repeated about every 10-12 weeks to be effective.

How Medicare covers Botox treatments

Medicare usually requires doctors to provide both diagnostic codes and service codes on the claim for Medicare to cover a service correctly. Essentially, the doctor has to confirm that the patient needs the procedure. Medicare may require the doctor to try other treatments before it covers Botox. 

Medicare covers Botox treatment as long as all required codes are on the claim. Medicare Part B pays 80% after the patient pays the annual deductible. In 2019, the Part B annual deductible is $185, increasing to $197 in 2020. 

For example, if a patient receives a Botox treatment as her first Part B service of the year, she will have to pay $185 out of pocket, then Part B will pay 80% of the leftover amount. The other 20% is the patient’s responsibility unless she has a Medigap plan that covers her Part B coinsurance. After the next treatment, Medicare Part B will automatically cover 80% of the bill and the patient pays 20% for the service. 

Migraine treatments covered by Medicare Part D

Medicare Part D covers many kinds of medications such as pills, creams, certain injections, inhalers and more. While Medicare Part B covers outpatient services and some medications administered by medical professionals, Medicare Part D covers medications from the pharmacy that beneficiaries administer themselves. 

Each Part D plan has different premiums, deductibles, copays, coinsurance and formularies set by the insurer; however, there are rules insurers must follow. For instance, in 2019, the deductible for Part D can be anywhere from $0 to $415, but no higher. Also, drug formularies must include at least two drugs in each drug class, meaning doctors will have options when prescribing a covered medication.

The most common classes of treatment for migraine are prescription and over-the-counter medications, including medications from the following drug classes:

• Analgesics
• Triptans
• Antidepressants
• Antipsychotics
• Nonsteroidal anti-inflammatories
• Stimulants

Medicare covers all of these classes of medications; however, not every Part D plan will cover every specific drug in each class.  

If a Medicare beneficiary is prescribed a medication to treat their migraine disease, the first thing they should do is make sure it’s included in their Part D plan’s formulary. If it is, that means the plan covers the medication. If the Part D plan has a deductible, they may have to pay out-of-pocket for the prescription until they meet the deductible. After that, they will pay either a copay or coinsurance. 

Migraine treatments not covered by Medicare

While acupuncture and massage therapy are also popular treatments for migraine they are not FDA-approved for migraine treatment. Medicare generally only covers FDA-approved treatments, so these options are excluded. 

Medicare offers substantial coverage for diagnosing and treating migraine. Beneficiaries who experience migraine attacks should talk with their doctors about treatment options covered by Medicare.

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MEET THE AUTHOR

Danielle K. Roberts is a Medicare insurance expert and co-founder at Boomer Benefits, where her team of experts help baby boomers with their Medicare decisions nationwide.