Does Medicare Cover Migraines?

Medicare Benefits Solutions
Oct 2, 2021

Today in the United States over four million people experience chronic migraines on a regular basis. For most of these people, working and functioning normally is impossible during a migraine attack, so getting effective treatment is vital. 

One of the most successful treatments for migraines used today is Botox injections. Botox – or botulinum toxin type A – is a nerve toxin that paralyzes muscles, and it is commonly used for cosmetic reasons. By using Botox for cosmetic treatments, medical professionals quickly realized that it also works well for treating headaches and migraines.

According to statistics, women are more likely to experience migraines than men. And while the occurrence of migraines decreases after the age of 60, there are thousands of seniors who live with the pain and debilitation of migraine headaches every day. For these seniors, having Medicare coverage for the diagnosis and treatment of migraines is a great advantage. Today, Medicare offers several solutions for the prevention and treatment of migraine disease, including Botox injections. Here’s a look at how your Medicare benefits can help.

Do your Medicare benefits cover migraines? 

Medicare recipients who have coverage through Original Medicare Parts A and B, or those who have a Medicare Advantage (Part C) plan, most likely have coverage for migraine diagnosis and treatment. 

Medicare Part B is outpatient medical insurance that covers doctors’ visits, preventive care services, durable medical equipment, lab work, x-rays, and injections like Botox that are given by a medical professional. 

Your Part B benefits may cover Botox injections as a migraine treatment if your health care provider – who accepts Medicare assignment – certifies that they are medically necessary to treat your condition.

Before prescribing Botox treatments, your healthcare provider may carry out diagnostic tests to confirm your migraine disease, and your Medicare Part B benefits also cover these tests. 

Original Medicare Part B pays 80 percent of the final approved cost of the diagnostic tests and treatments. You are responsible for the remaining 20 percent plus your Part B deductible. 

If you have Medicare Advantage (Part C), your provider must cover, at minimum, all the benefits that Original Medicare Parts A and B cover, and most Part C plans also include extra benefits. Depending on the type of Part C plan you have, you may be required to use healthcare providers, suppliers, and facilities that are within your plan’s network of providers. You might have to pay 100 percent of the costs for your diagnosis and treatment if you use providers outside the plan’s network.

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Who pays first when you have Medicare and Medicaid?

In the case of dual-eligibles, payment questions often come up since many people are unclear as to which program pays first for medical care. The first responsible entity is known as the primary payer while the secondary entity is often referred to as the supplemental payer.

Medicare is typically the primary payer when it comes to coverage for dual-eligibles; however, this can become more complicated when you involve things like private insurance in addition to Medicare and Medicaid. Depending on the circumstances, private insurance may be billed first.
Different states have varying rules that apply toward Medicaid benefits and the usage of Medicare benefits. 

Are there other migraine treatments that Medicare covers? 

For some Medicare recipients, Botox injections are not an option for treating migraines. In these instances, there are prescription medications, creams, inhalers, and other types of injections. For these treatments, you may need to have a prescription drug plan (Medicare Part D) to get coverage. 

You can get prescription drug coverage either through a stand-alone Part D plan or bundled together with your Medicare Advantage plan. These types of plans are sold by private insurance companies that work with Medicare. And while all Part D plans are required to provide coverage for at least two drugs in every drug class, providers have the option to choose which drugs to include on the formulary. For this reason, you should make sure your prescribed drug is on the formulary or ask your physician to prescribe one that is covered. 

How much you pay for your treatment depends on the type of medication, how the drug is categorized, and how much your plan charges for coinsurance. 

How much do Botox treatments cost without Medicare coverage? 

Without Medicare insurance, the cost of Botox treatments can vary according to where you live, who administers your treatment, and the dosage. Typically, each Botox session requires approximately 155 units of Botox and costs on average between $300.00 and $600.00. 

Fortunately, Medicare provides considerable coverage for the diagnosis and treatment of migraines. You can get more information about these benefits by discussing details with your healthcare provider.

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