Did you know that over 50 million people suffer from allergies annually here in the USA? While some people believe allergies to be a minor nuisance, they can be much more serious for some people. Considering the sheer number of people affected by allergies each year, they are actually considered to be a chronic illness.
Allergies come in many different forms too. There are skin allergies like eczema and food allergies like gluten sensitivity or an allergy to shellfish. Some people with allergies suffer asthma as well, which can be considerably more serious.
To diagnose allergies, doctors will often prescribe diagnostic exams or tests. If you are on Medicare, you’ll want to know how tests and treatments for allergies are covered, so let’s review Medicare’s outpatient and drug coverage for some common allergic conditions
Medicare Coverage for Eczema and Other Skin Allergies
Medicare provides coverage for a number of dermatology treatments for certain skin disorders. This may include psoriasis, dermatitis, shingles, rashes, and eczema. People with eczema suffer from skin that inflamed or itchy. The skin can feel dry and make by flakey. Usually, your Medicare doctor or dermatologist can diagnose eczema without testing and will often prescribe some lifestyle adaptations that you can make so that you have fewer eczema flares.
However, if your case is quite extensive, Medicare may cover more invasive treatments such as phototherapy. Dermatologists often prescribe phototherapy for adults with severe eczema. In this procedure, your doctor will expose your skin to UV light panels generated by a special machine. In the most common form of phototherapy, narrowband ultraviolet Blights are used which mimic the natural sunlight to treat eczema.
If other treatments have failed to produce positive results for your eczema, Medicare Part B may cover phototherapy. Part B is your outpatient coverage under Medicare so it will cover both your doctor visits regarding your skin condition and the procedure. In 2019, Medicare Part B has a deductible of $185. You will pay this deductible only once, and thereafter Medicare covers 80% of the costs of your Part B services. The other 20% is considered your cost-sharing, and you can expect to pay this yourself. Many beneficiaries enroll in Medigap coverage to help them pay for deductibles and coinsurance like this that Medicare does not pay.
There are also a number of medications which your doctor may prescribe to treat skin allergies. Outpatient medications are covered under Medicare Part D, which is voluntary prescription drug coverage that you can purchase to help reduce the costs of any prescription medications that you may need. Part D plans are offered by private insurance companies and each state may have two dozen or more plans to choose from. You can use Medicare’s website to search for the plan that offers you the best coverage for your specific medications.
Be sure to check the plan’s drug formulary to see the various types of allergy creams or oral medications available for your doctor to consider in your treatment.
Medicare Coverage of Various Food Allergies
Food allergies are also very common in America. Some of the more common allergens that can cause serious health reactions are peanuts, tree nuts, wheat, milk, soy, fish, eggs and crustacean shellfish. Some individuals are born with food allergies and learn about their allergy as a child. Other people develop certain food allergies slowly over time.
While food allergies could resolve on their own, more often than not they are something you will always be allergic to. Sometimes your doctor can perform skin tests or blood tests to confirm a food allergy and if documented as medically necessary by your doctor, Medicare Part B will cover these tests. Generally, Medicare will consider something medically necessary if there is a documented history of allergic reactions.
Another type of diagnostic test that Medicare may cover is a food challenge. In this test, the individual adds a certain percentage of a food type to their diet over a period of time. The percentage grows over time until a reaction occurs. Part B would also cover this test as it may be performed in a hospital outpatient setting.
If you are someone with severe food allergies or someone who is allergic to certain insects that sting, it may be necessary for you to carry an EpiPen for emergencies. This is an injectable dose of epinephrine that can counteract anaphylactic shock. Most Medicare Part D drug plans cover EpiPens. If you know that you need to carry an EpiPen, be sure that you confirm that your Part D drug plan includes your chose form of EpiPen in the plan’s drug formulary.
You can also check goodrx.com to see if any coupons are offered at your local pharmacy to reduce the cost of an EpiPen.
Medicare Coverage of Asthma and Breathing Disorders
Asthma is a chronic disease that involves the airways or bronchial tubes in your lungs. People with asthma have inflamed airways that can tighten or swell with makes it difficult to breathe. While some children may grow out of asthma, it can also be a long-term chronic health condition that a person deals with for a lifetime.
If your doctor suspects that you have asthma, he or she may administer an exam to test your pulmonary function. This may include spirometry or a bronchial challenge and these would be covered under Part B.
Some people with asthma find that their condition worsens as they grow older. Eventually, they may even need to use a nebulizer. This is considered durable medical equipment. Medicare Part B will pay for both the nebulizer and the medication used in the nebulizer. In most urban areas, Medicare has specific suppliers for DME that are approved as preferred providers. It’s very important that you purchase and/or rent any equipment from these providers if you want Part B to cover its share of the cost. Other breathing disorders such as COPD or emphysema are covered similarly to asthma under Part B.
Coverage Under Part C
Some Medicare beneficiaries opt to get their Medicare Part A, B, and often D benefits through a Medicare Advantage plan, which is considered Part C. This is optional and beneficiaries who enroll in these plans are agreeing to get their medical care through the plan instead of through Original Medicare.
These plans have networks, typically of an HMO or PPO style. Your plan may or may not cover you outside the network so it’s important that you carefully review how the plan works before joining one. You’ll want to make sure that your doctors are in the network for the plan and that any of your important allergy medications are covered on the plan’s built-in Part D formulary.
When you access healthcare services through your Medicare Advantage plan, you will pay a copay or coinsurance for each service according to the plan’s Summary of Benefits. For example, your plan may charge a $50 copay when you see a specialist or a 20% coinsurance for DME. This means you’ll have out-of-pocket costs for your healthcare services as you go along.
Each plan has an annual out-of-pocket maximum limit to protect you from spending beyond a certain dollar amount each year. This varies by plan, but in 2019, the maximum that this limit can be is $6700 in-network with any given plan. If your plan is a PPO that covers some out-of-network costs, there will be a separate often higher limit for that.
Carefully consider the benefits of a Part C plan before you enroll so that there are no unwelcome surprises related to your Medicare Advantage plan once you are enrolled.
Danielle K Roberts is the co-founder of Boomer Benefits where she and her team help baby boomers navigate their Medicare insurance options. She is a member of the Forbes Finance Council and writes frequently about Medicare, retirement and personal finance.