My grandmother used to say that aging was for the birds. After all, our bodies change but our minds and hearts are still young. In today’s world, we have many options to help ourselves look our best, and one of these is getting BOTOX injections. Over 6 million BOTOX injections occur in America every year.
While most of us think of BOTOX in the cosmetic sense, BOTOX injections today can also be used to treat facial muscle spasms, underarm sweating, cervical dystonia, and overactive bladder syndrome. Many physicians also use BOTOX to treat chronic migraines as well.
BOTOX injections paralyze certain muscles or block nerves to accomplish the end result. Results typically last from 3 to 12 months and then you’ll need to go in again for additional injections to maintain results.
BOTOX injections can fall into two main categories: cosmetic and medically necessary. Many people on Medicare wonder if Medicare will cover their BOTOX injections. Let’s review how Medicare determines coverage.
Will Medicare Cover BOTOX?
Medicare is our nation’s federal health insurance program for people aged 65 and older and people with certain disabilities. It was rolled out in 1965 for 19 million seniors but today covers over 55 million people.
Original Medicare has two parts:
- Part A covers hospital needs, which include inpatient stays, skilled nursing care, and hospice benefits.
- Part B covers outpatient needs, such as preventive care, doctor visits, lab testing, diagnostic imaging, surgeries and chemotherapy among other services.
In addition, you can also sign up for Medicare Part D, which is voluntary prescription drug coverage. Part D is the newest part of Medicare, and you can think of it as a pharmacy card that will give you access to discounted rates for your prescription drugs.
BOTOX injections usually fall under Part B since they are performed in a doctor’s office. Whenever a physician administers a medication to you in his office, he will bill that under Part B as an outpatient treatment.
Medicare’s coverage for BOTOX injections depends on what the injection is treating. If BOTOX is medically necessary to treat a health condition, then Medicare may indeed cover your injections. Your doctor will usually need to obtain a prior authorization from Medicare. However, Medicare will not cover BOTOX for cosmetic reasons, such as frown lines or forehead wrinkles.
In order for Medicare to cover a BOTOX injection, the procedure must be performed by a doctor who accepts Medicare. The doctor will bill Medicare, and Medicare will pay its share. Since medically necessary BOTOX injections fall under Part B, you can expect Medicare to cover 80% of the cost of your BOTOX injections after you have first met your annual Part B deductible, which is $183 in 2018.
Your Medicare Cost-Sharing
You would be responsible for the other 20% unless you have additional coverage. This is called your Part B coinsurance. Many people on Medicare purchase a Medicare supplement to help them cover their Medicare Part A and B deductibles, copays and coinsurance. Supplements are sold by dozens of health insurance companies across Medicare, including United Healthcare, Aetna, and Humana.
If you have enrolled in a Medicare supplement, Medicare will pay its share of your claim and then send the rest to your Medicare supplement insurance company. Depending on the Medicare gap plan you select, your Medicare supplement will cover some or all of that other 20% for your BOTOX injections.
The most comprehensive Medicare supplement is Plan F, which covers all of Medicare’s cost-sharing for you, leaving you with nothing out-of-pocket on Part A or B services.
Some individuals choose to enroll in private Medicare plans instead of original Medicare and a Medicare supplement. These are called Medicare Advantage plans. If you have a Medicare Advantage plan, then you are responsible for up to 20% of the cost of a medically necessary BOTOX injection. Check your plan’s Summary of Benefits to find out what your costs will be under the plan.
Danielle Roberts is a Medicare insurance expert from Fort Worth, TX. She and her team at Boomer Benefits help new Medicare beneficiaries across the nation to learn their benefits and select suitable supplemental coverage.