Quick Answer
ALS (amyotrophic lateral sclerosis, also known as Lou Gehrig's disease) is one of only two conditions - along with End Stage Renal Disease (ESRD) - that qualifies for Medicare without the standard 24-month waiting period. As soon as you are entitled to Social Security Disability Insurance (SSDI) benefits for ALS, you can enroll in Medicare. Medicare Part A covers inpatient hospital care, Part B covers outpatient services and home health care, and Part D covers prescription drugs.
Coverage Comparison by Plan Type
| Plan Type | Coverage | Notes |
|---|---|---|
| Medicare Part A (Inpatient) | Covered | Covers inpatient hospital stays, skilled nursing facility care, and hospice |
| Medicare Part B (Outpatient) | Covered | Covers outpatient services, home health care, DME, physical therapy, speech therapy |
| Medicare Part D (Drugs) | Covered | Covers prescription drugs including ALS medications; formulary varies by plan |
| Medicare Advantage (Part C) | Covered | Must cover same services as Original Medicare; may offer additional benefits |
Understanding Your Coverage Options
Medicare Part B - Outpatient & Home Health
Covers home health care, DME, and therapy servicesMedicare Part B is particularly important for ALS patients because it covers home health care services, which are critical as the disease progresses. To qualify for home health care, you must be under the care of a physician who creates and regularly reviews a care plan, and you must be certified as homebound - meaning you cannot leave home without considerable effort.
Part B also covers durable medical equipment (DME) that is medically necessary for ALS patients, including wheelchairs, communication devices, ventilators, and other equipment. Physical therapy, occupational therapy, and speech-language pathology services are also covered under Part B, which are essential for maintaining quality of life as ALS progresses.
ALS patients often need a wide range of DME and therapy services. Medicare Part B covers these as long as they are medically necessary and ordered by a Medicare-participating physician.
What It Covers
- Home health care services (skilled nursing, physical therapy, occupational therapy, speech therapy)
- Durable medical equipment (wheelchairs, power wheelchairs, communication devices)
- Ventilators and respiratory equipment
- Ankle-foot orthosis (AFO) braces - covered every 5 years for the same body part
- Outpatient physical, occupational, and speech-language pathology therapy
- Doctor visits and specialist consultations
- Diagnostic tests and lab work
What It Doesn't Cover
- Personal care services (bathing, dressing) when that is the only care needed
- 24-hour home care
- Meals delivered to your home
- Homemaker services
Part B: You pay 20% coinsurance after the $283 annual deductible (2026). Home health care covered by Medicare is $0 for approved services.
Medicare Part a - Inpatient & Hospice
Covers inpatient hospital care and hospiceMedicare Part A covers inpatient hospital stays for ALS patients, including any hospitalizations related to ALS complications such as respiratory failure, pneumonia, or surgical procedures. The standard Part A cost-sharing applies: $1,736 deductible per benefit period, with $0 coinsurance for days 1–60.
Hospice care is an important benefit for ALS patients. Medicare Part A covers hospice care when a doctor certifies that a patient has a terminal illness with a life expectancy of six months or less if the illness runs its normal course. ALS patients who choose hospice receive comfort-focused care rather than curative treatment, and Medicare covers nearly all hospice services.
What It Covers
- Inpatient hospital stays for ALS-related complications
- Skilled nursing facility care following a qualifying hospital stay
- Hospice care (comfort-focused care for terminal illness)
- Inpatient rehabilitation following hospitalization
What It Doesn't Cover
- Long-term custodial care (personal care without skilled nursing needs)
- Room and board at a nursing home (unless receiving skilled nursing care)
Part A: $1,736 deductible per benefit period; $0 coinsurance for days 1–60; $434/day for days 61–90 (2026). Hospice care: $0 for most services.
Medicare Advantage (Part C)
Covered - may offer additional benefits for ALS patientsMedicare Advantage plans must cover all services that Original Medicare covers, including all ALS-related care. Some Medicare Advantage plans may offer additional benefits that could be valuable for ALS patients, such as transportation to medical appointments, meal delivery, or expanded home health benefits.
However, Medicare Advantage plans use provider networks, which can be a significant consideration for ALS patients who may need specialized neurologists, ALS clinics, or specific DME suppliers. Before enrolling in a Medicare Advantage plan, verify that your ALS care team and preferred facilities are in-network.
What It Covers
- All ALS-related services covered by Original Medicare
- Additional benefits that may include transportation, meals, or expanded home health
What It Doesn't Cover
- Out-of-network providers (unless your plan allows out-of-network benefits)
- Services requiring prior authorization that was not obtained
Network Restrictions are a Key Consideration for ALS Patients
ALS patients often need specialized care from neurologists, ALS clinics, and specific DME suppliers. Before enrolling in a Medicare Advantage plan, verify that your entire care team is in-network. Switching to Original Medicare with a Medigap plan may provide more flexibility for ALS patients who need specialized care.
Key Medicare Costs for ALS Patients (2026)
| Service | Medicare Part | What Medicare Pays | Your Cost |
|---|---|---|---|
| Home health care (skilled nursing, therapy) | Part B | 100% for approved services | $0 |
| Durable medical equipment (wheelchair, ventilator) | Part B | 80% of approved amount | 20% coinsurance + $283 deductible |
| Outpatient therapy (PT, OT, speech) | Part B | 80% after deductible | 20% coinsurance + $283 deductible |
| Inpatient hospital stay (days 1–60) | Part A | 100% after deductible | $1,736 per benefit period |
| Hospice care | Part A | Nearly 100% | $0 for most services |
✦ ALS and Medicare: Special Eligibility Rules
No Waiting Period for ALS Patients
ALS is one of only two conditions (along with ESRD) that qualifies for Medicare without the standard 24-month waiting period. For most people under 65 who receive Social Security Disability Insurance (SSDI), Medicare coverage begins 24 months after their first SSDI payment. For ALS patients, Medicare coverage begins as soon as they are entitled to SSDI - there is no waiting period. Apply for Medicare as soon as you receive your ALS diagnosis and SSDI approval.
Apply for Medicare immediately after receiving your ALS diagnosis and SSDI approval. Do not wait - there is no 24-month waiting period for ALS patients.
Medigap Enrollment Rights for ALS Patients
ALS patients who are under 65 have the right to purchase a Medicare Supplement (Medigap) plan in states that require insurers to offer Medigap to Medicare beneficiaries under 65. Federal law only requires Medigap open enrollment for people 65 and older. However, some states have passed laws extending Medigap access to younger Medicare beneficiaries. Check your state's rules to understand your Medigap enrollment rights.
✦ Frequently Asked Questions
David Haass
AuthorDavid Haass is the Chief Technology Officer and Co-Founder of Elite Insurance Partners and MedicareFAQ.com. He is a member and regular contributor to Forbes Finance Council.
Ashlee Zareczny
ReviewerAshlee Zareczny is a licensed Medicare agent in all 50 states dedicated to educating those eligible for Medicare. She trains agents on CMS compliance guidelines.