Medicare Benefits For Alzheimer Patients

Paying For Alzheimers Care Overview

Medicare May Restrict Coverage of Alzheimer’s Drug

Alzheimers disease, Lewy Body dementia, Frontotemporal dementia , and other related memory disorders and dementia affect over 5.5 million aging Americans. Depending on the stage of these diseases, individuals can require 24-hour supervision or care. This means each year in the U.S., there are billions of hours spent caring for individuals with these conditions. While the vast majority of that care is provided by friends and family members, what happens when those caregivers are not available? Who pays for Alzheimers care? Fortunately, there are many programs that provide financial assistance, respite care, and other forms of aid to help families and caregivers.

The worldwide cost of dementia care is approximately 1 trillion U.S. dollars. If dementia care were a country, it would be the worlds 17th largest economy.

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Medicare Does Not Cover All Alzheimer’s Treatments

Unfortunately, there are some important Alzheimers treatments that Medicare does not fully cover or does not cover at all.

Original Medicare does not cover long-term care, prescription drug coverage, caregiving support and certain other services that may be needed for Alzheimers patients. As a result, people with Alzheimers may have high out-of-pocket costs.

Medicare And Medigap Coverage For Alzheimer’s Disease

Original Medicare provides coverage for various Alzheimers-related treatments, such as:

Diagnostic testing

At-home part-time skilled nursing care
At-home physical therapy.

Two services covered by Medicare Part A that people with Alzheimers may need are skilled nursing facility care and hospice care.

Part A will only cover your SNF care if you were hospitalized for 3 days and require daily care for the same condition for which you were hospitalized.

Part A also will cover hospice care, but only if your Alzheimers condition is terminal.

Medicare typically does not cover custodial care at home or in a nursing home if thats the only care you need.

Medicare Part A Deductible For Inpatient Services And Hospice Care

You must meet the Part A deductible before your Part A coverage kicks in for inpatient care related to dementia.

The Medicare Part A deductible is $1,556 per benefit period in 2022.

The Part A deductible is not annual, and you could experience more than one benefit period in a calendar year. A benefit period starts the day you are admitted for inpatient care and ends when you have not received inpatient care for 60 consecutive days.

If Part A covers hospice care related to your dementia or Alzheimers disease, you pay nothing for your hospice care, including the Part A deductible.

You may need to pay a 5 percent coinsurance for the Medicare-approved amount for inpatient respite care, as well as a $5 copayment for your prescription drugs while receiving hospice care.

What Is Alzheimers Disease

Alzheimers disease is a type of dementia that results in loss of memory, loss of thinking and language skills, and behavioral changes. It is a progressive and irreversible brain disease that attacks the brains nerve cells.

Minor Alzheimers symptoms may include:

Mild memory loss

Unfounded suspicions about friends and family members
Difficulty speaking, swallowing and walking

Alzheimers disease on its own is not fatal, but it does directly cause many complications that can result in fatal conditions such as pneumonia, infections, and an overall loss of bodily function.

What Medicare Coverage Options Are Available For People With Alzheimers

While Original Medicare typically cover most Alzheimers care services, other coverage options are also available, including Medicare Advantage and Medicare Part D prescription drug plans.

Medicare Special Needs Plans a special kind of Medicare Advantage plan are uniquely available to individuals with Alzheimers and other forms of dementia. These Special Needs Plans are uniquely designed for individuals with Alzheimers or dementia.

If your medications are not administered by a healthcare professional or prescribed as part of an inpatient hospital treatment, youll need to enroll in Medicare Part D or a Medicare Advantage plan if you would like additional coverage.

Medicaid, the Department of Veterans Affairs, and other state programs may also offer additional coverage options for individuals with Alzheimers or dementia.

Benefits Of The New Medicare Advantage Plans For Alzheimers

Under the changes, Medicare Advantage becomes more about practical improvements to the lives of Alzheimers sufferers. The Centers for Medicaid and Medicare Services says Medicare Advantage will cover Special Supplemental Benefits For Chronically Ill enrollees if the item or service has a reasonable expectation of improving or maintaining the health or overall function of the enrollee as it relates to their chronic disease. This can be interpreted broadly, but it is meant specifically for sufferers of long-term illnesses like Alzheimers and other dementias. For years, home health care and caregivers have only been available outside Medicare, but the new Advantage is changing to reflect these needs. Hot meals, rides to doctor appointments, and around-the-house safety improvements should also be covered and can keep people living in their homes longer instead of being placed in nursing homes.

Home Modifications

Non-Medical Home Care

Something essential for a person with Alzheimers, but not necessarily medical, is companionship. This can be someone around simply for supervision, recreation, and conversation. It can also be more personal help, like a professional who bathes, dresses, and helps with using the bathroom or eating or exercising. And it can also be a homemaker, who handles chores like tidying up and preparing meals. These services will now be an option under Medicare Advantage.

Adult Day Care

Memory Care / Assisted Living

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Medicare Part C Coverage

Medicare Part C gives you the choice of enrolling in a Medicare Advantage plan as an alternative to Original Medicare. You can choose from different types of MA plans, including a Preferred Provider Organization , Health Maintenance Organization , and a Point-of-Service plan. Medicare Advantage plans are required to provide at least the same coverage as Original Medicare Part A and Part B, but approves many plans include additional coverage. Additional benefits may include vision and dental care, fitness programs, and prescription drug coverage. However, they may come with limits on which doctors, health care providers, and hospitals you can use for your care.

You should compare each plan very carefully to learn about which Medicare options are available to you and which would work best for Alzheimers care. There are Special Needs Plans for Alzheimers disease available. These Special Needs Plans are Medicare Advantage plans that are designed to provide specialty care for people with certain diseases or chronic conditions. These are Medicare Advantage plans that specialize in coverage and care for people with these cognitive impairments. If it sounds like something would benefit you, dont be afraid to check into it when you start weighing your options for Medicare benefits.

What Isnt Covered For Alzheimers Disease

Biogen’s Alzheimer’s Drug Coverage Limited by U.S.

While Medicare covers a wide range of inpatient and outpatient services for Alzheimers disease, a service might not be covered in certain situations, including:

Nursing home care. Medicare will not cover nursing home care if its the only care you require for Alzheimers disease. If you require around-the-clock custodial care, you will pay the full out-of-pocket cost.
Off-label medications. Medicare covers certain medications only when theyre prescribed for an FDA-approved use. If your doctor decides to use a medication that isnt yet approved for Alzheimers symptoms, your prescription drug plan may not cover it.
Skilled nursing facility care. Medicare covers short-term nursing facility care, which generally includes many of the services, medications, and other needs you would have in an outpatient setting. However, youll only be covered for up to 20 days at no cost. After that, youll owe a portion of the costs as coinsurance each day.

If youre concerned that your plan wont cover a service or medication, you can reach out to your doctor or insurance provider to check.

Alzheimers disease is a type of dementia that causes progressive cognitive decline. It primarily affects people over age 65 and accounts for roughly 60 percent to 80 percent of dementia cases, according to the Alzheimers Association.

Early symptoms of Alzheimers disease may include:

inability to remember new information
behavioral changes
increased paranoia

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Do All New Plans Have These Benefits

No, not all new Medicare Advantage plans will have these benefits. Medicare Advantage plans have the option to cover these aspects of life with Alzheimers or dementia, but specifics of the plans differ because they are offered through private companies. Specifics can be fluid, so check with an insurer in your area about what options are available. Further complicating matters is the two-year rollout of the new Medicare Advantage and its updating interpretation of supplemental benefits. While the mandate to expand the definition of what MA covers has passed into law, it will unroll slowly, so check for updates on what can be paid for through Medicare Advantage.

Medicare Does Cover: Some Rehabilitative Care

If home health services like physical or occupational therapy are needed after a hospitalization, Medicare will cover these treatments to an extent.

As long as its considered rehab and not long-term care, Medicare will pay for up to 100 days of care in a skilled nursing facility each benefit period, according to U.S. News & World Report.

In cases where temporary home health care is needed, Medicare will also cover 35 hours a week for 60 days at a time.

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Does Dementia Qualify For Medicare Coverage

Original Medicare may cover some but not all costs related to dementia care.

Medicare Part A hospital insurance will typically cover some of the following costs:

Inpatient hospital care related to dementia or Alzheimers care
Up to 100 days of skilled nursing facility care under certain circumstances
Hospice care in the home, nursing facility or inpatient hospice facility for end of life care

Medicare Part B may cover other services related to dementia care, such as:

Annual cognitive assessment as part of your Medicare Annual Wellness Visit
Care planning services for individuals diagnosed with dementia
Any additional diagnostic testing that is ordered by your doctor
Occupational therapy that is ordered by your doctor to help improve cognitive function

Speak with your doctor directly for more Medicare coverage information related to your dementia or Alzheimers care.

Does Medicare Pay For Assisted Living For Alzheimers Patients

Original Medicare will pay for medical care provided in assisted living however, it will not pay for room and board or long-term custodial care, such as assistance with bathing, dressing, and eating, in an assisted living facility. Under specific circumstances, Medicare will help pay for a beneficiarys stay in a skilled nursing facility for up to 100 days.

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Alzheimers And Original Medicare Coverage

Alzheimers patients receive a lot of financial support from Original Medicare when it comes to things like doctors visits, part-time skilled nursing care, at-home physical therapy, hospice care, and diagnostic testing.

Medicare will give Alzheimers patients nursing home coverage for a registered nurse, physical therapist, or a licensed practical nurse. It will also pay for up to 100 days of skilled nursing home care under limited circumstances.

Medicare covers inpatient hospital care and some of the doctors fees and other medical items for people with Alzheimers or dementia who are age 65 or older as well.

Fortunately, under a new health law, Original Medicare will now cover doctors screenings for cognitive impairment. During such a test, a doctor will look at a patients medical history, do a neurological and physical examination, conduct blood tests, do brain imaging and test a patients mental functions. Once the person is diagnosed, they can begin to receive early treatment of their Alzheimers.

Medicare steps up to help when a person is in the late stages of Alzheimers and needs 24-hour care, though the coverage can be spotty and may need to be supplemented with care from family members. Medicare will also only pay for 100 days of nursing home care, and it has to happen following a stay in a hospital. For example, if an Alzheimers patient breaks a leg and needs to be admitted into the hospital, they will be covered for 100 days of care.

Medicare Advantage And Medicare Prescription Drug Coverage Can Add Support For Vital Medications And Services

While Original Medicare covers most available Alzheimers treatments and services, it doesnt cover everything. For instance, Medicare Part B offers coverage for outpatient medications that are administered by a medical professional. It will not cover other general prescription medications. It also will not cover certain other services needed by many seniors. This is where Medicare Part C, also known as Medicare Advantage, and Medicare Part D Prescription Drug coverage can help.

Medicare Advantage provides coverage for all Alzheimers treatment services covered under Original Medicare. It also provides coverage for additional services that help seniors with cognitive issues maintain good health and hygiene. In addition to treatment for Alzheimers disease, Medicare Advantage plans often cover:

Medical supplies
Transportation to and from medical appointments

Medicare Part D plans will cover most prescription medications formulated to help combat the effects of Alzheimers. There are some prescription medications that your Part D plan may not cover, or for which there are restrictions in place. One such medication is Biogens new Alzheimers medication, aducanumab, which is also known as Aduhelm.

Medicare has limited coverage of Aduhelm to beneficiaries who have been accepted into clinical Phase III studies for the medication. These patients tend to be healthier than other beneficiaries who otherwise would have access to Aduhelm.

Medicares Benefits For Alzheimers & Dementia

There is not a simple answer to the question does Medicare pay for Alzheimers care?. Medicare, like most health insurance, does not differentiate Alzheimers and dementia care from other conditions such as heart disease. Instead, Medicare has certain policies with regards to when and how much it will pay for care. For example, Medicare will pay for 100% of the cost of nursing home care if it is medically necessary for 20 days and 80% of the cost for an extra 80 days. If an individual with Alzheimers requires care in a psychiatric hospital, Medicare increases the number of days they will provide assistance up to 190 days.

Medicare does not pay for custodial or personal care that is provided in an assisted living residence. But it will pay for medical care provided in that location. The same applies for home care and adult day care. Personal care services, assistance with the activities of daily living and supervision that are typically necessary for Alzheimers patients are not covered. But medical care is covered. There is an exception to this for individuals receiving hospice care at home. Medicare will pay for homemaker services, which includes personal assistance for individuals determined to be in the final 6 months of their life.

New in 2019, Medicare Advantage plans are able to offer some long-term care services and supports as a supplemental health benefit, given they:

Home modifications
Personal emergency response systems
Homemaker services

Medicare Advantage Plans May Offer More Benefits For Dementia Care

Hospice: What does the Medicare benefit include and how to choose the best program

As part of the Chronic Care Act of 2018, Medicare Advantage plan providers are able to provide expanded benefits to their beneficiaries, called supplemental benefits, starting in 2019 and 2020.

Some of these additional benefits may include:

Home modifications, such as bathroom grab bars
Non-medical home care, such as custodial care

Because Medicare Advantage plans are sold by private insurance companies, plan availability and the benefits they offer may vary from one location to another.

To learn more about Medicare Advantage plans in your area, your eligibility to enroll, and the benefits that they offer, call to speak with a licensed insurance agent today.

Compare Medicare Advantage plans in your area

Or call 1-800-557-6059TTY Users: 711 24/7 to speak with a licensed insurance agent.

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Medigap Can Help With Dementia

Medigap plans will cover the coinsurance payments youd otherwise be responsible for paying. Our licensed Medicare agents can help you find a policy that makes sense for your situation. Give us a call at the number above to learn about your rates today! Or, fill out an online rate form to see your rates now!

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Medicare Advantage For Alzheimers And Dementia Patients

The official U.S. government website for Medicare reports that Medicare Advantage plans offer the same benefits as Medicare Part A and Part B, including:

Up to 100 days in a nursing home
Up to 35 hours a week of home health care for homebound people
Most medical care, including regular visits with a doctor and hospital care for infections and other issues

Additionally, the Centers for Medicare & Medicaid Services notes that, once Medicare Advantage beneficiaries begin receiving hospice care from a Medicare-approved provider, Original Medicare will cover all needs related to their terminal illness. These patients can retain their Medicare Advantage coverage as long as they continue to pay its premiums, and use either Original Medicare or their Advantage coverage for health issues unrelated to their terminal illness.

Every Medicare Advantage plan is different, so itâs important to read the plan documents and compare the plans available in your state. Some additional benefits various plans offer include:

Prescription drug coverage, including for dementia drugs
Additional in-home care beyond the 35 hours per week original Medicare authorizes
Meal deliveries

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How Will Medicare Cover People With Early

Medicare may provide coverage for early-onset Alzheimers for individuals with Alzheimers who are under age 65. Many times, early-onset Alzheimers shows up when someone is in their 40s or 50s. If you or someone you care for has been diagnosed with early-onset Alzheimers, they will qualify for Medicare after receiving disability benefits for 24 months.