There are an estimated 6.5 million people aged 65 and older who have Alzheimer’s in the U.S., and 73% are over the age of 75. It is likely surprising to learn that Medicare provides only 64% of the total health care and long-term costs of people with Alzheimer’s or other types of dementia. The out-of-pocket spending for Medicare beneficiaries is expected to be 25% of the average costs of caring for someone with Alzheimer’s or dementia. Here’s what you should know when dealing with Medicare Coverage and Alzheimer’s and Dementia.
Outline of Medicare Benefits relating to Dementia or Alzheimer’s
Original Medicare pays for some, but not all healthcare costs for people who have Medicare coverage, whether the individual has dementia or Alzheimer’s disease or not.
The first coverage benefit that a newly enrolled beneficiary often takes advantage of is the “Welcome to Medicare” preventive visit within the first 12 months of their Medicare coverage. Medicare Part B covers the visit. There is no Part B deductible, but you may have to pay your coinsurance costs.
The visit includes screenings such as blood pressure, a simple vision exam, and a review of your risk for depression. The doctor may administer needed vaccines or make referrals for additional screenings.
Medicare beneficiaries are eligible for an annual wellness visit. It is not a physical exam. It updates your personalized plan for disease and disability prevention. The doctor may notice signs of cognitive impairment indicative of dementia or Alzheimer’s disease during the covered cognitive assessment portion of the exam. Medicare indicates that some signs of cognitive impairment include:
- Difficulty remembering things or difficulty concentrating
- Trouble learning new things
- Difficulty with handling finances
- Difficulty making decisions about everyday life
Medicare covers a more thorough cognitive assessment at a separate visit. Medicare Part B covers the exam, and the beneficiary pays 20% of the cost after meeting the annual deductible. Medicare also covers the development of a care plan, which helps an individual manage or address their symptoms.
In What Ways Does Medicare Provide Coverage for Alzheimer’s and Dementia Patients?
It is important to note that Medicare Part A and Medicare Part B do not cover everything, even if a person has a medical condition such as dementia or Alzheimer’s. Some services not covered by Medicare Part A and Part B include:
- Long-term care, often called custodial care
- Dental care and dentures
- Annual eye exams
Medicare covers diagnostic testing, including MRIs, CT scans, or PET scans. Physicians use these tests to see if there are any changes in the brain, brain abnormalities, or to see if the brain activity has increased or decreased from the last diagnostic tests. The person on Medicare pays their usual 20% of the cost of these tests. Medicare covers individualized care planning if a person has dementia or Alzheimer’s.
Individualized treatment plans often include recommendations for long-term care, skilled nursing care, medication, in-home care, or nursing home care. Medicare covers some but not all treatments. Medicare covers skilled-nursing care at a skilled nursing facility if it is part of physician-ordered care and after the required three consecutive days in the hospital. Part A pays for up to 20 days of skilled nursing care. Part A also covers up to 80 additional days but requires the beneficiary to pay daily coinsurance payments.
Dementia and Alzheimer’s patients may need mental health care. There is no cost for an annual mental health screening, Medicare covers mental health treatment. Each person receiving mental health care pays their 20% copay. The cost varies, depending on where a person receives treatment.
Medicare pays for hospice care for terminally ill beneficiaries who have less than six months to live, and who choose to receive hospice benefits rather than eligible Part A benefits.
Medicare pays for some home health care costs under certain circumstances. Examples of coverage requirements include that a doctor orders the services, the individual must not be able to leave home, and the person requires some nursing care.
Medicare does not cover cooking, cleaning, or similar home services. Medicare also does not cover care for activities of daily living (ADLs) like bathing or grooming. Medicare covers training for a family member to administer some care in only 16 states.
Medicare Part D covers some prescription medications for Alzheimer’s and dementia treatment if the Medicare beneficiary has part D coverage. Medicare likely requires copayment and may impose quantity limits or prior authorization for certain drugs.
Medicare does not cover home care aides, adult day care, or respite care. The exception is that Medicare covers most costs of up to five consecutive days of respite care for individuals receiving hospice care.
Does Medicaid Cover Dementia Care?
A Medicare beneficiary may also be eligible for Medicaid under certain conditions. The person must have limited assets and a low income. Each state administers its own Medicaid program. Dually eligible beneficiaries qualify for both Medicare and Medicaid, which may cover some costs for dementia care not covered by Medicare. It is important to note the following:
- The Medicare Extra Help program is called the Medicare Qualified Beneficiary (QMB) Program. It pays the Part A and Part B premiums, deductibles, copayments, and coinsurance.
- The Specified Low-Income Medicare Beneficiary (SLMB) Program pays Part B premiums. The Qualified Individual (QI) Program also covers only Part B premiums.
- Medicaid covers nursing home costs for people with Alzheimer’s and dementia who meet Medicaid eligibility requirements.
Remember that Medicare and Medicaid may not cover all dementia and Alzheimer’s related care and costs. It is the responsibility of program beneficiaries or their family members to understand coverage and out-of-pocket costs.
- Yearly “Wellness” Visit, Medicare.
- Is Your Service Covered?, Medicare.
- Alzheimer’s Caregiving, National Institute on Aging.
- Financial Planning, Alzheimer’s Association.
- Dually Eligible for Medicare and Medicaid, CMS.