Medicare Alzheimer's

There are about 5.5 million Americans who are 65 or over living with Alzheimer’s dementia, the sixth-leading cause of death among Medicare-aged individuals.1 That’s why it’s important to ask questions about Medicare Alzheimer’s coverage and understand what Medicare will—and will not—cover for treatment.

We’ve compiled some common Medicare Alzheimer’s questions to help you understand your options for Alzheimer’s treatment and care.

Does Medicare Cover Alzheimer’s Disease?

Original Medicare (Parts A & B) does not address Alzheimer’s disease or other dementias as a single diagnosis with universal coverage, but it does cover in-patient hospital care and some related expenses.2 That’s why after an Alzheimer’s diagnosis, there’s not always a direct path to ensure that Medicare will cover all—or most—of the treatment costs.

What Does Medicare Cover for Alzheimer’s Care?

There are limitations, but Original Medicare (Parts A and B) covers a variety of medical services Alzheimer’s patients often need beyond regular doctor visits. Here are a few of these medical services.

  • Annual Wellness Visit/Health Risk Assessment. Medicare covers an annual cognitive impairment assessment to check for signs of Alzheimer’s disease. The visit will include a health risk assessment to help prevent disease and disability based on current health and risk factors.3
  • Diagnostic Testing. When ordered by a physician, Medicare will cover CT scans, MRIs and EEG scans to help doctors determine brain abnormalities or trauma that can cause dementias.4
  • Mental Health Services. Some covered services include psychiatric evaluations, diagnostic tests, individual and family counseling, medication management, and yearly depression screenings.5
  • Prescription Drugs. Medicare will pay some—or all—of your prescription drug costs as long as you are enrolled in a Medicare Part D prescription drug plan either by itself or as part of a Medicare Advantage plan.
  • Some Rehabilitative Care. If an Alzheimer’s patient requires medically necessary nursing home care, Medicare will only help for for the first 100 days.2 For psychiatric hospitals, Medicare will provide 80% coverage for up to 190 days.6
  • Caregiver Training for Family Members. In some states, Medicare offers customized behavioral training provided by home health nurses for families and caregivers.7
  • Hospice Care. Medicare pays 100% of hospice care if doctors can certify that the patient is terminally ill with a life expectancy of six months or less.8

What Is Not Covered Under Medicare for Alzheimer’s Care?

Original Medicare (Parts A and B) does not cover some of the most expensive services for Alzheimer’s patients. Patients, or their families, could be 100% financially responsible for some of the following healthcare costs.

  • Long-Term or Custodial Care. Long-term care is a big expense and is not covered by Original Medicare or Medicare Advantage (Part C) plans. Medicare will pay for medical care provided in a facility or adult day care but does not pay for personal care services or assistance with activities of daily living (i.e., getting dressed, bathing, and eating).9 These are the average 2020 monthly costs for nursing homes and other outsourced care:11
    • Home-based care: $4,481-$4,576
    • Adult day care: $1,603
    • Assisted living facility: $4,300
    • Nursing home (semi-private room): $7,756
    • Nursing home (private room): $8,821
  • Alternative Therapy. Original Medicare does not pay for alternative treatments such as acupuncture,11 nutritional supplements,12 vitamins, or herbal remedies13 to help treat dementia disorders. However, some Medicare Advantage plans will cover some of these types of alternative therapies. Check with your insurance company to see if your Medicare Advantage policy covers any of these services.
  • Most Home Health Services. This includes meal delivery, in-home 24-hour care, and homemaker services.14 Again, some Medicare Advantage plans may help with some of these costs, but plans differ, so check your policy or ask your insurance company or a licensed agent on available coverage options.

Does Medicare Pay for Alzheimer’s Testing?

Medicare will pay for a health risk assessment at an annual wellness visit with a physician. After an Alzheimer’s diagnosis, Medicare will also pay for cognitive assessment and care planning services.3

Does Medicare Pay for Assisted Living for Alzheimer’s Patients?

Original Medicare (Parts A and B) 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 beneficiary’s stay in a skilled nursing facility up to 100 days.2

Does Medicare Pay for In-Home Senior Care?

Medicare does not pay for most in-home health services, but there are a few medically necessary exceptions. Under certain circumstances, and only when a doctor deems it medically necessary, Medicare will cover speech, occupational, and/or physical therapy or intermittent nursing care provided at the patient’s home. However, Medicare will not pay for in-home 24-hour care and homemaker services.15 Select Medicare Advantage plans may help with some of these costs, but plans differ. Check your policy, call your insurance company, or contact a licensed agent about available coverage options.

Options to Help Pay for Alzheimer’s Care

Original Medicare (Parts A and B) pays for some costs associated with Alzheimer’s disease, but there are also some insurance options that could help with care-related expenses.

  • Some Medicare Advantage (Part C) plans often offer coverage that Original Medicare does not, such as home health services, transportation to and from doctor appointments, and adaptations to your home. But not all extra benefits are available with all Medicare Advantage plans.
  • Long-term care and disability supplemental insurance plans can also help with Alzheimer’s costs, depending on the plan. You must be enrolled in one of these supplemental plans prior to a diagnosis.16
  • Some life insurance policies will allow you to borrow a policy’s cash value or offer accelerated death benefits.16

Talk with a licensed health insurance agent about which options would work best for you and your family’s needs.

Medicare Special Needs Plans for Alzheimer’s Patients

Medicare Advantage offers Special Needs Plans (SNPs) created specifically for seniors with Alzheimer’s disease and other dementia disorders. Medicare SNPs tailor their benefits, provider choices, and drug formularies to best meet the specific needs of the groups they serve. You need a reference from a specialist to participate in an SNP.2

HealthMarkets Can Help Answer Your Medicare Alzheimer’s Questions

HealthMarkets can help you find insurance solutions for Alzheimer’s care, ranging from long-term care supplemental insurance to Medicare Advantage plans. Use the HealthMarkets FitScore® to compare Medicare Advantage plans and enroll in one that fits your needs. You can also talk to a licensed health insurance agent anytime at (800) 488-7621 about your Medicare Alzheimer’s coverage options.

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References
  1. National Institute on Aging (NIA). May 22, 2019. Retrieved from https://www.nia.nih.gov/health/alzheimers-disease-fact-sheet.
  2. Alzheimer’s Association. 2021. https://www.alz.org/help-support/caregiving/financial-legal-planning/medicare.
  3. Centers For Medicare & Medicaid Services. Retrieved from https://www.medicare.gov/coverage/yearly-wellness-visits. Assessed March 4, 2021.
  4. Alzheimer’s Association. 2020. Retrieved from https://www.alz.org/media/documents/alzheimers-dementia-medicare-fee-for-service-ts.pdf.
  5. Centers For Medicare & Medicaid Services. Retrieved from https://www.medicare.gov/coverage/mental-health-care-outpatient. Assessed March 4, 2021.
  6. Centers For Medicare & Medicaid Services. Retrieved from https://www.medicare.gov/coverage/mental-health-care-inpatient. Assessed March 4, 2021.
  7. Alzheimer’s Association. February 2020. Retrieved from https://www.alz.org/media/documents/alzheimers-dementia-medicare-benefit-for-caregiver-training-ts.pdf.
  8. Centers For Medicare & Medicaid Services. Retrieved from https://www.medicare.gov/coverage/hospice-care. Accessed March 4, 2021.
  9. Centers For Medicare & Medicaid Services. Retrieved from https://www.medicare.gov/coverage/long-term-care. Assessed March 4, 2021.
  10. Cost of Care Survey. Geworth. https://www.genworth.com/aging-and-you/finances/cost-of-care.html. 2020.
  11. Centers For Medicare & Medicaid Services. Retrieved from https://www.medicare.gov/coverage/acupuncture. Retrieved from March 4, 2021.
  12. Centers For Medicare & Medicaid Services. Retrieved from https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=242&ver=1. Accessed March 4, 2021.
  13. Centers For Medicare & Medicaid Services. Retrieved from https://www.medicare.gov/coverage/prescription-drugs-outpatient. Accessed March 4, 2021.
  14. Centers For Medicare & Medicaid Services. Retrieved from https://www.medicare.gov/coverage/home-health-services. Accessed March 4, 2021.
  15. Centers For Medicare & Medicaid Services. Retrieved from https://www.medicare.gov/coverage/home-health-services#. Accessed March 4, 2021.
  16. Alzheimer’s Association. 2021. Retrieved from https://www.alz.org/help-support/caregiving/financial-legal-planning/insurance.

HealthMarkets’ FitScore intends to identify plans that fit your needs. You should carefully review official plan materials.

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