Alzheimer’s Disease – Dementia and Medicare Coverage
This article was updated on: 09/10/2018
Alzheimer’s disease is the most common form of dementia, involving the parts of the brain that control thought, memory, and language, according to the Centers for Disease Control and Prevention (CDC).
If you’ve come across this article, you may be wondering whether Medicare covers Alzheimer’s disease, such as diagnostic tests, doctor services, and prescription drugs. According to the Alzheimer’s Association, Alzheimer’s disease is progressive in nature and the type of care and assistance needed may change, depending on the stage of the disease. Medicare covers a variety of hospital and outpatient services to help you manage and treat your condition at each stage.
Early stage Alzheimer’s disease and Medicare coverage
One of the distinguishing signs of Alzheimer’s disease is memory loss. According to the Alzheimer’s Association, a person with early stage Alzheimer’s is usually still relatively independent but may experience forgetfulness, have trouble remembering names or common words, or misplace items. This memory loss worsens over time and may be accompanied by confusion or depression. In early stages of the condition, the focus is on proper diagnosis and development of a care plan.
If you’re enrolled in both Medicare Part A (hospital insurance) and Part B (medical and outpatient insurance), Medicare’s coverage for early stage Alzheimer’s disease includes the following benefits:
- Annual “Wellness” visit and health risk assessment. Part B covers the cost of an annual “Wellness” visit, which comes at no cost if you see a doctor that accepts assignment. The yearly physical exam includes a health risk assessment, which includes questions about your health and may be a starting point for identifying symptoms that lead to a diagnosis. During your visit, your doctor will also perform an assessment to check for cognitive issues. Your doctor is also available to discuss advance care planning options with you, including advance directives, so that your wishes are carried out if you lose the ability to make decisions for yourself. There is no cost for this annual “Wellness” exam if you see a doctor who accepts assignment.
- Diagnostic radiology tests. Part B covers diagnostic tests such as MRIs, CT scans, and PET scans when ordered by a physician to confirm or rule out a diagnosis of Alzheimer’s disease and how far the disease has progressed. This can be a critical step in care planning. You may be responsible for 20% of the Medicare-approved cost and the Part B deductible, if you haven’t yet reached it for the year. If you get the tests done in a hospital outpatient setting, you may owe a copayment.
- Hospital, doctor, and mental health services. Part B covers physician services, including doctor visits and follow-up care. Mental health services are also covered, including counseling sessions from behavioral health specialists and psychiatrists who accept assignment. Part B also pays 100% of the approved amount for an annual depression screening if your doctor accepts assignment and you get it in a primary care setting. These are important benefits because people with Alzheimer’s disease may experience depression, anxiety, or frustration, especially as their memory loss worsens. If hospital care is necessary, Part A provides coverage for inpatient care. Your costs may vary depending on the services you need, but could include deductibles, copayments, and coinsurance costs.
- Prescription drugs. Part A covers prescription drugs you need as part of an inpatient hospital stay, and Part B offers limited coverage for medications that you can’t give yourself (such as infusion drugs or other types that a doctor must administer). However, for coverage of Alzheimer’s medications that you take at home, you’ll need Medicare Part D prescription drug coverage, which is available through Medicare-contracted private insurance companies. Part D coverage is offered through either a stand-alone Medicare Prescription Drug Plan, which complements Original Medicare, or a Medicare Advantage Prescription Drug plan, which offers all of your Medicare coverage under a single plan. Since coverage varies, be sure to check the plan’s formulary, or list of covered prescription drugs, to make sure your medications are covered by the plan. While a plan’s formulary may change at any time, you’ll be notified by the plan when required by law. Cholinesterase inhibitors are a commonly prescribed Alzheimer’s medication and are used to treat the cognitive symptoms (memory loss, confusion, and problems with thinking and reasoning) of the disease, according to the Alzheimer’s Association.
Middle stage Alzheimer’s disease and Medicare coverage
During middle stage Alzheimer’s disease, individuals require more care than in early stages. This is often the stage where the patient starts exhibiting more intense confusion and increased difficulty communicating with others. If you’re caring for a loved one with middle stage Alzheimer’s, you may notice bigger changes in behavior or mood.
Many people at this stage may need home health aides, adult day care, or assisted living. Unfortunately, Medicare coverage for these services is limited. Medicare Part B provides short-term, limited home health coverage in some situations, but this is covered only if the individual is unable to leave home without considerable hardship and needs intermittent skilled nursing care or therapy services (such as physical therapy or occupational therapy). Medicare won’t cover the care if you need full-time nursing care.
When it comes to assisted living services like adult day care or assisted living facilities, Medicare doesn’t cover this type of care. However, there may be community programs available in your area that provide elder care services for those who need some assistance but can still live independently. This might include meal services, medical transportation, or social services for seniors. Here is a list of options that may be helpful as you consider your situation and the level of help you need.
Medicare coverage for medical care and health services that were initiated in early stages of the disease continue to be available through the middle and last stages of Alzheimer’s as needed, and as ordered by a physician.
Late stage Alzheimer’s disease and Medicare coverage
In late stages of Alzheimer’s disease, individuals require extensive care twenty-four hours a day, including personal care assistance. An individual who has Alzheimer’s disease at this stage commonly has profound memory loss, may no longer be able to communicate verbally, and either will need help walking or can’t walk at all. He or she may have incontinence, as well as angry or aggressive outbursts. At this point, family caregivers often can no longer provide the care that is needed.
People with late stage Alzheimer’s often require full-time nursing home care. Unfortunately, Medicare generally does not cover long-term care. Most nursing home care is personal care, or “custodial care,” which involves help with daily living tasks like eating or bathing. Medicare only covers skilled nursing care in certain situations, like during a short-term stay at a skilled nursing facility after a qualifying hospital stay. However, if you are a Medicare beneficiary with limited income, many state Medicaid programs cover long-term services, including nursing home care. This may be an option you can look into, and you can find out more by contacting your state’s Medicaid program.
In the final stages of Alzheimer’s disease, hospice care may be needed. Hospice care is covered by Part A, and it includes coverage for a variety of services ordered by the hospice physician, including:
- Durable medical equipment
- Nursing and therapy services
- Hospice aide services
- Prescription drugs for symptom control or pain relief only
- Short term, temporary respite care to relieve family members who are caregivers
- Homemaker services
- Grief counseling
Medicare plan options
Medicare beneficiaries have a few options when it comes to how they get or supplement their benefits. These may be particularly important to beneficiaries diagnosed with Alzheimer’s disease.
- Medicare Supplement (Medigap) plans are offered by private insurance companies and can help pay out-of-pocket costs for services covered under Part A and Part B. Different Medicare Supplement plans pay for different amounts of those costs, such as copayments, coinsurance, and deductibles.
Medicare Advantage plans are offered by private insurance companies contracted with Medicare to provide at least the same level of coverage as Original Medicare (except hospice care, which continues to be covered by Part A). In addition, Medicare Advantage plans often offer additional benefits. For example, many plans include Part D prescription drug coverage. Many plans also include routine dental, vision, hearing, or wellness programs.
Medicare Advantage Special Needs Plans are available in some locations. This is a type of Medicare Advantage plan that is specially designed around the unique needs of people, with specific diseases or characteristics. A Medicare Advantage Special Needs Plan for those with Alzheimer’s may have special coordination services to help enrollees better manage their condition or formularies that include commonly prescribed Alzheimer’s medications.
Resources for Alzheimer’s disease
The Alzheimer’s Foundation of America offers additional resources for those with Alzheimer’s and their caregivers. You can contact a licensed social workers at this organization to learn about local resources in your area. Or, to speak to someone at the organization, call the Alzheimer’s Foundation of America toll-free at 1-866-232-8484 Mon-Fri 9AM to 9PM EST and Sat 9AM to 1 PM. You also use the live chat option through the website here.
If you’d like more information about how Medicare covers medical services you may need, I’m here to answer any questions you may have. If you prefer to set up a phone appointment with me or request a personalized email, you’ll find links to do both of those below as well. To take a look at plan options available where you live, use the Compare Plans button on this page.
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Medicare Supplement insurance plans are not connected with or endorsed by the U.S. government or the federal Medicare program.