Does Medicare Pay for Adult Day Care for Dementia Patients?

Steven Mott by Steven Mott | Licensed since 2012
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This article was updated on: 09/12/2018

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What is dementia?

According to the Alzheimer’s Association, dementia is a general term for severe mental decline which interferes with daily life. Alzheimer’s is the most common type of dementia. Signs of Alzheimer’s and dementia could include poor judgement and decision making, difficulty having a conversation, and misplacing things and being unable to find them. Alzheimer’s can make it difficult to complete daily tasks. More than five million Americans are living with Alzheimer’s and many of them need constant care. If you care for a loved one with Alzheimer’s dementia, it may be difficult to find help paying for respite care. Under Original Medicare (Part A and Part B), there are no benefits for custodial care like adult day care. You may have other options, however, to get the help you need.

What can adult day care provide to adults with dementia?

According to the Alzheimer’s Association, more than 15 million Americans provide unpaid care for people with Alzheimer’s and other dementias. While friends and family may be able to provide some care for adults suffering from dementia, at times these unpaid caregivers may need a break so they can attend school, go to work, or carry out other life duties.

According to eldercare.gov, adult day care centers can provide care and companionship for older adults who need help and supervision during the day. Eldercare.gov lists two types of adult day care.

  • Adult social day care provides recreation, meals, social activities and some health services, although the focus is on the activities.
  • Adult day health care offers intensive health, therapeutic, and social services to those with more serious medical conditions. Other services that adult day care centers could provide include: counseling, evening care, physical therapy, transportation, and medication management.

If Medicare doesn’t cover adult day care, does it cover any home care services?

According to eldercare.gov, adult day can centers can cost $25 to $100 per day depending on the services offered and the geographical region. Original Medicare, Part A and Part B, may cover hospital and medical care for beneficiaries with Alzheimer’s disease.  Part A and/or Part B may cover some home health-care services if your doctor believes they are medically necessary for your care, provided the services are provided by a home health agency certified by Medicare. Although it doesn’t pay for adult day care, in-home meal delivery, or homemaking services, you may qualify for coverage of home services such as:

  • Physical therapy
  • Speech/language therapy
  • Occupational therapy
  • Medical social services

Your doctor would have to order these services as medically necessary. If you qualify, you generally pay nothing for home health services for a limited period of time.

Does Medicare ever cover respite care in the home?

Medicare defines respite care as temporary care in a facility such as a nursing home to give the caregiver some time off. Generally, respite care for a dementia patient isn’t covered early on.

Medicare typically does cover respite care as part of the hospice care benefit under Part A. According to the National Institute on Aging (NIA), Alzheimer’s is a terminal illness with recognizable end-of-life symptoms. You are generally eligible for hospice and respite care if your health-care provider certifies you are approaching the end of life and you agree to comfort care instead of medical treatment, and sign a statement with Medicare confirming that decision.

If you qualify for the hospice benefit, you pay nothing for your eligible home health-care services, including short-term respite care provided in a nursing home or hospice inpatient facility. Although the hospice benefit doesn’t cover adult day care services, it does cover inpatient respite care; you may be asked to pay 5% of the allowable charges.

Are there other programs available to help with adult day care expenses?

Programs of All-Inclusive Aid for the Elderly (PACE) is a joint program between Medicare and Medicaid. It is designed to help older adults stay in their homes instead of entering nursing home care. PACE programs might pay for all services covered by Medicare and Medicaid that your doctor believes are medically necessary for your care, including but not limited to:

  • Adult day care
  • Emergency care
  • Meals
  • Home care
  •  Dentistry Prescription drugs
  • Other specialty medical care and therapies

To qualify for PACE, you must:

  • Be age 55 or over
  • Be enrolled in Medicare, Medicaid, or both
  • Live in a PACE service area (not all states have PACE programs)
  • Need a nursing-home level of care, according to your doctor
  • Be able to safely stay in your home with the appropriate support services

You can find out if there’s a PACE program in your state and if you’re eligible for services on the PACE program page on Medicare’s website.

Do Medicare Advantage plans or Medicare Supplement plans cover adult day care?

Medicare Advantage and Medicare Supplement plans are provided by private insurance companies approved by Medicare, which means they are able to determine what coverage they will offer plan enrollees. Medicare Advantage plans must cover everything included in Original Medicare (except for hospice care, which is still covered under Part A), but they may offer additional benefits for adult day care. Consult the plan information documents of the plans you are interested in for more information.

Keep in mind that all plan types and benefits may not be available in all locations and you must continue to pay your Part B premium if you enroll in Medicare Advantage, plus any additional premiums required by your plan.

Long-term care insurance and Veterans Administration policies may also help cover costs associated with adult day care.

Would you like more information about Medicare and adult day care or respite care services for dementia? I am happy to answer your questions. If you prefer, you can schedule a phone call or request an email by clicking on the buttons below. You can also find out about plan options in your area by clicking the Compare Plans button.

The product and service descriptions, if any, provided on these Medicare.com Web pages are not intended to constitute offers to sell or solicitations in connection with any product or service. All products are not available in all areas and are subject to applicable laws, rules, and regulations.

The purpose of this communication is the solicitation of insurance.  Contact will be made by an insurance agent/producer or insurance company.

Medicare Supplement insurance plans are not connected with or endorsed by the U.S. government or the Federal Medicare program.

The product and service descriptions, if any, provided on these Medicare.com Web pages are not intended to constitute offers to sell or solicitations in connection with any product or service. All products are not available in all areas and are subject to applicable laws, rules, and regulations.

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