Medicare and Alzheimer’s Disease/Dementia: What You Need to Know

Fortunately, Medicare beneficiaries afflicted with Alzheimer’s Disease and their families may be getting some welcome relief soon: Congress is looking at approving two promising prescription drugs that may help treat or slow the onset of Alzheimer’s symptoms.

It’s important for all Medicare beneficiaries to understand how Medicare covers Alzheimer’s dementia, and other cognitive disorders that commonly affect older Americans, and how to get the most out of your Medicare benefits.

This blog will explore what you need to know about Medicare and Alzheimer’s/ Dementia disorders, how it covers, and what Medicare leaves out.

We will also explore circumstances under which Medicare Part A may provide coverage. By understanding these aspects, you can make informed decisions and access the necessary care and support for you or your loved one.

Medicare Coverage for Alzheimer’s Disease

Here’s an overview of the key components:

Medicare Benefits for Alzheimer’s Patients

Exclusions

First, you must understand that Medicare alone doesn’t cover everything.

Neither Medicare, Medicare Advantage, or Medigap insurance includes coverage long-term custodial care, such as assisted living facilities and skilled nursing homes. The only such coverage Medicare provides is for a limited stay in a skilled nursing facility immediately after a hospitalization. But once your medical situation stabilizes, you won’t qualify for Medicare benefits for that facility.

Generally, when it comes to long-term care costs, you’ll need to pay out of your own resources, own a long-term care insurance policy, qualify for Veterans Administration Assistance, or rely on Medicaid.

The Limitations of Medicaid

Medicaid is designed for poor and indigent individuals.

First, Medicaid has strict income qualifications, which vary by state.

Second, Medicaid also has some complicated rules governing how much property and other assets and of what type you are allowed to own before you are disqualified from receiving benefits.

Without proper planning, Medicaid will require you to spend down nearly all your personal assets before they will help you with long term care costs.

Medicare planning can be quite complex. So it’s important to seek the services of an experienced elder law attorney well before you may need to enter a nursing facility. They can help you learn what resources are available, and help you structure your assets to help preserve your eligibility for Medicaid, while protecting your assets from seizure by state Medicaid officials recouping benefits paid.

Medicare Part A and Alzheimer’s Disease

Medicare Part A is designed to cover hospitalizations and care facilities for acute illnesses and injuries, but does not cover long-term custodial care.

Here’s how Medicare Part A works with Alzheimer’s:

After you’ve covered your Part A deductible ($1600 in 2023, Medicare Part A pays for up to 60 days of hospitalization per benefit period. From 60 to 90 days, Medicare will pay for some costs but not all of them. You will have a substantial additional copay per day of hospitalization beyond that.

Most people choose to own a Medigap or Medicare Advantage plan to help with Medicare deductibles and copays under Part A and Part B, which can be potentially devastating without some additional protection.

Medicare Part A also includes limited benefits for skilled nursing stays, but only after a hospitalization, and only up to 100 days.

The first 20 days of skilled nursing care after a hospitalization are covered with no copay. Days 21 to 100 are subject to a copay of up to $200.

Your doctor must certify that the nursing facility stay is medically necessary.

Medicare hospice care for Alzheimer’s patients

Medicare Part A also includes a comprehensive hospice benefit for those expected to pass away within six months.

Alzheimer’s Disease and Medicare Part B 

Medicare Part B covers medically necessary services and preventive care. For Alzheimer’s and Dementia, Part B provides coverage for doctor’s visits, diagnostic tests, and certain outpatient services.

In 2021, the FDA approved a new Alzheimer’s drug called Aduhelm. This new brand-name drug costs nearly $60,000 for a year of treatment.  It’s an infusion therapy, not a drug that you would obtain from your pharmacy. So the cost would be covered under Medicare Part B, not under a Part D prescription drug plan.

Aduhelm is an excellent reason to own a Medicare Supplement (Medigap) plan.

Without additional coverage in place, you would have to pay 20 percent of the total cost out of pocket. But since Aduhelm falls under Part B, not Part D, a Medigap Plan G, or N plan would cover the entire cost of treatment, except for the Part B deductible, which is $216 as of 2023.

Medicare Preventive Services and Alzheimer’s Screening

Medicare Part B covers annual wellness visits with your primary care doctor.

These benefits include a comprehensive assessment to evaluate overall health, cognitive function, and any potential risk factors related to Alzheimer’s or Dementia.

These visits allow healthcare providers to detect early signs of cognitive impairment and provide appropriate care management.

Diagnostic Testing

Alzheimer’s patients must undergo frequent lab testing and other diagnostic services.

Under Medicare Part B, coverage is available for diagnostic tests common with Alzheimer’s patients. These include neuroimaging (such as CT scans or MRIs) and neuropsychological assessments.

These tests help in diagnosing Alzheimer’s or Dementia and developing an appropriate treatment plan.

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Medicare Part B Costs 

Medicare Part B has premiums, copays, and a deductible to consider.

As of 2023, the standard monthly premium for Medicare Part B enrollees is be $164.90.

Medicare Part B also has a deductible of $216 as of 2013. You are also responsible for 20% of all physicians’ charges. This is over and above hospitalization costs which are partially covered under Medicare Part A.

This 20% copay under Part B can really add up. So it’s a good idea to have additional Medicare Supplement insurance (Medigap) in place. 

Alzheimer’s and Medicare Part D  

Medicare Part D provides coverage for prescription medications, including those used to manage symptoms and slow the progression of Alzheimer’s disease.

Original Medicare (Part A or Part B) does not normally include prescription drug coverage unless the drug is administered directly by your doctor or in a hospital setting. If you want prescription drug coverage, you must either purchase a standalone Part D policy, or enroll in a Medicare Advantage plan that includes prescription drug benefits.

It’s important to review your specific Part D plan for details on covered medications and potential restrictions.

Medicare Reimbursement for Alzheimer’s Medications

Medicare reimbursement for Alzheimer’s Medications normally occurs via Medicare Part D standalone prescription drug policies, or through a Medicare Advantage Plan that includes a built-in Part D component.

However, Medicare Part D does not currently include coverage for Leqembi, a promising medication that helps slow the onset of dementia. The reason: tThe drug currently costs over $26,000 per year.

Medicare also restricts access to another drug, Eisai, which just finished clinical trials. However, the Veterans Administration covers the cost of Leqembi for qualified veterans.

Meanwhile, a group of 23 state attorneys general are pushing for Medicare to approve access to these drugs for those Alzheimer’s patients who don’t qualify for VA benefits.

Note: Medigap policies do not include prescription drug coverage. If you enroll in a Medigap plan and you want prescription drug coverage, you must purchase a standalone Medicare Part D plan to work alongside your Medigap benefits.

The same is true if you choose the Medi-Share 65+ healthsharing alternative. 

Covered Services for Alzheimer’s and Dementia

Medicare provides coverage for various services related to Alzheimer’s and Dementia care.

Here are some key areas:

Physician Services – Medicare Part B covers visits to primary care physicians, specialists, and other healthcare providers involved in the management of Alzheimer’s or Dementia.

These visits include evaluations, consultations, and discussions regarding treatment options and care planning.

Cognitive Therapy – Medicare may cover cognitive rehabilitation services provided by qualified healthcare professionals.

Covered cognitive therapies aim to enhance cognitive abilities, memory, and functional skills in individuals with Alzheimer’s or Dementia.

Brain Training – Brain training uses mental exercises to improve memory and prevent or slow the on by improving neural networks within the brain.

Medicare itself does not cover brain training therapies directly. But some Medicare Advantage plans offer coverage for brain fitness programs or cognitive training programs.

Currently, about 25% of private Medicare Advantage plans offer these kinds of cognitive services as a preventative measure, as opposed to a treatment for existing memory loss or dementia issues.

Home Health Services – For individuals with advanced stages of Alzheimer’s or dementia, Medicare Part A covers hospice care.

Under certain circumstances, Medicare Part A may provide coverage for home health services, such as skilled nursing care, therapy services, and home health aide support. 

This coverage is available if the individual is homebound and requires skilled care to manage their Alzheimer’s or dementia.

Hospice Care – Hospice care provides comprehensive support to manage symptoms, alleviate pain, and enhance quality of life during the end stages of the disease.

For individuals with advanced stages of Alzheimer’s or dementia, Medicare Part A covers hospice care.

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Medicare Guidelines for Alzheimer’s Treatment With Monoclonal Antibodies

Recently, Medicare officials announced that the program will now cover monoclonal antibodies that target amyloid (or plaque) for the treatment of Alzheimer’s disease.

To be Medicare-eligible, the treatment must receive traditional approval from the Food and Drug Administration (FDA) under coverage with evidence development (CED).

Meanwhile, Medicare will also provide enhanced access and coverage for people with Medicare participating in CMS-approved studies, such as a data collection through routine clinical practice or registries.

More information on Medicare and monoclonal antibody treatment for Alzheimer’s patients is available here.

Healthsharing and Alzheimer’s Disease – An Affordable Alternative to Big Insurance Companies

Another affordable option is the Medi-Share 65+ health sharing plan, which is a money-saving, cost-effective non-insurance solution that helps pay all Part A and Part B deductibles and copays.

With Medi-Share 65+, your maximum out-of-pocket exposure to Medicare Part A and Part B-related costs is generally limited to just $500 per household per year. 

And Medi-Share 65+ is usually available at around half the cost of the comparable Medigap Plan F in most areas. 

Learn more about Medi-Share 65+

Medicare Advantage Plans for Alzheimer’s Patients

Medicare Advantage – also called Medicare Part C – allows Medicare beneficiaries to access their Medicare benefits via a private managed care plan.

Recently, the federal Centers for Medicare and Medicaid Services have authorized Medicare Advantage organizations to develop plans to provide more focused care for people with special medical needs, including Alzheimer’s and dementia.

Eligibility for Medicare Advantage Special Needs Plans is limited to the following circumstances:

• People who live in certain institutions (like nursing homes) or who require nursing care at home
• People who are eligible for both Medicare and Medicaid
• People who have specific chronic or disabling conditions (like diabetes, End-Stage Renal Disease, HIV/AIDS, chronic heart failure, or Alzheimer’s/dementia)

Medicaid and Alzheimer’s Coverage

Medicaid is the state-run program to provide access to medical care and nursing home care for the poor and indigent.

Medicaid plays a vital role in covering long-term care services, such as nursing home care or home and community-based services, which are often necessary for individuals with Alzheimer’s disease.

Medicaid’s coverage for long-term care is particularly crucial for individuals with limited financial resources, as Alzheimer’s care expenses can quickly deplete savings and assets.

Medicaid Eligibility

Medicaid eligibility criteria for individuals with Alzheimer’s disease primarily revolve around income and asset limitations. Details of both sets of limitations vary by state.  Individuals may qualify for Medicaid if their income falls below a certain percentage of the federal poverty level (FPL).

Asset limits also differ by state, with some states considering both income and assets, while others focus solely on income.

The disadvantage to relying on Medicaid for long term care for Alzheimer’s and dementia, or for any other reason, is that without detailed advance planning, Medicaid eligibility rules may require you to spend your assets down to the poverty level before you can receive benefits.

Some assets, such as home equity, are not countable when it comes to determining Medicaid eligibility. But after you pass on, or you can no longer live in your home, state Medicaid recovery officials may put a lien on your home and other assets or recover assets from probate to reimburse the state for the cost of your care.

Long Term Care Insurance vs. Medicaid

This is why it’s preferable to own long-term care insurance, rather than rely on Medicaid for nursing home care.

Long-term care insurance policies vary in coverage and cost, but they generally help cover the expenses associated with Alzheimer’s care, including assisted living, nursing homes, and in-home care. Private insurance can provide individuals with more flexibility in choosing the type and quality of care they receive, allowing for personalized care options tailored to their specific needs.

Importance of Care Coordination and Support

While Medicare provides coverage for various services, it’s important to emphasize the significance of care coordination and support for individuals with Alzheimer’s and dementia.

Medicare patients and their families and supporters should take advantage of these resources:

Care Planning

Work with your healthcare provider to develop a care plan that addresses the specific needs of the individual with Alzheimer’s or dementia.

The care plan should include strategies for managing symptoms, coordinating care among healthcare providers, and engaging support services.

Supportive Services

Explore community resources, support groups, and organizations specializing in Alzheimer’s and dementia care.

These resources can provide guidance, education, and emotional support for individuals and their families.

Caregiver Assistance

Caregivers play a crucial role in the management of Alzheimer’s and dementia.

Unfortunately, Medicare does not typically cover long-term care or custodial care provided by caregivers. But respite care services may be available under certain circumstances. Look for programs and organizations that offer respite care to give caregivers a break and prevent burnout.

Conclusion

Understanding the Medicare coverage available for Alzheimer’s and dementia is essential for individuals and families navigating this challenging journey.

Medicare Part B covers wellness visits, assessments, and diagnostic testing, while Part A may provide coverage for home health services and hospice care under specific circumstances.

By leveraging the available coverage and accessing care coordination and support resources, individuals with Alzheimer’s and dementia can receive the necessary care and support to manage their condition effectively.

Remember to consult with healthcare providers, review your specific Medicare plan, and explore community resources for comprehensive care and assistance throughout the Alzheimer’s and dementia journey.

For Further Reading

More Medicare Advantage Plans Cover Brain Training Programs
Long-Term Care Insurance

Medicare and Alzheimer’s Frequently Asked Questions

Does Medicare cover the diagnosis of Alzheimer’s disease or dementia?

Yes, Medicare covers diagnostic services, including doctor’s visits and diagnostic tests, to assess and diagnose Alzheimer’s disease or dementia.

What services does Medicare Part B cover for individuals with Alzheimer’s or dementia?

Medicare Part B covers doctor’s visits, cognitive assessments, diagnostic tests, outpatient therapy services, and certain medications used to manage symptoms associated with Alzheimer’s or dementia.

Does Medicare cover memory care services or assisted living for individuals with Alzheimer’s or dementia?

No, Medicare typically does not cover long-term care services, such as memory care or assisted living facility expenses. However, Medicare Part A may provide limited coverage for skilled nursing care in specific situations.

Can Medicare cover home health care for Alzheimer’s or dementia patients?

Yes, Medicare Part A may cover home health care services for individuals with Alzheimer’s or dementia if they meet certain eligibility criteria, such as being homebound and requiring skilled nursing care or therapy services.

Does Medicare cover prescription medications for Alzheimer’s or dementia treatment?

Yes, Medicare Part D provides coverage for prescription medications used to manage symptoms and slow the progression of Alzheimer’s disease or dementia. However, coverage may vary depending on the specific Part D plan and formulary. Access to some of the most advanced drugs is extremely limited, even under part D, as of May 2023.

Are there any programs or resources available to support caregivers of Alzheimer’s or dementia patients?

While Medicare does not directly provide caregiver support, there are community resources, support groups, and organizations that offer assistance, education, and respite care services to support caregivers of individuals with Alzheimer’s or dementia.

Can individuals with Alzheimer’s or dementia receive hospice care under Medicare?

Yes, Medicare Part A covers hospice care for individuals with advanced stages of Alzheimer’s or dementia. Hospice care provides comprehensive support to manage symptoms and enhance quality of life during end-of-life stages.

Does Medicare cover counseling or mental health services for individuals with Alzheimer’s or dementia?

Yes, Medicare covers counseling and mental health services, including psychotherapy and psychiatric evaluations, which can be beneficial for individuals with Alzheimer’s or dementia and their families.

Are there any preventive services covered by Medicare for Alzheimer’s or dementia?

Medicare Part B covers annual wellness visits, which may include cognitive assessments and screenings for cognitive impairments. Early detection of cognitive decline is essential in managing Alzheimer’s or dementia.

Can individuals with Alzheimer’s or dementia participate in clinical trials under Medicare?

Yes, Medicare may cover certain costs associated with participating in approved clinical trials for Alzheimer’s disease or dementia. However, specific eligibility requirements and coverage details vary, so it’s important to consult with Medicare and the trial organizers.