Alzheimer's & Dementia Medicare Coverage
Facing a diagnosis of Alzheimer’s or dementia can be challenging. For many, it’s only made worse by being unsure what type of Medicare Alzheimer’s and dementia coverage may be available. Medicare can pay for some services related to these conditions. All the general Medicare coverage you have with your plan remains in place. However, the type of treatment you receive for your needs may or may not have full coverage.
Does Medicare Pay For Dementia Care?
Medicare can cover most care during any stage of Alzheimer’s or dementia, including evaluation, diagnosis and treatment. This can include:
Cognitive assessments and necessary diagnostic testing
Home safety evaluation
Planning for care
Hospital stays (some limits apply, just as they do for any other medical condition)
Some mental health services can be covered under Medicare. However, you may still have to pay deductibles in these situations.
Facts About Alzheimer’s and Medicare
More than 6 million people in the U.S. are living with Alzheimer’s, a disease that kills more people than breast cancer and prostate cancer combined.
Alzheimer’s is a progressive disease and the most common type of dementia. It often starts with minor memory loss and can lead to the loss of the ability to control thoughts and language.
More than one in nine Americans ages 65 and older has Alzheimer’s — the sixth-leading cause of death in our country.
The Alzheimer’s Association projects that by 2050, Alzheimer’s will cost the U.S. more than $1.1 trillion.
Medicare Part B offers important coverage to combat this costly and incurable disease, including annual wellness visits , where your provider looks for signs of dementia, and a more thorough cognitive assessment to establish or confirm a diagnosis.
Why would I need a full cognitive assessment?
Your doctor will complete a general cognitive exam at your yearly wellness appointment. If they notice anything they’d like to further investigate, they’ll schedule a cognitive assessment for a separate appointment time to conduct a more thorough review. The cognitive assessment is also helpful to identify other conditions, like depression and anxiety, which can often affect cognition.
Who can offer a cognitive assessment?
Any clinician eligible to report evaluation and management (E/M) services can perform a cognitive assessment. This includes physicians, nurse practitioners, clinical nurse specialists and physician assistants.
What happens during a cognitive assessment?
This important assessment is offered in an office or outpatient setting, at a private home or care facility, and, as of Jan. 1, 2021, Medicare has permanently covered cognitive assessments via telehealth.
Can I bring anyone to my cognitive assessment appointment?
Yes. Spouses, friends or caregivers are encouraged to join you at your cognitive assessment to help answer your doctor’s questions and take notes for you to review after your appointment.
How do I pay for the cognitive assessment?
Anyone with Medicare Part B is eligible for this assessment, and the Part B deductible and coinsurance will apply.
Medicare and Dementia Prescription Coverage
As with other medical needs, Medicare Part D coverage can be necessary to cover the cost of prescription medications needed to treat dementia or Alzheimer’s. Alternatively, individuals who have Medicare Advantage — also known as Medicare Part C coverage — may need to have a plan that provides prescription medication coverage. The amount paid depends on the medications prescribed, as plans and coverage levels may differ.
Does Medicare Cover Memory Care?
The answer to this question depends on the type of care being sought. During the early stages of Alzheimer’s and dementia, some people may need to seek additional help around the home to make sure they remain safe and well. This may include accessing approved home health services. These services are typically only available when deemed necessary by medical providers. Additionally, they are capped at 35 hours a week and only available to people who are homebound, which means they are not easily able to leave their homes.
Medicare may provide coverage for adult day care centers. These are locations where a person can spend time during the day while their caregivers are not available, such as during work periods.
Does Medicare Cover Nursing Home Care for Dementia?
When it comes to Medicare, dementia and Alzheimer’s care, as the condition progresses, a person may require more types and higher levels of care. Sometimes it is not possible to provide that care in the home setting.
In later stages, Medicare may cover some costs related to skilled nursing facilities, but there are limitations. Generally, a person needs to have a medical need for this that is recognized by a medical provider. Then, the first 100 days in a nursing home or skilled nursing facility may be covered under Medicare. This typically includes special care units within nursing homes designed to provide care to individuals with dementia or Alzheimer’s disease.
Medicare may also provide coverage for hospice services. This may include hospice services in a skilled nursing facility.
Covering the Gap in Coverage
There’s often a gap in coverage for many dementia and Alzheimer’s patients. Simply, Medicare can not cover all the needs of most people with these conditions. For example, it typically does not provide coverage for extended nursing home stays beyond those 100 days. Out-of-pocket costs can rise after this point. Additionally, Medicare can not provide coverage for custodial care or assisted living facilities.
In these situations, a person may wish to seek out a Medicare supplemental plan to cover those gaps. Purchasing this type of policy may defray some of those additional costs.
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