Medicare and Alzheimer’s Coverage: What You Need to Know

There are more than 6 million Americans who are 65 or older living with Alzheimer’s dementia, the sixth-leading cause of death among Medicare-aged individuals.¹ Understanding what Medicare will and will not cover is important as you manage your Alzheimer’s diagnosis.

We’ve compiled some commonly asked questions to help you understand Medicare coverage.

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. That’s why it’s not always easy to understand what Medicare will and won’t cover when it comes to Alzheimer’s Disease.

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.
• 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.
• Mental Health Services. Some covered services include psychiatric evaluations, diagnostic tests, individual and family counseling, medication management, and yearly depression screenings.
• 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 pay only help pay for the first 100 days.² For psychiatric hospitals, Medicare will provide coverage, but there is a lifetime limit of 190 days.
• Caregiver Training for Family Members. In some states, Medicare offers customized behavioral training provided by home health nurses for families and caregivers.
• Hospice Care. Medicare pays 100% of hospice care if doctors can certify that the patient is terminally ill with a life expectancy of 6 months or less.

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

Original Medicare (Parts A and B) does not cover some services that may be given after a diagnosis such as Alzheimer’s disease. Patients, or their and families, could be 100% 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 day care, but does not pay for personal care services or assistance with activities of daily living (i.e., getting dressed, bathing, and eating). These are the average 2020 monthly costs for nursing homes and other outsourced care:³
  • 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, nutritional supplements, vitamins, or herbal remedies to help treat dementia disorders. However, some Medicare Advantage plans may 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. 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?

Original Medicare (Parts A & B) 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.

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 for up to 100 days.

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.

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.

HealthMarkets Can Help Answer Your Medicare Questions

HealthMarkets can help you find insurance solutions for your needs, including Medicare plans. Compare Medicare plans online today, at no cost to you. You can also talk to a licensed insurance agent about your Medicare coverage options by calling (800) 827-9990.