Kathleen Allen, LCSW, C-ASWCM
Kathleen Allen has been working with older adults and their families for over 20 years.
Every 65 seconds, someone in the United States develops Alzheimer’s disease, the most common form of dementia. If you or a loved one has received a diagnosis of Alzheimer’s disease, financial considerations related to ensuring quality care likely will be among the top priorities to address. You won’t be alone. With an estimated 500,000 new cases of Alzheimer’s disease diagnosed annually in the U.S.—expected to triple by 2050—millions of people will find themselves needing to understand how Medicaid and Medicare, two federal programs, cover health care for this population.
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Medicare is a federal health insurance program for people aged 65 or older and for people with disabilities who meet specific eligibility requirements. The population affected by Alzheimer’s disease is largely over age 65, and Medicare also will cover younger people with early-onset Alzheimer’s who have received Social Security disability benefits for two years.
Medicare covers some, but not all, of the services that people with Alzheimer's disease may need. Long-term care services, such as custodial care in a nursing facility or at home, are among the services that Medicare does not cover.
To receive Medicare coverage, a person must be a U.S. citizen or legal U.S. resident who has lived in the country for 5 consecutive years. Your initial enrollment period for Medicare is within a seven-month window: the three months before your 65th birthday, the month you turn 65, and the three months after you turn 65. If you miss this window, don’t worry! There is also a general enrollment period each year from January 1 through March 31.
Understanding the kinds of coverage offered by Medicare and how to access coverage is crucial to ensuring good health care and quality of life. Medicare is split into four “parts,” each designated by a letter: A, B, C, and D. Parts A and B are considered “original Medicare” and cover hospital and inpatient care (Part A) and visits to outpatient care (Part B). You will enroll for these parts first. To enroll, contact your local Social Security office or the national office through its website or by phone (1-800-772-1213).
Part C, also known as Medicare Advantage, is a way to access the coverage of Parts A and B through private insurance in a package that also often will include Part D, which is Medicare prescription drug coverage. Such packages may also include other benefits, such as vision and dental, depending on the insurer. You also can sign up for Medicare Part D separately.
In the sections below, you will find more detail about these “parts” of Medicare and what their purpose and coverage is.
For people with Alzheimer’s disease who need financial support for long-term care, the federal Medicaid program may cover some or all such costs. The program coverage is variable, as Medicaid is usually administered by state-level agencies, which may have different eligibility requirements and benefits.
People with Alzheimer’s disease may qualify for long-term care coverage under Medicaid if they meet income and asset limits. To apply for Medicaid, call your state’s department of human services or Medicaid assistance program or your county’s department of social services.
Each of the four parts of Medicare covers a different area of personal health care. For someone with Alzheimer’s disease, “original Medicare,” or Parts A and B, will cover every stage, from diagnosis through treatment and planning of care. It also covers care planning services for people with Alzheimer’s disease. This coverage includes:
neuropsychiatric testing and other evaluations of cognitive function, including memory, reasoning, and basic mathematical calculations.
safety evaluations such as for driving
caregiver identification and needs
development of care directives
planning for palliative care, and
referrals for community services not only for the person with Alzheimer’s disease but also for caregivers.
Care plans should be updated at least annually, and your healthcare provider should help with developing the plan.
Original Medicare does not, however, cover:
vitamins and supplements you can buy over the counter.
adult day care
respite care (except for hospice care under Part A)
incontinence products, or
support care for daily living activities such as bathing and eating.
Part A covers:
care and medications received while staying at the hospital (with no copayment for up to 60 days and a daily rate from 61 to 90 days)
inpatient or outpatient rehabilitation services after a hospital stay.
psychiatric care (with limits on inpatient care duration)
skilled nursing care in a facility (with no daily copayment for days 1-20; copayment up to $200 per day for days 21-100; no part A coverage for days 101 and beyond), and
some skilled home care, and hospice care.
Most people receiving this benefit will not have to pay a monthly premium, but there are copays, often that kick in after a certain time period, and a deductible to meet.
Some things not covered under Part A include:
long-term stay in a hospital or psychiatric facility (no coverage at all once a stay exceeds 90 days)
24-hour home care
support care for activities of daily living such as eating or bathing,
and care received outside of the U.S.
Part B covers doctors' services, outpatient care, and medical supplies. It also covers preventive care, such as an annual checkup, receiving a flu shot, and mammograms. Part B covers medical tests including x-rays and other imaging (such as magnetic resonance imaging, or MRIs), electrocardiograms to check heart function, and routine and standard diagnostic blood tests. However, Medicare does not cover commercially available blood tests specific to Alzheimer’s disease. Financial aid may be available directly through the test manufacturers.
Especially important for people with Alzheimer’s disease is Part B coverage of occupational and physical therapy, speech language pathology services, mental health care, and short-term, part-time skilled nursing and health aide care at home.
Part B does not cover hearing tests or hearing aids, vision care (eye exams, glasses, contact lenses), routine dental care, most prescription drugs (but see Part D, below), and routine foot care, which can be important for people with diabetes.
Part B requires a monthly premium. In 2023, the standard monthly premium for Part B is $164.90. For individuals and couples with a modified adjusted gross income above $97,000 and $194,000, respectively, the monthly premium is adjusted to include an income-related monthly adjustment amount (also known as IRMAA).
Part C plans are all-inclusive plans that combine the coverage of Parts A, B, and D (coverage of prescription drugs; see below). Not all Part C plans are accepted by all providers, so before enrolling in one, be sure you know which providers are in the network. Part C plans sometimes include additional benefits beyond those covered by Parts A, B, and D, such as dental or vision care, although at an additional cost. Medicare Part C premiums vary according to the plan.
Part D is for people who do not have prescription benefits through a commercial insurance plan (see also the section on Medicare Advantage Plans below). You will need Part D coverage for medications obtained through a pharmacy rather than during a hospital stay or from your healthcare provider directly. You must enroll first in Part A or B to enroll in Part D. To find a Part D plan, visit the federal Medicare website, where you can compare coverage and prices. Be sure to look through which medications each plan covers before making your choice, as they do not all cover Alzheimer’s-related drugs.
People with Alzheimer’s disease may also be able to gain further coverage through other programs, including Medicaid, some state programs, or the Department of Veterans Affairs.
These plans are a specific type of Medicare Advantage plan designed to provide coordinated care for certain patient populations, including people with dementia-related conditions such as Alzheimer’s disease. Special Needs Plans are tailored to the condition the plan covers, including options for providers, benefits, and which drugs are covered (called the formulary).
These plans cover everything that Parts A and B cover but add in services to meet the needs of the covered patient population, including prescription drug coverage. As with the other Medicare Advantage plans, Special Needs Plans are offered by private insurance companies.
It is important to know that Medicare does not cover 100% of any medical claim. In general, when you see your physician or are in the hospital, 20% of the bill will not be covered by Medicare. Medicare supplement plans provide more complete coverage. With Medicare plus the supplement (also known as “Medigap”), you will have fewer out-of-pocket expenses than with Medicare alone. Commercial health plans through a current or former employer can also provide the supplemental coverage you need with Medicare.
Currently, 10 such Medigap plans are available. Although they operate under a framework standardized by the government, they are purchased from private insurance companies. The plans are expected to offer the same basic benefits, but costs and any further coverage can vary among companies offering these plans.
The newest treatments approved to fight Alzheimer’s disease are immune-based anti-amyloid therapies, which work by clearing different forms of amyloid-beta in the brain. For patients to receive coverage of these drugs, Aduhelm and Leqembi, the Centers for Medicare and Medicaid Services (CMS) has established some special rules.
For Leqembi, the CMS has ruled that the drug can be prescribed only for people diagnosed with early cognitive impairment or mild dementia caused by Alzheimer’s disease who are under the care of a qualified physician. In addition, physicians who prescribe Leqembi must participate in patient registries for the drug to be covered. The registries collect demographic, diagnosis, and medical history, along with the results of brain scans and tests that determine levels of amyloid, a key protein in Alzheimer’s disease.
The CMS has proposed a change in Medicare coverage of positron-emission tomography (PET) scans for beta-amyloid, which are required to confirm a diagnosis and follow-up for people being prescribed Leqembi. The proposed change would lift this limitation and allow private insurers that process Medicare claims to cover more than one scan and scans outside of clinical trials. The fate of the proposal is expected to be decided in fall 2023. Other kinds of testing for amyloid, such as blood or cerebrospinal fluid testing, are not yet covered under a national Medicare policy.
For Aduhelm, coverage is granted only for patients who are enrolled in a clinical trial approved by the CMS or supported by the National Institutes of Health.
|What is covered
|What is not covered
|Hospital care and in-hospital medications, skilled nursing care, inpatient/outpatient rehabilitation, hospice care
|Long-term hospital stay (>90 days), 24-hour home care, care received outside of the U.S.
|Medically necessary and preventive services
|Medical services and supplies needed to diagnose or treat a medical condition, including Alzheimer’s disease, preventive care, medical tests, occupational/physical therapy, speech services, mental health care, short-term/part-time skilled nursing, and health aide care at home
|Hearing tests/hearing aids, eye exams/glasses/contact lenses, routine dental care, most prescription drugs, routine foot care
|Parts A, B and D (also called “Medicare Advantage”)
|All-inclusive plans that combine the coverage of Parts A, B, and D, sometimes with other benefits (e.g., vision, dental)
|This will vary depending on the plan you choose.
|Medications obtained through a pharmacy
|Coverage varies based on which plan you choose; be sure to check for coverage of Alzheimer’s treatments.
Kathleen Allen has been working with older adults and their families for over 20 years.
BrightFocus Foundation is a premier global nonprofit funder of research to defeat Alzheimer’s, macular degeneration, and glaucoma. Through its flagship research programs — Alzheimer’s Disease Research, National Glaucoma Research, and Macular Degeneration Research — the Foundation has awarded nearly $290 million in groundbreaking research funding over the past 50 years and shares the latest research findings, expert information, and resources to empower the millions impacted by these devastating diseases. Learn more at brightfocus.org.
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