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What benefits does Medicare provide for Alzheimer’s patients?

In this article, we will examine what benefits Medicare provides in the context of the needs experienced by Alzheimer’s patients in the early, mid and late stages of the disease. As the condition progresses, the care requirements for individuals stricken with the disease vary significantly. For each stage, we will examine what are the typical symptoms and behaviors, the associated care needs and which of those needs are covered by Medicare benefits.

Early-stage Alzheimer’s

For the purposes of this article, we define early-stage Alzheimer’s as the period of time during diagnosis and the first year following confirmation of the condition. At the early stage, the symptoms of the disease are not severe; they include difficulty finding the right words, performing basic math without paper, repeating questions and misplacing objects. Behaviorally, one may notice unusual mood swings especially when the stricken individual is presented with a socially or mentally challenging situation.

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None of these symptoms result in a need for care, but they are significant enough where one might become concerned and seek medical attention and that is where the expenses associated with Alzheimer’s care begin.

Diagnosing Alzheimer’s can be an expensive process because there is not a single definitive test. Instead the process consists of ruling out other conditions with similar symptoms which do have definitive tests and mental evaluations with a team of specialists including neurologists, psychiatrists and psychologists. Since this is a diagnostic process, Medicare Part B will cover 80% of the cost once an individual has paid their Part B deductible ($203 in 2021).

Following a diagnosis of Alzheimer’s, some individuals will require psychological counseling for the associated conditions like depression and aggression, or they might need physical and occupational therapies. Provided these services are considered medically necessary and prescribed by a doctor, Medicare Part B will pay 80% of these costs. In fact, recent changes to Medicare removed the caps on the amount of therapies individuals can receive.

It is worth noting that Medicare Supplemental Insurance can cover the 20% coinsurance that beneficiaries would otherwise have to pay themselves. There are also Medicare Special Needs Plans (SNP) designed specifically for individuals with Alzheimer’s.

A change to Medicare in 2017 was the addition of care planning as a service. Care planning helps patients to understand both what their medical options are, as well as alternative treatments, clinical trials, and even non-medical support. To be clear, Medicare won’t necessarily pay for all these services, but will pay to put together a plan to access them. For persons with Alzheimer’s and their families, care planning is a much needed as well as much overlooked benefit.

Most individuals will want to begin with Alzheimer’s medications soon after diagnosis; in some cases, certain medications have been shown to delay the progression of the disease. Medicare Part D helps pay for prescription drugs and most standard Alzheimer’s medications are on Medicare’s approved drugs list.

In 2021, the FDA approved Aduhelm, a new Alzheimer’s medication that costs $56,000 for a year of treatment (the drug does not cure Alzheimer’s, so patients will need to take it on an ongoing basis). It’s an infusion therapy, so it would be covered under Medicare Part B rather than Part D (Part D is for drugs that are obtained at a pharmacy, whereas Part B covers medications that are infused in a doctor’s office or hospital). Aduhelm’s FDA approval has been controversial, and CMS may impose coverage limits on how Medicare will pay for it. But even if it’s covered like any other infusion treatment under Part B, it would still leave beneficiaries with substantial out-of-pocket costs unless they have supplemental insurance, and is likely to result in premium increases for Medicare Part B.

Middle-stage Alzheimer’s

As Alzheimer’s progresses into the middle stage, the associated symptoms become more severe. One can expect persistent memory loss and confusion associated with present and past events. There is a minor loss of motor skills and coordination, and slowness to movement. Mood changes also become more severe; often aggravated by the confusion the individuals are experiencing.

For the most part, the disease at this stage requires supervision and gentle reminders, but skilled care is not required. Some activities of daily living (ADLs) are compromised such as properly dressing oneself for the weather, taking medications, and eating. Therefore, personal care assistance may be required in addition to supervision.

Some families choose to provide personal care at home with the help of family members or home care aides, while other families prefer to receive personal care and supervision in an assisted living location or adult daycare. Assisted living specifically for persons with Alzheimer’s is referred to as “memory care.” Unfortunately, Medicare does not provide benefits for custodial care or supervision either at home or in memory care residences and the cost of memory care can be high.

Often, as Alzheimer’s progresses to the middle stage, families become interested in trying alternative therapies such as acupuncture or herbal medicine. As with personal/custodial care, alternative therapies are not a covered Medicare benefit.

In summary, while Medicare continues to pay for doctors’ visits and prescription drugs, there are few additional covered benefits by Medicare as one’s Alzheimer’s progresses from early to middle stage.

Late-stage Alzheimer’s

Late-stage Alzheimer’s is characterized by severe memory issues such as forgetting the names of spouses and caregivers, incontinence or great difficulty using a toilet, and even the loss of ability to respond to one’s environment. Behaviorally, individuals may become delusional or compulsive and experience hallucinations.

At this point, 24-hour care – either at home or in a skilled nursing residence – becomes necessary. Also, at this point, Medicare may begin to pay for additional services. However, qualification can be tricky and the coverage intermittent. Families may find themselves using a variety of Medicare services interspersed with their own caregiving.

While nursing home care may be required, Medicare will only pay for 100 days of skilled nursing care and it must be following a hospital stay. While persons with Alzheimer’s may require nursing home care, they don’t often have a precipitating event that necessitates a hospital stay. Medicare will pay for home health care for up to 35 hours a week, but the individual must be certified as “homebound.” While some late-stage Alzheimer’s patients may be physically able to leave their homes, they may still qualify as homebound because they are psychologically unable to function outside the home. Then again, they may not qualify because home health care is not supposed to be for a “continuous” need.

Finally, Medicare provides an all-inclusive hospice benefit for individuals determined to have less than six months to live. Very late-stage Alzheimer’s patients will qualify for this program which includes all palliative care that the patient needs, as well as counseling for the individual and their family.

Despite its shortcomings, Medicare, when used fully – and especially when augmented with Medicare Supplemental Insurance – can make a significant contribution towards the expense of caring for a loved one with Alzheimer’s. Readers may want to explore this article which discusses other Medicaid and Veterans’ benefits for Alzheimer’s.

But it’s important for families to be aware of the fact that Medicare will not cover extended stays in a nursing home or in-home long-term-care for seniors who need assistance with their activities of daily living due to Alzheimer’s (Medicaid does, if the patient has an asset level and income low enough to qualify for the program; you can click on a state on this map to see how Medicaid can supplement Medicare to provide comprehensive coverage for beneficiaries with limited financial resources). If a medical situation – a broken hip, for example – results in a hospital stay of at least three days, Medicare will cover up to 100 days for rehabilitation in a nursing home. But nursing home stays can extend far beyond that, and can cost thousands of dollars per month unless Medicaid or a long-term care insurance policy is available to pick up the tab.

In 2019, only about 7% of Americans age 50 or older had long-term care insurance, and many people find the premiums to be prohibitively expensive. But such coverage can complement Medicare, picking up the cost of custodial care while Medicare pays for “medically necessary” care.


Alex Guerrero is one the founders of PayingforSeniorCare.com, a site created and maintained by the American Elder Care Research Organization.

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Randy Grundleger
1 year ago

My dad, a WWII veteran, has late-stage Alzheimer’s and is currently residing in a memory care facility in Bluffton, SC. The monthly costs are staggering. I wanted to know if there are any Medicare benefits to be had.

barbara
1 year ago

If you have his DD 214 number you can call the veterans administration some of the facilities will help you get money but you must do the work yourself there is not a form they will tell you about but you must call in and ask for information for World War II vets that have Alzheimer’s I had my parents in a facility and I lost out on over $7000 because they help the World War II vet and they help the spouse but you have to ask them and you have to do the research to find the information they do not have it on the veterans website

Barbara
1 year ago

How can I find out about the 35 hours Medicare will pay for home health care homebound know I need some assistance I’m caring for a friend and she’s getting worse and worse

Admin
Josh Schultz
1 year ago
Reply to  Barbara

More information about Medicare coverage for home care is here: https://www.medicareresources.org/faqs/how-much-in-home-care-will-medicare-cover/

Seasons Alzheimer’s Care and Assisted Living
1 year ago

Good analysis of benefits provided by medicare for Alzheimer’s patients in the early, mid and late stages of the disease. Keep up the excellent work!

9 months ago

My sister-in-law has late stage Alzheimer’s and my brother has late stage COPD and can’t take care of her. They live on Social Security with only a small savings. He is a Veteran they live in Iowa. What are their options?

Josh Schultz
9 months ago
Reply to  Sandra Siewert

I suggest researching whether they qualify for Medicaid. Here is an article about the home and community based services that Medicaid could cover for them: https://www.medicareresources.org/glossary/home-and-community-based-services-hcbs/.

This website has information about eligibility limits in Iowa: https://www.medicaidplanningassistance.org/medicaid-eligibility-iowa/

Luz best
1 year ago

How can I fine a nursing home to my mother she had dementia she is 88 years old bad n my wife n I can’t take care of her we are also sick
N in our 70 , how can I fine a place right away
She has Medicare n Medicaid .
Can someone please tell me what I can do
Thank you
Mrs best

Illy
11 months ago
Reply to  Luz best

If she already had both Medicaid and Medicare there is not much else but to start researching/ contacting individual nursing homes to see if they suit her needs. If they do not accept Medicaid likely they can inform you of some that do. Or your state Medicaid website should have the info somewhere. Once you choose one most will guide you if not handle most of the insurance transition , depending your state Medicaid may need to be changed from one status to another.. and they will do and income asset check looking back at 5 yrs. Because the homes cost more state verifies there’s no hidden monies to pay for it. Hope this helps, try not to jump through unnecessary hoops. Seem like you got it under control.

Karla V. Busch-McEwen
11 months ago

I am POA for a very close friend with stage 6 Alzheimers, no children or husband, after trying to care for her in her home for 1.5 years, she began to need 24 hour care, which I could not provide and she could not afford. Now she is in a very good memory care facility but costs are so high. Where do I go to find out if she can get help with her memory care expenses?

Admin
Josh Schultz
11 months ago

I am sorry to hear about your close friend. Depending on her income and assets, she might be eligible for Medicaid, which could help with some of those costs: https://www.medicareresources.org/medicare-benefits/how-medicaid-supports-1-in-5-medicare-enrollees/

Patricia Pennacchio
4 months ago

How do I access the Care Planning Services that Medicare added in 2017?

Mom is 88 diagnosed with Dementia Early Alzheimer’s we think she’s in the middle stage memory is shot, she’s not eating much and we would like to tap into this Planning Service for guidance and moving forward so we know where we are going with her care. I called Medicare today and was told that I have to have her Doctor order this service. What does the doctor do call Medicare and set up a Social Worker to evaluate her and set up the plan?? The Medicare representative really didn’t know anything about this Service. I need guidance could someone tell me how this works.

Thank you so much!

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