Does Medicare cover Alzheimer’s care?

How much does Medicare pay for Alzheimer’s care?

As explained by the Alzheimer’s Association, most people with Alzheimer’s progress through three stages of the disease: mild Alzheimer’s dementia (early-stage), moderate Alzheimer’s dementia (middle-stage), and severe Alzheimer’s dementia (late-stage).¹

The medical and custodial care needs vary by person and from one stage of the disease to another. But these needs may include tests and procedures necessary for diagnosis, medications, care planning, mental health care, custodial long-term care, and hospice care. Other than custodial long-term care, all of these services may be covered by Medicare, as detailed below.

Medicare does spend a significant amount of money on care for beneficiaries with Alzheimer’s disease. According to the Alzheimer’s Association, Medicare pays an annual average of $21,973 for patients with Alzheimer’s or other dementia, versus $7,918 for patients without Alzheimer’s or other dementia. Unfortunately, annual out-of-pocket costs are also significantly higher for those with Alzheimer’s or other dementia: An average of $10,289 versus $2,529 for those without Alzheimer’s or other dementia.²

Roughly half of all Medicare beneficiaries are covered by Original Medicare and half have Medicare Advantage.³

How does Original Medicare cover Alzheimer’s disease?

For those with Original Medicare:

• Medicare Part A covers inpatient care, some skilled nursing facility care, some home healthcare, and hospice care.⁴
• Medicare Part B covers physician and outpatient care. This includes services such as medically necessary care to diagnose or treat a medical condition, preventive care, ambulance transport and emergency department visits, durable medical equipment, and infusion medications administered in a clinic or doctor’s office.⁵
• Medicare Part D (obtained via a private insurer, and not part of Original Medicare) covers self-administered prescription drugs.⁶

How does Medicare Advantage cover Alzheimer’s disease?

For those with Medicare Advantage:

• All of the benefits of Medicare Part A and Part B are provided via one private plan, with out-of-pocket costs that vary by plan.
• Most Medicare Advantage plans also include Medicare Part D coverage for prescription drugs.⁷
• Depending on where a person lives, a dementia-specific Medicare Advantage Special Needs Plan (SNP) may be available.⁸ But according to KFF, most areas do not have dementia-specific SNPs available in 2024.⁹

How is Alzheimer’s covered under Medicare Part A?

Under the Medicare Part A benefit, people with Alzheimer’s are more likely to be hospitalized and more likely to receive care in a skilled nursing facility than those who don’t have the disease. (The care is often needed for conditions other than Alzheimer’s. Most people with Alzheimer’s also have at least one other medical condition.)¹⁰

Alzheimer’s is a fatal condition,¹¹ and patients can access the Medicare Part A hospice benefit once a medical professional certifies that the patient’s life expectancy is six months or less.¹²

How does Medicare Part B cover services related to Alzheimer’s disease?

Numerous services related to Alzheimer’s disease are covered under Medicare Part B. These include:

• Cognitive assessments, tests, and imaging necessary for diagnosis¹³
• Care planning¹⁴
• A home safety evaluation¹⁵
• FDA-approved infusion medications¹⁶
• Outpatient mental health care¹⁷
• Visits to the emergency department¹⁸
• Durable medical equipment such as a hospital bed¹⁹ or a wheelchair for in-home use²⁰

Does Medicare pay for in-home care for Alzheimer’s patients?

Depending on the circumstances, Medicare Part A will pay for up to 35 hours of in-home care per week. To receive this coverage, the patient must be “homebound” and need part-time skilled nursing care.²¹

If full-time care is needed, the patient isn’t eligible for home health care. And home health aide care (assistance with activities of daily living) is only covered if the patient is receiving skilled care at the same time. (Skilled care can include physical, occupational, or speech therapy, or skilled nursing care.)²²

If and when an Alzheimer’s patient transitions to hospice care, the hospice coverage will be provided under Medicare Part A, with very little in out-of-pocket costs. In most cases, hospice care is provided in a patient’s home.¹²

Some Medicare Advantage plans offer supplemental benefits for enrollees with certain chronic medical conditions. These can include assistance with some activities of daily living.²³ But the specifics vary by plan and that type of supplemental benefit is much less frequently available than supplemental benefits such as dental and vision coverage.²⁴

Are Alzheimer’s medications covered by Medicare?

Yes, Medicare will generally cover FDA-approved medications for Alzheimer’s. Medicare Part D will cover self-administered medications, while Medicare Part B will cover medications administered as an infusion in a medical office.²⁵

The Food and Drug Administration (FDA) has approved a variety of medications that slow the progression of Alzheimer’s or treat its symptoms. Different medications are used depending on the patient’s stage of Alzheimer’s.²⁶

Some medications prescribed to Alzheimer’s patients, such as brexiprazole,²⁷ donepezil, rivastigmine, galantamine, and memantine,²⁸ are covered under Medicare Part D.²⁹ (Note that each Medicare Part D plan sets its own formulary – covered drug list – so the specific drugs covered will vary from one plan to another.²⁹)

Anti-amyloid monoclonal antibody treatments (Leqembi and Aduhelm) are administered as an infusion and are covered under Medicare Part B.³⁰ (Note that coverage under Medicare Part B means that the beneficiary must pay 20% of the cost, after paying the Part B deductible, and there is no cap on out-of-pocket costs under Original Medicare. But Medigap plans will pay some or all of that 20% coinsurance charge.) In 2023, CMS clarified that Medicare Part B would cover infusion drugs approved by the FDA to slow the progression of Alzheimer’s under the following conditions:¹⁶

• The patient must be enrolled in Medicare Part B
• The patient must have mild cognitive impairment or early dementia caused by Alzheimer’s
• The patient’s physician must report clinical data via a portal that allows CMS to study “how these drugs work in the real world”¹⁶

In general, a Medicare beneficiary with Alzheimer’s disease will have coverage for medications necessary to slow the progression of their disease or treat its symptoms. But since each Medicare Part D plan sets its own formulary, patients and their caregivers should evaluate their coverage each year during the Medicare annual election period. This is an opportunity to switch to a different plan if there’s an option that will provide better coverage of specific medications recommended by the patient’s doctor.

Does Medicare cover nursing home care for Alzheimer’s patients?

Medicare does not cover custodial long-term care in any setting, including a nursing home.³¹ Medicare will cover up to 100 days in a skilled nursing facility following an inpatient hospital stay, in situations where a patient needs skilled nursing care – meaning more than just assistance with activities of daily living.³²

According to the Alzheimer’s Association, about a third of older adults with Alzheimer’s or other types of dementia live in nursing homes, as opposed to only about 2% of those without any form of dementia.³³ And nursing home care tends to be the largest expense for people with Alzheimer’s and other dementias.³⁴

Medicaid does cover custodial long-term care for those with limited income and financial assets. Nationwide, Medicaid is the primary payer of long-term care services.³⁵ Millions of Medicare beneficiaries are dually eligible for both Medicare and Medicaid.³⁶ This allows them to have coverage for their medical needs as well as their custodial long-term care needs, by utilizing the benefits of each program.