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How Medicare covers Alzheimer’s Disease

Savvy Senior

Dear Savvy Senior, What all does Medicare cover when it comes to Alzheimer’s disease? My wife was recently diagnosed with early stage Alzheimer’s and I would like to find out what’s covered and what’s not. - Researching Spouse

Dear Spouse,

Most medical costs to treat beneficiaries with Alzheimer’s disease are covered by Medicare, but unfortunately long-term custodial care costs that most patients eventually need are not. Here’s a breakdown of what Medicare does and doesn’t cover when it comes to Alzheimer’s disease, along with some tips that can help you plan ahead.

Medical care: For the most part, ongoing medical care to diagnose and treat Alzheimer’s disease is covered by Medicare Part B, including visits to primary care doctors and specialists, lab tests, speech and occupational therapy, home health care and outpatient counseling services. Medicare pays 80 percent of these costs, and you will be responsible for the remaining 20 percent after you’ve met your annual $147 Part B deductible.

Inpatient hospital care is also covered under Medicare Part A with a $1,216 deductible and coinsurance. And, as part of health care reform, Medicare is also covering 100 percent of annual wellness visits, which includes testing for cognitive impairment.

Medications: Most Alzheimer’s medications are covered under Medicare’s Part D prescription drug plans, but plans vary on copayments. If you have a Part D plan, use the Medicare Plan Finder tool at medicare.gov/find-a-plan to compare your plan’s total drug costs against other plans to be sure you’re getting the best coverage. The Alzheimer’s Association offers a chart on coverage for common Alzheimer’s drugs – go to alz.org and type “drug chart” in the search field to find it.

Long-term custodial care: Many seniors are surprised to learn that Medicare does not cover long-term custodial care. This includes nursing home care, the costs of assisted living facilities and adult day care. Medicare does, however, pay for some shorter-term nursing home care, but only up to 100 days following a three-day inpatient hospital stay.

Hiring home help for bathing, toileting and dressing (this is known as custodial care) is not covered by Medicare either unless your wife is also receiving skilled-nursing care or physical or occupational therapy to help with the recovery from an illness or injury.

To help with these costs, you may want to consider a long-term care insurance policy. Or if your income and assets are very limited, you may qualify for Medicaid. See longtermcare.gov for a breakdown of long-term care planning options.

Hospice: In the final stages of the disease, Medicare Part A covers nearly all aspects of hospice care, including doctor services, nursing care, drugs, medical equipment and supplies, physical and occupational therapy, homemaker services, counseling and respite care. To qualify, a doctor must certify that a patient has six months or less to live.

Other Insurance: If you don’t have a Medigap (Medicare supplemental insurance) policy, you should consider getting one. A Medigap plan will help pay for things that aren’t covered by Medicare like copayments, coinsurance and deductibles. To search for plans in your area, visit medicare.gov and click on “Supplements & Other Insurance” or call Medicare at 800-633-4227 and ask them to mail you a free copy of the “Choosing a Medigap Policy” publication 02110.

Or, if you’re enrolled in a Medicare Advantage plan (like an HMO or PPO), your plan must give you at least the same coverage as original Medicare does, but make sure your doctors are in your insurer’s network to avoid excess costs. Also find out whether you need a referral or prior authorization before getting care.

Financial Assistance: If you can’t afford your Medicare out-of-pocket costs, or need help with medication expenses, there are government programs that can help. Go to benefitscheckup.org to search, or contact your Eldercare Locator (800-677-1116) who can refer you to local services to assist you.

Send your senior questions to: Savvy Senior, P.O. Box 5443, Norman, OK 73070, or visit SavvySenior.org. Jim Miller is a contributor to the NBC Today show and author of “The Savvy Senior” book.

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