Both original Medicare and Medicare Advantage help with dementia costs, but the deductibles, copayments, and coinsurance differ between the two programs.
Medicare helps pay for some services at every stage of dementia. Some areas of coverage include tests to evaluate a person’s thinking skills, along with home health care, prescription drugs, and hospice.
In this article, we describe dementia and examine Medicare coverage of dementia from the early to late stages. We also identify which dementia-related services are not covered. Finally, we look at wellness visits, eligibility, and costs involved.
We may use a few terms in this piece that can be helpful to understand when selecting the best insurance plan:
- Deductible: This is an annual amount that a person must spend out of pocket within a certain time period before an insurer starts to fund their treatments.
- Coinsurance: This is a percentage of a treatment cost that a person will need to self-fund. For Medicare Part B, this comes to 20%.
- Copayment: This is a fixed dollar amount that an insured person pays when receiving certain treatments. For Medicare, this usually applies to prescription drugs.
Dementia is the loss of the ability to think, reason, and remember. The condition involves the loss of skills to such an extent that it hinders a person’s ability to engage in normal daily activities. Such skills include self-management, language, problem solving, and attention.
In addition to affecting the mind, dementia may also affect the emotions. As a consequence, some people with the condition may experience a personality change.
Dementia can range from mild to severe. Symptoms start when nerve cells in the brain lose connections with other brain cells, or the nerve cells stop working and die. As healthy people age, they lose nerve cells, but someone with dementia loses them at a faster rate.
According to the National Institute on Aging, dementia affects up to half of all individuals aged 85 and older; however, dementia is not considered to be a normal part of aging.
There are different types of dementia, with Alzheimer’s disease being the most common type.
Medicare provides help with services a person with dementia needs at every stage of the illness. The chart below shows an overview of Medicare coverage. It is followed by more details about the coverage of each part.
|Part A||Coverage includes home health care, the first 100 days in a nursing home, and hospice care.|
|Part B||Coverage includes preventive services, such as wellness visits, along with medical tests, doctor visits, and equipment.|
|Part C||Coverage includes the benefits of Part A and Part B. Some plans add prescription drug coverage and extra perks, such as transport for doctors visits.|
|Part D||Coverage involves prescription drugs.|
|Medigap||Coverage includes some or all of Part A and Part B uncovered costs, which are deductibles, copayments, and coinsurance.|
Original Medicare (Part A and Part B)
During the early stages of dementia, many individuals benefit from being in their own home.
Medicare Part A pays for up to 35 hours per week of home healthcare for a person certified as homebound.
Part B covers tests, doctor visits, and medical items.
In the later stages of dementia, people are often unable to live at home. At this point, they usually need 24/7 care.
Part A pays for the first 100 days in a nursing home.
When a doctor determines that a person with dementia has less than 6 months to live, Medicare pays for hospice care.
This coverage includes doctor, nursing, and personal care, along with counseling and prescription drugs. The coverage does not depend on location, and a person is covered whether receiving the care at home, in a hospice facility, or in a nursing facility.
This cost does not include a deductible. The coinsurance is minimal.
Medicare Advantage (Part C) plans are an alternative to original Medicare. Other parts of Medicare include Part D and Medigap.
Part C provides dementia-related services covered under Medicare Part A and Part B. The plans may also include additional benefits, such as rides to doctor appointments. However, deductibles, copayments, and coinsurance may differ from original Medicare.
One type of Advantage plan, a Special Needs Plan, offers benefits that are tailored to chronic conditions, including dementia.
People with original Medicare may choose to buy a Part D plan to get prescriptions drug coverage. The costs vary among plans and the companies that offer them.
Medigap is Medicare supplement insurance. The plans help with the uncovered costs of Medicare parts A and B, which include deductibles, copayments, and coinsurance.
Although Medicare helps with healthcare costs associated with dementia, coverage does not include everything a person may need. The following are uncovered services:
- 24-hour-per-day care at home
- care in a nursing home beyond the first 100 days
- adult day care
- incontinence supplies
- meals delivered to the home
- personal care, such as bathing and dressing, when this is the only care a person needs
- homemaking care, such as laundry and shopping, when this is the only care a person needs
- nutritional supplements
Medicare’s coverage of dementia can begin before the condition starts to develop. An annual wellness visit may detect early symptoms of dementia or Alzheimer’s disease.
The wellness visit involves a personalized plan to help prevent the condition. A doctor bases the plan on an individual’s health and risk factors after considering the following:
- family and personal medical history
- prescription medications
- height, weight, and blood pressure measurements
- any symptoms or signs of dementia
The personalized plan may include treatment options if some degree of dementia is present. It may also recommend lifestyle practices, such as:
- eating a nutritious diet
- getting regular exercise
- participating is social activities
- engaging in mentally stimulating activities, such as crossword puzzles
Eligibility and costs of wellness visits
People with original Medicare or Medicare Advantage are eligible for the program.
The deductible applies and a person must pay a coinsurance if a doctor orders additional tests or performs extra services, or if Medicare preventive services do not cover the additional tests.
Someone with an Advantage plan is also eligible for wellness visits. It is free of charge if they go to an in-network provider.
Medicare coverage for a person with dementia begins with preventive services in the form of annual wellness visits.
If a person develops dementia, the coverage helps with costs throughout the span of the disease. This coverage includes hospice care in the last months of life.
Whether people have original Medicare or an Advantage plan, they are eligible for the coverage. However, the two programs have different deductibles, copayments, and coinsurance costs.