Both original Medicare and Medicare Advantage help with dementia costs, but the deductibles, copayments, and coinsurance differ between the two programs.
Physical changes in the brain are responsible for dementia, which is a progressive condition. As the symptoms become more severe, a person will need different treatment and care.
Medicare helps pay for some services at every stage of dementia. The areas of coverage include tests to evaluate a person’s thinking skills, home healthcare, prescription drugs, and hospice.
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.
This article explains dementia and examines Medicare coverage from the early to late stages of the condition. The article also identifies the dementia-related services that Medicare does not cover.
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Medicare provides help with services that a person with dementia needs at every stage of the illness. The chart below shows an overview of Medicare coverage for dementia. More details about the coverage of each part then follow.
|Part A||Coverage includes home healthcare, 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 D||Coverage includes prescription drugs.|
|Medigap||Coverage includes some or all of Part A’s and Part B’s uncovered costs, which are deductibles, copayments, and coinsurance.|
Original Medicare (Part A and Part B)
Original Medicare offers coverage for services at different stages of dementia.
Medicare’s coverage of dementia can begin before the condition starts to develop. A doctor may detect early symptoms of dementia or Alzheimer’s disease during an annual wellness visit.
The wellness visit involves creating 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 in social activities
- engaging in mentally stimulating activities, such as crossword puzzles
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.
There is no deductible or coinsurance, but doctor visits, equipment, and other medical tests involve a 20% coinsurance. Also, the annual Part B deductible of $203 applies.
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 skilled nursing facility (SNF). An SNF is a facility that provides medical or nursing care. This care is not the same as a person would receive in a nursing home, where they may receive help with bathing, dressing, or eating but not medical care or therapy services.
This cost does not include a deductible. There is no cost for the coinsurance for days 1–20. From day 21 to day 100, the cost is $185.50. After 100 days, a person is responsible for the full cost.
Medigap is Medicare supplement insurance. Medigap plans help pay for the uncovered costs of Medicare parts A and B, which include deductibles, copayments, and coinsurance, such as those for skilled nursing care.
When a doctor determines that a person with dementia has 6 months or less 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 they are receiving the care at home, in a hospice facility, or in a nursing facility.
This cost does not include a deductible, and the coinsurance is minimal.
Medicare Advantage (Part C) plans are an alternative to original Medicare.
Part C provides dementia-related services that Medicare Part A and Part B cover. The plans may also include additional benefits, such as rides to doctor appointments. However, the deductibles, copayments, and coinsurance may differ from those in original Medicare.
One type of Advantage plan, a Special Needs Plan, offers benefits that are tailored to chronic conditions, including dementia.
While original Medicare coverage tends to be uniform, Medicare Advantage plans can vary widely. A person should carefully read each policy’s explanation of benefits when determining the best option for them.
Although Medicare helps with healthcare costs associated with dementia, coverage does not include everything that a person may need. Services that it does not cover include:
- 24-hour-per-day care at home
- care in a skilled nursing facility beyond the first 100 days
- adult day care
- incontinence supplies
- meal delivery services
- personal care, such as bathing and dressing, when this is the only care that a person needs
- homemaking care, such as laundry and shopping, when this is the only care that a person needs
- nutritional supplements
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 course of the disease. This coverage includes hospice care in the last months of life.
Whether people have original Medicare or a Medicare Advantage plan, they are eligible for the coverage. However, the two programs have different deductibles, copayments, and coinsurance costs. Anyone who is unsure of the details of their coverage should speak with their plan provider.