Many people may associate Medicare and Dementia because dementia is a condition associated with age. It is true that 1 in 3 seniors today die with Alzheimer’s or another form of dementia. However, there are currently over 5 million Americans of ALL ages suffering from dementia today.
Medicare covers any medically necessary care for dementia just like any other disease or illness. Many people with dementia need custodial care though, and Medicare’s coverage for this is limited. In this post, we’ll review dementia and it’s common treatments. We’ll also go over what is covered and not covered by Medicare.
Dementia is a brain disorder that causes a loss of mental processes and cognitive function. Some of the common symptoms are:
- memory loss
- problems with speaking or language
- personality changes
- impaired ability to reason
- inability to focus
- visual impairment and perception
It is also a progressive disease. There is usually a slow decline in one’s mental ability that ultimately results in an inability to continue performing activities of daily living. (For more information ad a free download about the causes of dementia, visit this post.)
Does Medicare Cover Dementia Care?
Medicare will usually cover care that is considered medically necessary by your physician (who accepts Medicare). Original Medicare is divided into two parts: hospital and outpatient coverage.
Medicare Part A pays for your inpatient hospital stays. It also covers skilled nursing care and hospice benefits.
Medicare Part B pays for your outpatient needs. This includes preventive care, doctor appointments, lab tests, diagnostic imaging such as CT scans, home health care, physical therapy, durable medical equipment (DME) among other benefits.
You are responsible for some cost-sharing. This includes deductibles for Parts A and B as well as any coinsurance and copays.
Since dementia is usually a progressive rather than an acute disease, most of your care will fall under Part B. Medicare will pay for a cognitive assessment as part of your annual physical. Your physician may order diagnostic testing to view abnormalities in your brain. Occupational therapy to improve cognitive function is also another covered benefit.
Does Medicare Cover Home Care for Dementia?
When dementia progresses to its middle stages, the need for care becomes greater. There is a greater degree of confusion and people begin to need help with everyday tasks. Medicare may pay for caregiver training under Part B.
Home health care is also covered by Medicare Part B but with certain qualifying criteria. The patient must be homebound and require physical, occupational or speech therapy or intermittent nursing care. A Medicare doctor must certify the necessity of these services.
Medicare does not cover custodial care without the above qualifying criteria. In general, Medicare does not pay for home health aides who only help with cleaning, cooking, dressing, bathing or similar activities of daily living. This kind of personal care assistance will only be covered if the patient is also unable to leave the home and needing skilled nursing services for the above criteria mentioned.
Skilled Nursing Facility Care for Dementia
Sometimes your physician may send you to a skilled nursing facility (SNF) for care after a qualifying hospital stay. Medicare Part A provides this benefit. It is designed to help people recover their strength and function and return to caring for themselves independently.
Because the benefit is designed for recovery, Part A will only cover a maximum of 100 days in a SNF. You are responsible for all costs after 100 days.
Your therapists in the facility must be reporting your continued improvement during this stay. Because dementia often causes a decline in function rather than an improvement, Medicare may or may not cover that SNF care. It’s important that your treating physician file the necessary paperwork to ensure coverage.
Prescription Coverage for Dementia under Medicare
Today we have a number of medications available to people with dementia. These medications help with confusion, loss of memory and in some cases, hallucinations. Some of the most common are Aricept (donepezil) and Namenda (memantine).
If your doctor suspects that dementia has been caused by an underlying condition such as stroke, then medications may also be prescribed to help prevent further strokes.
Medicare beneficiaries can sign up for a Medicare Part D drug plan to help them with the costs of outpatient prescription drugs. Deductibles and copays may apply based on which insurance company’s plan that you enroll in.
Does Medicare Cover Assisted Living for Dementia?
Unfortunately, Medicare does not cover any assisted-living or long-term care, even if you have dementia. The only possible exception is if you have been in the hospital and are transferred to a SNF for skilled nursing and physical, occupation or speech therapy. Again, Medicare would only provide up to 100 days in any given benefit period.
Since this is the case, Medicare beneficiaries are encouraged to plan ahead for the potential costs one day of long-term care. There are long-term care policies you can purchase when you are younger and still healthy that will help to pay for future costs of assisted living or nursing home care. If you do not have long-term care insurance, then you will need to private pay for the costs of these facilities.
In late stage dementia, there may be a time when you need to be transferred from assisted living or a nursing home into hospice care. Medicare does cover hospice care in any certified hospice facility. Your doctor must certify that life expectancy is six months or less.
Hospice benefits under Part A may include everything from nursing care to grief counseling for you and your family.
Covering the Gaps with Medicare and Dementia
Medicare Part A and B both have deductibles for which you are responsible. Part B also only covers 80% of your outpatient costs. You are responsible for the rest.
If you are enrolled in a Medigap plan, it will help to cover some or all of these costs. It’s important to enroll in supplemental coverage before you develop dementia or any other serious or chronic condition. All Medicare beneficiaries have a 6-month Medigap open enrollment window when they first enroll in Part B. During this window, you can enroll in any Medigap plan without health questions or underwriting.
Medicare beneficiaries also have the option to consider enrollment into a private Medicare Part C (Advantage) plan instead of Original Medicare. Your cost-sharing for Medicare Part A, B and D services will vary by the plan you choose.
Need help with covering the gaps in Medicare? Call us today at 1-855-732-9055.