Dealing with diseases such as Alzheimer’s or dementia is undeniably challenging. When you factor in the intricacies of financial and legal preparations, along with grasping the role of Medicare as a source of payment, it’s easy to feel lost in the crowd.
Vital to being a responsible caregiver is understanding the extent of coverage provided by Medicare. It is common for people to mistakenly assume that Medicare covers certain aspects of healthcare that it actually does not cover, so ensuring accurate knowledge is crucial.
LivWell Seniors suggests beginning your journey into understanding Medicare by exploring the Alzheimer’s Association’s informative article, which provides an introductory overview of Medicare and its offerings. We consider it a valuable starting point.
If the person with Alzheimer’s or dementia is a Medicare beneficiary, Medicare will pay for some, but not all, care costs.
Medicare is a federal health insurance program generally for people age 65 or older who are receiving Social Security retirement benefits or who are younger than 65 and received Social Security disability benefits for at least 24 months. Regardless of whether receiving retirement and/or disability benefits or not, everyone should apply for Medicare three months prior to his or her 65th birthday to avoid future penalties.
- Medicare covers inpatient hospital care and some of the doctors’ fees and other medical items for people with Alzheimer’s or dementia who are age 65 or older. Medicare Part D also covers many prescription drugs.
- Medicare will pay for up to 100 days of skilled nursing home care under limited circumstances. However, custodial long-term nursing home care is not covered.
- Medicare will pay for hospice care delivered in the home, a nursing care community or an inpatient hospice setting for people with dementia who are determined by a doctor to be near the end of life.
What is Medicare Part B?
Where Medicare Part A covers hospital and skilled nursing care, Medicare Part B helps pay for services from doctors and other health care providers, outpatient care, home health care, durable medical equipment and some preventive services.
In order to avoid a penalty, constituents should enroll in Part B between January 1 and March 31 of each year (the open enrollment period). For more information about enrollment, individuals should contact their local Social Security Administration offices or call 1-800-772-1213.
Medicare Part B Costs
Part B beneficiaries pay a premium each month. The standard premium for 2022 is $170.10, although individuals with a modified adjusted gross income beyond a certain amount will pay an extra charge as well as the standard premium. A chart outlining those extra fees can be found on medicare.gov/basics/costs/medicare-costs.
Part B beneficiaries also pay a deductible. In 2022, the deductible is $233. Once that is met, beneficiaries typically pay 20 percent of the Medicare-approved amount for most Part B services, including Part B-covered drugs.
Medicare Annual Wellness Visit and Health Risk Assessment
Medicare pays for an Annual Wellness Visit once every 12 months. Prior to or during an annual wellness visit appointment, a Medicare beneficiary (or caregiver) can be asked by his or her doctor or health professional to complete a Health Risk Assessment (HRA). The HRA includes some questions about the beneficiary’s health which may provide important information to discuss with the health professional during the annual wellness visit and can be used as a way of starting the diagnostic process. Care partners or caregivers can provide information to the physician prior to the Annual Wellness Visit to help ensure a thorough assessment.
Cognitive Assessment and Care Plan Services
Medicare covers care planning services for people recently diagnosed with cognitive impairment, including Alzheimer’s and other dementias. Care planning allows individuals and their caregivers to learn about medical and non-medical treatments, clinical trials and services available in the community, and additional information and support that can contribute to a higher quality of life.
Medicare coverage can be supplemented with Medigap, a private insurance policy that covers copayments and deductibles required by Medicare. The more expensive Medigap policies may cover additional items.
Medicare Managed Care
Medicare Advantage (also called Part C) allows you to choose Medicare “managed care” in lieu of traditional Medicare, such as:
- Medicare Health Maintenance Organization (HMO)
- Preferred Provider Organization (PPO)
- Point Of Service (POS) plan
Medicare Advantage plans are offered by private companies approved by Medicare. These Medicare plans may provide services (such as dental and vision) not covered by traditional Medicare and usually have limits on which hospitals, doctors, and other healthcare providers you can use.
Read each plan carefully. Learn about the many Medicare options and whether they are right for the person with dementia. You can also contact your State Health Insurance Assistance Program (SHIP) (shiphelp.org) for free one-on-one help and publications.
Special Needs Plans (SNP) for Alzheimer’s Disease
There are Medicare Special Needs Plans (SNPs) available for individuals with dementia, including Alzheimer’s disease. SNPs are Medicare Advantage plans that specialize in care and coverage for beneficiaries with dementia. Only Medicare beneficiaries with dementia can enroll in these plans.
To find the Medicare SNPs in your area: Use the online Medicare Plan Finder at medicare.gov/plan-compare or call Medicare at 800-633-4227.