Does Medicare Cover Alzheimer's Care: What You Should Know

The Alzheimer's Association estimates that more than 5 million people in the United States are living with Alzheimer's Disease. That number is projected to reach 14 million by 2050, so it's important for families and caregivers to understand what options they have when it comes to care. We'll walk you through how Medicare works for those who suffer from this disease, as well as some other considerations that may affect your decision of where to live and type of care if you or a loved one are diagnosed with different forms of dementia or Alzheimer's.

What is Alzheimer’s Disease?

Alzheimer's disease currently affects more than five million older adult Americans. Alzheimer's is a type of dementia that causes problems with memory, thinking, and behavior. It is a progressive disorder that causes memory loss, as well as other cognitive declines such as difficulty with speaking or swallowing, confusion and problems performing daily tasks like getting dressed or using the bathroom by oneself. This leads to needing long-term care in an environment where they can receive personal care by professional staff 24 hours a day. 

For more information, the Alzheimer's Association can help you find a local chapter that provides information and support groups for people with dementia, family members, and their caregivers.

What is Medicare and who can qualify for Medicare coverage?

The federal government provides Medicare benefits to people aged 65 or older, younger people with disabilities, and anyone with End-Stage Renal Disease (permanent kidney failure requiring dialysis). It also covers those in need of skilled nursing care following a hospital stay.

To qualify for Medicare, you must meet the Social Security Administration requirements either by age or disability. To receive coverage under Medicare Part A (hospitalization), you need to have worked at least ten years in jobs where there were payroll taxes and not be eligible for retirement benefits from a federal, state, or local government agency. For Medicare Part B (outpatient services), you need to be receiving Social Security benefits and not have other coverage. If your spouse is younger than age 65, they will receive Medicare if you apply for it and meet eligibility requirements.

What services does Medicare cover for Alzheimer’s Disease and dementia?

Medicare covers a wide range of services for those with dementia, including inpatient and outpatient care, skilled nursing home services (which includes 24-hour supervision), hospice care, and respite care. If your loved one has both medical and behavioral symptoms from an Alzheimer's diagnosis, Medicare will cover up to 100 days of skilled nursing home care under limited circumstances. However, custodial long-term nursing home care is not covered.

Inpatient hospital services for this diagnosis are covered up to 190 days in a lifetime with some exceptions that could include skilled nursing facility (SNF) care if it is medically necessary. 

Medicare does not cover long-term skilled nursing facility stays unless the person has been hospitalized within 30 days of admission to a nursing home, or is in need of daily assistance with activities for self care. 

Which Alzheimer's care services does Medicare cover?

Medicare will cover some but not all costs associated with Alzheimer’s care. Here is a list of what Medicare pays for:

• Inpatient hospital care.
• Doctor visits and wellness visits.
• Laboratory tests, screenings and evaluations necessary for dementia diagnosis.
• Rehabilitation is covered as long as it is considered short-term rehab.
• Temporary home health care (i.e. intermittent skilled nursing care, as well as physical, occupational, and speech therapy) can be covered for 35 hours a week for 60 days at a time. But keep in mind Medicare only covers services that a doctor orders at a certified home health agency.
• Medications deemed necessary for Alzheimer’s symptoms covered by Medicare Part D under the prescription drug coverage option.
• Short-term nursing facility care, which may include many of the services and medications you would have in an outpatient setting. However, Medicare only provides coverage for up to 20 days at no cost; thereafter it is subject to coinsurance fees and copays each day.
• Skilled Nursing Facility care is covered only for a short period of time after a hospitalization. Medicare covers up to 100 days of skilled nursing home care with skilled care within a facility that has a Medicare license.
• Physical therapy, medical equipment, speech therapy, and mental health services.
• Hospice care for late stages of Alzheimer's.

Which Alzheimer’s care services does Medicare NOT cover?

While Medicare covers quite a bit of services for Alzheimer’s there are also things that are not covered:

• Nursing home care is not covered by Medicare. If a nursing home (SNF) is the only care you require for Alzheimer’s then other coverage will be needed. If you require around the clock care then the costs will be considered out of pocket costs.
• Memory care
• Rent and housing costs
• Meals
• Assisted living or skilled nursing facilities are not covered, but the costs can be supplemented with some Medicare policies that will pay out of pocket for the services.
• Custodial Care which includes helping with activities of daily living (ADLs) such as bathing, eating, dressing, and personal hygiene are not generally covered.
• Some prescription drugs are not covered by Medicare. Medicare does not cover the use of medications that are neither approved nor prescribed for Alzheimer's.

Does Medicare cover long-term care?

Medicare does not typically cover the costs of long-term care if that is the only care that is needed. Long-term care is also known as custodial care. Most nursing homes are considered custodial care. Other programs like Medicaid may help provide assistance in this area.

Does Medicare cover nursing homes for dementia patients?

Medicare will pay for only the first 100 days in a nursing home. After that, you must cover all your own costs or get help from other sources such as  Medicaid services, private health insurance, or out of pocket to cover the long-term care necessities.

What can I do if my loved one has been denied coverage by Medicare?

If you have a loved one who has been denied coverage by Medicare, there are several things that you can do. First, find out why they have been denied. Did they fail to meet the policy's requirements? Many people believe that once an individual reaches a certain age, he or she is automatically entitled to Part A and B. This is not so. If you or your loved one have been denied coverage by Medicare, check to see if they met the eligibility requirements and find out why they were denied.

If they were denied because of a mistake such as an incorrect social security number or lack of citizenship, contact the insurance provider right away and ask them what information needs to be corrected to have the coverage reinstated. If your loved one was not seen by a doctor within a certain time frame, then there is likely an issue with that as well and you should ask what needs to be done in order for the coverage to resume.

If your loved one has been denied coverage due to a pre-existing medical condition, then you should look into signing up for a private Medicare supplemental, Medigap, or a Medicare advantage plan that will help to cover the costs of any medical care expenses not covered by the original Medicare plan. 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. Learn more information about Medicare SNPs.

Finally, if none of the above can help you with your situation, consider contacting a reputable Social Security Disability attorney. Your loved one may be entitled to file for SSDI or SSI benefits.

This is only the beginning of what Medicare does for people who have Alzheimer's disease and other dementias. To learn more about how Medicare can help you, visit the Medicare website.

Plan ahead

Medicare provides some assistance with dementia care, but it’s important to plan for the services that Medicare won't cover. Planning ahead can reduce financial burden and allow you to focus on your loved one’s physical health and emotional well-being in advance of needing assistance.