What Medicare Does and Doesn’t Cover for Alzheimer’s Care

It’s important to plan ahead for Alzheimer’s and dementia and understand what Medicare will and won’t cover

Long term care for someone with Alzheimer’s or dementia is expensive. To be able to provide the best care possible, it’s important to plan ahead for future care costs. HealthMarkets explains what Medicare does and doesn’t cover for Alzheimer’s and dementia care.

As of 2019, an estimated 5.8 million Americans are living with Alzheimer’s disease or another form of dementia. And the majority are 65 years old or older, according to the Alzheimer’s Association.

This degenerative condition affects a person’s level of independence and ability to function in permanent, life-altering ways.

But the impact of Alzheimer’s extends to family members, too. In many cases, the patient’s adult children will take on a caregiving role, which requires time, effort and a major financial commitment.

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Even with Medicare benefits, the average expenses of treating this disease are steep.

A recent poll conducted by Genworth Financial outlined the average costs for monthly Alzheimer’s treatment options in the United States:

Home-based care ranges from $4,004 – $4,195
Adult daycare is $1,560
Assisted living facilities are $4,000 for a private room
Nursing homes are $7,441 for a semi-private room or $8,365 for a private room

While these prices can differ between states, the fact remains – Alzheimer’s is expensive.

As a caregiver, it’s essential to know which areas of treatment Medicare will cover and which out-of-pocket expenses require planning.

This knowledge will better equip you to manage the financial responsibilities associated with Alzheimer’s, so they don’t become another source of conflict, tension or unpredictability as your older adult’s illness progresses.

We explain two areas of care that Medicare does cover and two areas it doesn’t cover.

Medicare DOES cover: medically necessary care

The Centers for Medicare & Medicaid Services (CMS) defines medical necessity as “services or supplies that: are proper and needed for the diagnosis or treatment of your medical condition, are provided for the diagnosis, direct care, and treatment of your medical condition, meet the standards of good medical practice in the local area, and aren’t mainly for the convenience of you or your doctor.”

These usually include doctor’s visits, laboratory tests, required procedures, and certain specialist referrals or emergency care.

Some prescription drugs are also viewed as medical necessities under Medicare Part D coverage, if the medication has been approved to treat or manage Alzheimer’s symptoms.

Medicare DOESN’T cover: custodial care

As symptoms advance, most Alzheimer’s and dementia patients need help with activities of daily living (ADLs) like personal hygiene, eating, dressing, and bathing.

Medicare refers to these services as custodial care and generally will not cover them.

But Investopedia notes two exceptions: “[if] the care is considered medically necessary and prescribed by a licensed physician or authorized medical personnel, and [if] the care is conducted by a healthcare provider who participates in Medicare.”

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Medicare DOES cover: some rehabilitative care

If home health services like physical or occupational therapy are needed after a hospitalization, Medicare will cover these treatments – to an extent.

As long as it’s considered rehab and not long-term care, Medicare will pay for up to 100 days of care in a skilled nursing facility each benefit period, according to U.S. News & World Report.

In cases where temporary home health care is needed, Medicare will also cover 35 hours a week for 60 days at a time.

Medicare DOESN’T Cover: long-term care facilities or memory care

In the later stages of Alzheimer’s or dementia, your older adult might need to move to an assisted living community, nursing home, or memory care community.

Medicare won’t cover this type of care and housing, but Medicare Supplement policies can help with some of the out-of-pocket costs.

On average, assisted living costs $48,000 per year and is more affordable than 24/7 in-home care.

Planning ahead reduces worry

Medicare helps pay for some levels of dementia treatment and care, but it’s also necessary to prepare for the services that Medicare doesn’t cover.

Planning ahead for future care costs can reduce the financial burden and allow you to focus on your older adult’s physical and emotional well-being.

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Guest contributor: Michael Z. Stahl serves as executive vice president of HealthMarkets – one of the nation’s largest independent insurance agencies in the Medicare, individual and supplemental health, life, and small group insurance markets. He has a bachelor’s degree in economics from The Wharton School, University of Pennsylvania and holds the chartered property casualty underwriter (CPCU), associate in insurance accounting and finance (AIAF) and associate in reinsurance (ARe). An avid Kansas City Royals fan, he lives in Dallas with his wife and children.

Image: Napoleon Care Center

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