Does Medicare pay for Alzheimer's care? A detailed guide

According to the Alzheimer's Association, Medicare spends significantly more on beneficiaries with Alzheimer's, yet many families are unprepared for the high out-of-pocket costs. The short answer to 'Does Medicare pay for Alzheimer's care?' is yes, but it comes with critical limitations that affect long-term planning.

Quick Summary

Medicare provides coverage for medically necessary services related to Alzheimer's, such as diagnosis, doctor visits, and prescriptions, but crucially excludes the long-term custodial care that most patients eventually need.

Key Points

• Limited Long-Term Coverage: Medicare covers many medical aspects of Alzheimer's but does not pay for long-term custodial care, including extensive nursing home stays or assisted living.

• Custodial vs. Skilled Care: Medicare distinguishes between skilled medical care (covered) and non-medical custodial care (not covered), which includes help with daily activities like bathing and eating.

• Early-Onset Eligibility: Individuals under age 65 with early-onset Alzheimer's can become eligible for Medicare after receiving Social Security Disability benefits for 24 months.

• New Drug Coverage: Newer anti-amyloid treatments like Leqembi are covered under Medicare Part B, but typically with conditions such as documented plaque levels and enrollment in a registry.

• Medicaid as a Supplement: For those with low income and assets, Medicaid can provide critical coverage for the long-term custodial care that Medicare does not.

• Care Planning is Covered: Medicare Part B covers care planning services, helping patients and caregivers coordinate medical and non-medical treatment options and resources.

Understanding Medicare's Role in Alzheimer's Care

Medicare is a federal health insurance program for people 65 and older, and some younger individuals with disabilities. It is important to know what Medicare covers for Alzheimer's disease and where coverage gaps exist.

What Original Medicare (Parts A & B) Covers

Original Medicare, consisting of Part A (Hospital Insurance) and Part B (Medical Insurance), covers essential medical services for Alzheimer's diagnosis and treatment.

Medicare Part A: Hospital Insurance

Part A helps cover inpatient hospital stays, skilled nursing facility (SNF) care, home health care, and hospice care. Skilled nursing care is limited to 100 days per benefit period after a qualifying hospital stay and covers skilled needs, not long-term residence. Hospice covers end-of-life care for symptom management. Home health is covered for skilled services if homebound.

Medicare Part B: Medical Insurance

Part B covers outpatient services for managing Alzheimer's. This includes doctor visits, cognitive assessments during annual wellness visits, and diagnostic tests like lab work and scans. Therapies like physical and occupational therapy are covered, as are mental health services. Durable Medical Equipment (DME) like walkers is also included.

What Medicare Does NOT Cover for Alzheimer's Care

The biggest gap in Medicare coverage for Alzheimer's is long-term care. This includes:

• Custodial Care: Non-medical help with daily activities (ADLs) like bathing and dressing is not covered if it's the only care needed.
• Long-Term Facilities: Medicare does not cover extended stays in nursing homes, memory care, or assisted living.
• Other Services: Adult day care, 24-hour home care, and most respite care are generally not covered.

Medicare Advantage (Part C) and Part D

These private plans offer additional coverage options.

Medicare Advantage (Part C)

These plans include Original Medicare benefits and often prescription drug coverage. Some offer extra benefits like dental and vision. Special Needs Plans (C-SNPs) exist for those with chronic conditions like dementia, offering tailored benefits.

Medicare Part D (Prescription Drugs)

For Original Medicare beneficiaries, a Part D plan covers self-administered prescription drugs for Alzheimer's symptoms. Newer infusion drugs like Leqembi are covered under Part B for early-stage Alzheimer's patients meeting specific criteria and enrolled in a registry.

Financial Strategies for Alzheimer's Care

Since Medicare has limitations, other financial options are important:

• Medicaid: This program can cover long-term care, including nursing home costs, for eligible individuals with limited income.

• Long-Term Care Insurance: Private policies can cover custodial care, though premiums can be high.

• Veterans Benefits: The VA may offer assistance for veterans and spouses.

• Community Resources: Local agencies and the Alzheimer's Association can help find programs.

• Medicare vs. Medicaid: The Custodial Care Gap

Feature	Original Medicare	Medicaid (Eligibility Varies)
Custodial Care (ADLs)	Generally not covered	Often covers long-term care and custodial needs
Long-Term Nursing Home	Up to 100 days for skilled care	May cover extended nursing home stays
Assisted Living/Memory Care	Does not cover room & board	May cover services in approved facilities
Home Health Aide (Personal Care)	Only if tied to skilled services	Can cover in-home personal care

For more information and resources, families can visit the Alzheimer's Association to help navigate the financial aspects of Alzheimer's care.

Conclusion: Planning for a Comprehensive Care Strategy

Medicare covers the medical aspects of Alzheimer's but does not cover the significant costs of long-term custodial care, assisted living, and extended nursing home stays. Proactive planning is essential. Understanding Medicare's limits and exploring options like Medicare Advantage, Medicaid, long-term care insurance, and veterans benefits can help families build a comprehensive care strategy.

Frequently Asked Questions

Does Medicare pay for assisted living or memory care facilities?

No, Original Medicare does not cover the cost of room, board, or most custodial care services in assisted living or memory care facilities. While Medicare may cover medically necessary services provided within the facility (like physical therapy), it does not cover long-term residential costs.

What is the difference between skilled care and custodial care?

Skilled care is medical care provided by licensed professionals, such as nurses or therapists. Custodial care is non-medical assistance with activities of daily living (ADLs), such as bathing and dressing. Medicare covers skilled care but generally not custodial care.

Does Medicare cover the new Alzheimer's drugs?

Medicare Part B covers newer anti-amyloid infusion drugs like Leqembi for individuals with mild cognitive impairment or early-stage Alzheimer's, but coverage requires meeting specific criteria, such as confirmed beta-amyloid plaque and enrollment in a qualifying registry.

Will Medicare pay for in-home caregivers for Alzheimer's patients?

Medicare will not pay for personal aides or caregivers for custodial care if that is the only service needed. It will only cover part-time or intermittent home health aide services if they are provided alongside skilled medical care, like nursing or therapy.

Does Medicare cover hospice care for an Alzheimer's patient?

Yes, Medicare Part A covers hospice care for an individual with late-stage Alzheimer's, provided a doctor certifies they have a life expectancy of six months or less. This coverage focuses on comfort and symptom management rather than curative treatment.

Can people under 65 get Medicare coverage for Alzheimer's?

Yes. Individuals under age 65 who are diagnosed with early-onset Alzheimer's can become eligible for Medicare if they have been receiving Social Security Disability Insurance (SSDI) benefits for 24 months.

What happens when Medicare's 100 days of skilled nursing facility coverage runs out?

After the 100-day limit, Medicare stops paying for the stay, and the patient is responsible for all subsequent costs. Families must then use private funds, Medicaid, or other resources to cover continued care.