older couple talking to a doctor about alzheimer's

Alzheimer’s and Medicare: Understanding Coverage

If you have a loved one who’s been diagnosed with Alzheimer’s, understanding Medicare is essential for planning ahead. Confusion over medical coverage shouldn’t add to the stress that already comes with the disease. Below is a basic Medicare primer designed especially for those who are facing a diagnosis of Alzheimer’s disease.


What is Medicare?

Medicare is a federal health insurance program for people who are 65 or older (or for people who have been receiving social security disability payments for at least two years). Everyone should apply for Medicare three months before their 65th birthday.

What does Medicare cover?

Medicare’s coverage is similar to that of private medical insurance: it covers doctor’s visits, hospital care, prescription drugs, etc. As with most medical insurance, though, you have to pay deductibles, copays, and coinsurance as well as a monthly premium.

Medicare will cover the diagnosis of Alzheimer’s and the costs of its treatments (medicines and therapies) as long as they are approved (not experimental) and certified by your doctor as medically necessary.

What doesn’t Medicare cover?

The most important thing to know about Medicare, when you’re planning around Alzheimer’s, is that Medicare does not cover long-term (custodial) nursing home care. Also, be aware that Medicare has no out-of-pocket yearly maximum. Medicare also does not cover assistance with activities of daily living (ADLs) such as dressing and personal hygiene.

How can you fill the gaps in your Medicare coverage?

Medicaid is a government program that provides health coverage to low-income Americans. If you are 65 and your income is low, you may be eligible for Medicare and Medicaid at the same time, which supplement each other.

Medicaid will pay for long-term nursing home care, but only if your income and assets are below a certain level.

You can also buy a private supplementary policy (Medigap) to cover the copays, deductibles, and coinsurance that come with Medicare.

Another option is to sign up for a Medicare Advantage Plan instead of straight Medicare. A Medicare Advantage Plan is insurance from a private company that contracts with Medicare to provide you with benefits. Medicare Advantage Plans vary in terms of premiums, coverage, and copays, deductibles, and coinsurance costs, as well as access to specific doctors and other practitioners. All Medicare Advantage Plans have an out-of-pocket maximum.

One kind of Medicare Advantage Plan is a Special Needs Plan (SNP) that is designed for people with specific diseases.

How can you tailor Medicare for Alzheimer’s?

One kind of Medicare Advantage Plan is a Special Needs Plan (SNP) that is designed for people with specific diseases. If you choose an Alzheimer’s SNP, the provider list and drug formulary will be better targeted to your needs.

A couple of years ago, Medicare began covering cognitive assessments and care plan services. This is a special visit to your doctor focused on dementia symptoms, to assess cognition, evaluate symptoms, and draft a written care plan. Your doctor will also take your complete history and review all your medications. Caregivers can participate in the assessment process to ensure a thorough diagnosis.

For more information visit medicareresources.org.


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