June is Alzheimer’s & Brain Awareness Month, focused on increasing awareness about Alzheimer’s to encourage action in the fight to end the disease. According to the Alzheimer’s Association, one in three seniors dies from Alzheimer’s disease or another dementia. To learn about this disease and make sure you and your loved ones are prepared, let’s review what Medicare covers in relation to Alzheimer’s.
Alzheimer’s has 7 stages. The early stages of Alzheimer’s are marked by symptoms that generally don’t require care but do spark that initial doctor’s visit in the search for a diagnosis. During this time, an individual might struggle to find the right word, forget where they left something, ask the same question repeatedly, or experience mood swings. This initial doctor’s visit will most likely be the first of many.
Because an “Alzheimer’s test” doesn’t exist, doctors instead initiate a process of eliminating other potential diseases that could be causing these symptoms, and that could mean collaboration with neurologists, psychiatrists, psychologists, as well as ordering various brain scans. It can quickly become a pricey process, but it’s also a diagnostic one, so Medicare Part B is applied. Part B of original Medicare will pay 80% of the bill after the patient has met the Part B annual deductible. For reference, the annual deductible is $226 for 2023. If the individual has purchased Medicare Supplemental Insurance (something worth having during the early stages of this disease), the supplemental insurance will handle the remaining 20%.
If that diagnostic process ends with a determination that it is Alzheimer’s, the treatments vary. Most patients immediately start taking medications that can help slow the progress of the disease. Medicare Part D will help cover the cost of the drug so long as it is on its approved drug list, as many common Alzheimer’s drugs are. Other treatments can include various forms of therapy—physical, occupational or sessions with a mental health care professional. Provided these services are considered “medically necessary” and prescribed by a doctor, Medicare Part B will again cover 80% of these costs. And again, if you have a Medicare Supplement – also referred to as a Medigap policy – it will pick up the 20% not covered by Medicare Part B.
As the condition worsens, the initial symptoms—memory loss, confusion, mood swings—become more pronounced and other symptoms, including physical ones, can become apparent, for example, a patient may begin to struggle with coordination and motor skills. Family members may decide that more oversight is needed, either through their own supervision, in-home health care, or adult day-care. It is important to note that not all these costs will be covered by Medicare.
As the disease enters the late-stage, symptoms will progress to the point where 24-hour care is needed. A patient might experience extreme confusion or even become delusional, may begin wandering, and incontinence can set in. This is the point where residential care will be needed. Medicare does not offer long-term care to help pay for residential care. Medicare coverage will only apply, in “limited circumstances”—for example, if a patient is hospitalized for at least three days and then needs nursing home care, Medicare will cover skilled nursing home care for up to 100 days.
The reality, however, is that 100 days may only prove to be a fraction of the amount of nursing or in-home health care that an Alzheimer’s patient will eventually require. Once a person needs help with activities of daily living – referred to as ADL’s including but not limited to dressing, personal hygiene, eating, basic mobility – Medicare considers this “custodial care”, meaning it’s non-medical. As such, it is not considered medically necessary and therefore Medicare does not cover the bill.
At the very end stage—when a patient has less than six months to live—a Medicare hospice benefit is available. It comprehensively covers the costs of doctors, nursing, drugs, counseling for family members, and other home services. There is no cost for hospice care and medications are provided for a small copay. If the patient is in a nursing home, Medicare will only cover the hospice services, not room and board.
The period just before hospice – when long-term care is required – can be financially devastating. Long-term care can cost thousands of dollars a month and be required for an extended period. The average Alzheimer’s patient lives four to eight years after diagnosis, and this is where having a long-term care policy—something you’ll need to purchase outside of Medicare—is key. And here’s the crucial thing to know: Once someone is diagnosed with Alzheimer’s, they cannot apply for long-term care insurance.
It’s wise to start looking into long-term care insurance when you’re in your 50s or early 60s, before premiums skyrocket or your health begins to worsen and the policies available to you narrow. It’s wise to consult with an independent agent who can discuss these various options with you, so that you and your family can be better equipped to handle a disease like Alzheimer’s.
Learn more about Alzheimer’s & Brain Awareness Month and how Medicare can cover health expenses related to cognitive illnesses here.