How Medicare Covers Alzheimer’s Disease

Dear Savvy Senior,

What exactly does Medicare cover when it comes to Alzheimer’s disease? My husband was recently diagnosed with early-stage Alzheimer’s, and we would like to find out what’s covered and what isn’t.

     --Planning Ahead

Dear Planning,

I’m very sorry to hear about your husband’s diagnosis, but you’ll be happy to know that most medical costs to treat beneficiaries with Alzheimer’s disease are covered by Medicare. Unfortunately, long-term custodial care costs that most patients eventually need are not. Here’s a breakdown of what Medicare does and doesn’t cover when it comes to Alzheimer’s disease, along with some tips that can help you plan ahead.

Medical care: For the most part, ongoing medical care to diagnose and treat Alzheimer’s disease is covered by Medicare Part B, including visits to primary care doctors and specialists, lab tests, speech and occupational therapy, home health care and outpatient counseling services. Medicare pays 80 percent of these costs, and you will be responsible for the remaining 20 percent after you’ve met your annual $233 Part B deductible.

Sixty days of inpatient hospital care is also covered under Medicare Part A after you pay a $1,556 deductible. Beyond 60 days, a daily coinsurance fee is added.

Medications: Most Alzheimer’s medications are covered under Medicare’s Part D prescription drug plans, but coverage varies so check his plan’s formulary. The only exception is Aduhelm, the controversial new drug that is estimated to cost $28,200 per year. Medicare Part B will only cover this drug if your husband is enrolled in a clinical trial.

Long-term custodial care: It’s important to understand that original Medicare does not cover long-term custodial care. This includes nursing home care, the costs of assisted living facilities and adult day care. Medicare does, however, pay for some shorter-term nursing home care, but only up to 100 days following a three-day inpatient hospital stay.

Hiring home help for bathing, toileting and dressing (this is known as custodial care) is not covered by Medicare either unless your husband is also receiving skilled-nursing care or physical or occupational therapy.

To help with these costs, you may want to look into getting a long-term care insurance policy or short-term care plan (see aaltci.org/stc) if possible, or if your income and assets are very limited, you may qualify for Medicaid. To investigate your financial options for long-term care, go to PayingForSeniorCare.com.

Hospice: In the final stages of the disease, Medicare Part A covers nearly all aspects of hospice care, including doctor services, nursing care, drugs, medical equipment and supplies, physical and occupational therapy, homemaker services, counseling and respite care. To qualify, a doctor must certify that a patient has six months or less to live.

Other Insurance and Assistance

If your husband is enrolled in original Medicare and he doesn’t have a supplemental insurance (Medigap) policy, you should consider getting him one. A Medigap plan will help pay for things that aren’t covered by Medicare like copayments, coinsurance and deductibles. To search for plans in your area, go to Medicare.gov/plan-compare and click on “Medigap policy only.”

Or, if you’re enrolled in a Medicare Advantage plan (like an HMO or PPO), his plan must provide him at least the same coverage as original Medicare does. Some advantage plans may also offer additional coverage for home care services.

If you can’t afford your Medicare out-of-pocket costs or need help with medication expenses, there are Medicare Savings Programs and the Extra Help program that provide financial assistance for medications. To learn more, see Medicare.gov/your-medicare-costs/get-help-paying-costs.

You can also get help through your State Health Insurance Assistance Program (see SHIBA or call 800-562-6900) which provides free Medicare and long-term care counseling.

Send your senior questions to: Savvy Senior, P.O. Box 5443, Norman, OK 73070, or visit SavvySenior.org. Jim Miller is a contributor to the NBC Today show and author of “The Savvy Senior” book.