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Medicare

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If the person with Alzheimer's or dementia is a Medicare beneficiary, Medicare will pay for some, but not all, care costs.


About Medicare

Medicare is a federal health insurance program generally for people age 65 or older who are receiving Social Security retirement benefits or who are younger than 65 and received Social Security disability benefits for at least 24 months. Regardless of whether receiving retirement and/or disability benefits or not, everyone should apply for Medicare three months prior to his or her 65th birthday to avoid future penalties.

  • Medicare covers inpatient hospital care and some of the doctors' fees and other medical items for people with Alzheimer's or dementia who are age 65 or older. Medicare Part D also covers many prescription drugs.
  • Medicare will pay for up to 100 days of skilled nursing home care under limited circumstances. However, custodial long-term nursing home care is not covered.
  • Medicare will pay for hospice care delivered in the home, a nursing facility or an inpatient hospice facility for people with dementia who are determined by a doctor to be near the end of life.

See Medicare's website for more information, including:

Reminder: Medicare covers an Annual Wellness Visit and Health Risk Assessment. Medicare pays for an Annual Wellness Visit once every 12 months. Prior to or during an annual wellness visit appointment, a Medicare beneficiary (or caregiver) can be asked by his or her doctor or health professional to complete a Health Risk Assessment (HRA). The HRA includes some questions about the beneficiary’s health which may provide important information to discuss with the health professional during the annual wellness visit, and can be used as a way of starting the diagnostic process Care partners or caregivers can provide information to the physician prior to the Annual Wellness Visit to help ensure a thorough assessment.

Medicare covers cognitive assessment and care planning sessions

As of January 1, 2017, for the first time people living with Alzheimer's and their caregivers have access to cognitive assessment and person-centered care planning services under Medicare.

What is care planning?
Care planning is a process that helps people with a diagnosis of cognitive impairment, Alzheimer’s disease or other dementia and their caregivers by providing information about medical and non-medical treatments, support services and clinical trials available in the community. Because dementia can complicate the management of other chronic health conditions, care planning is important to coordinating a person’s overall care. Proper care planning can result in fewer hospitalizations and emergency room visits, and better medication management — helping improve outcomes and maintain quality of life.

Does Medicare cover care planning?
Medicare now covers assessment and care planning by medical professionals, such as physicians, physician assistants, nurse practitioners and clinical nurse specialists for individuals with cognitive impairment and their families.

What will the assessment and care planning address?
Person-centered assessment and planning covered by Medicare includes the clinical, functional, care and support-related elements listed below:

  • Evaluating cognition and function.
  • Assessing symptoms.
  • Reviewing and reconciling medication.
  • Evaluating safety (including driving ability).
  • Identifying caregivers and caregiver needs.
  • Identifying and assessing care directives (e.g., living will, medical power of attorney, healthcare proxy, etc.)
  • Planning for palliative care needs.
  • Referring to community services for both individual and caregiver.

Learn more: Medicare Coverage of Care Planning for People with Cognitive Impairment (PDF).

Medigap

Medicare coverage can be supplemented with Medigap, a private insurance policy that covers copayments and deductibles required by Medicare. The more expensive Medigap policies may cover additional items.

Learn more: Medigap's website

Medicare managed care

Medicare Advantage (also called Part C) allows you to choose Medicare "managed care" in lieu of traditional Medicare, such as:

  • Medicare health maintenance organization (HMO)
  • Preferred provider organization (PPO)
  • Point of service (POS) plan

Medicare Advantage plans are offered by private companies approved by Medicare. These Medicare plans may provide services (such as dental and vision) not covered by traditional Medicare and usually have limits on which hospitals, doctors and other health care providers you can use.

Read each plan carefully. Learn about the many Medicare options and whether they are right for the person with dementia. You can also contact your State Health Insurance Assistance Program (SHIP) for free one-on-one help and publications.

Learn more: Medicare's website has information about Medicare managed care.

Special Needs Plans (SNP) for Alzheimer's disease

There are Medicare Special Needs Plans (SNPs) available for individuals with dementia, including Alzheimer’s disease. SNPs are Medicare Advantage plans that specialize in care and coverage for beneficiaries with dementia. Only Medicare beneficiaries with dementia can enroll in these plans. Learn more information about Medicare SNPs in Medicare's Guide to SNPs.

To find the Medicare SNPs in your area:

Help Is Available

Medicare.gov provides information about Medicare, open enrollment, benefits and how to find Medicare plans, facilities or providers. You also can call Medicare at 800.633.4227.

Medicare Basics for Caregivers  is an online version of Medicare's booklet, "Medicare Basics: A Guide for Families and Friends of People with Medicare."

BenefitsCheckUp is an online tool that shows whether you are eligible for a variety of governmental programs.

Medicaid.gov provides information about Medicaid, including what it is and who qualifies for it.

Shiptalk.org offers information about the State Health Insurance Assistance Program (SHIP) in your state.

Medicare Rights Center is an independent, non-profit group that provides information and assistance for people with Medicare.

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