Learn What Medicare Covers in Dementia Care

A dementia diagnosis takes more than an emotional toll; it raises concerns about insurance coverage for medical services. The good news is that Medicare provides coverage for certain aspects of dementia care. However, there are substantial gaps that often require out-of-pocket expenses. Understanding Medicare’s role in dementia care is essential to being prepared to manage the disease.

What is dementia?

Dementia is a term for various brain disorders that significantly affect cognitive function, often linked to aging. It primarily impacts memory, problem-solving, and daily self-care. Alzheimer's disease is the most common type, but there are others.

Dementia causes problems with:

• Memory Loss. Those affected may forget recent events and can't recognize loved ones as the disease worsens.
• Daily Tasks. Simple tasks become difficult, leading to challenges with appointments, finances, and even basic self-care.

The different types of dementia include:

• Alzheimer's. Abnormal brain protein deposits are the main cause.
• Lewy body. Also due to abnormal protein deposits, causing hallucinations and sleep issues.
• Parkinson's dementia. Starts with difficulty with movement and later turns into dementia.
• Vascular dementia. Linked to strokes or other diseases of the brain.
• Frontotemporal lobar dementia. Shrinking of the frontal and temporal lobes of the brain, leading to unusual behaviors.

Dementia can also result from traumatic brain injury, Huntington's disease, infections, or substance abuse. Some people experience a combination of different dementia types, known as "mixed dementia."

Does Medicare cover dementia care?

Original Medicare covers various services related to dementia care. Because each part of Medicare has its unique role, they collectively offer coverage for the different stages of dementia.

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Here's how Medicare can help you or your loved one with dementia care:

Stage of dementia: early/mild cognitive impairment

Medicare Part B covers visits with your healthcare providers. This includes neurological tests and mental health exams to diagnose and assess cognitive issues. Medicare Part D can help cover prescription drugs to manage early dementia symptoms.

Stage of dementia: moderate cognitive decline

Medicare Part B continues to cover visits with healthcare providers for the ongoing medical management of dementia symptoms. This involves monitoring the effectiveness of medications and managing any other health conditions you may have.

Part B also covers speech, occupational, and physical therapy. These can be beneficial in preserving cognitive and functional abilities.

Stage of dementia: severe cognitive decline

Medicare Part A covers inpatient hospital stays. This is important because this stage may involve hospitalizations due to continued decline and dementia-related complications. Part A also covers up to 100 days of care in a skilled nursing facility (SNF) following a qualifying hospital stay. Staying in an SNF can help with rehabilitation or provide the necessary nursing care.

Parts A and B cover home health services, including intermittent skilled nursing care and physical and occupational therapy. These services can be provided in the comfort of your home if they are medically necessary and the person affected is certified as homebound.

Original Medicare includes hospice benefits under Part A. This can provide comfort, care, and support for dementia patients nearing the end of life. However, the affected person must have a prognosis of six months or less. Hospice care can happen at home or in a facility.

Medicare offers valuable help with dementia care, but it may not cover all the personal and custodial needs that people in advanced stages of dementia often need.

This means that Original Medicare helps with medical treatment for dementia, like doctor visits, hospital stays, and some medications. But it doesn’t pay for daily personal assistance or long-term care, including help with bathing or living in a care facility for an extended time.

Planning and looking into additional resources, such as Medicaid (income qualifications apply), long-term care insurance, or personal savings, may be necessary to address these aspects of dementia care.

How much does Medicare pay for dementia care?

Here’s an overview of how Medicare can help pay for your or your loved one’s dementia care:

Medicare Part A (hospital insurance)

• Covers hospital stays. You’ll be responsible for a $1,600 deductible for the memory care facilities first 60 days you’re hospitalized. If you stay longer — from day 61 to 90 — expect to pay an additional $400 daily.
• Covers up to 100 days in an SNF if you need daily skilled care or therapy. Medicare pays all costs for the first 20 days in an SNF. For days 21 to 100, you pay a copayment of up to $200 per day in 2023.
• Covers hospice care if dementia is terminal. Medicare pays most of the costs of hospice with little copayment from you. However, you must continue to pay your premiums.
• Together with Medicare Part B, it helps cover up to 35 hours a week of home health services for people with dementia who are certified as homebound. Homebound means you have difficulty leaving your house due to illness or injury.

Medicare Part B (medical insurance)

• Covers doctor visits to diagnose and monitor dementia. Medicare pays 80% of the approved amount after you meet your $226 deductible for 2023. You pay 20% coinsurance.
• Covers testing. You pay a 20% coinsurance for these services, too.

Medicare Part D (prescription drug coverage)

• Covers FDA-approved medications. You pay a monthly premium for Part D coverage and cost-sharing on drugs.
• Your deductible for Medicare Part D plans can vary, but the maximum you’ll pay is $505 in 2023.

Does Medicare pay for assisted living for dementia care?

Assisted living facilities are considered custodial long-term care and are generally not covered by Medicare.

However, Medicare may cover medical services and equipment for those residing in assisted living facilities. For instance, Medicare Part B may cover healthcare provider visits or specific durable medical equipment like a wheelchair while you or your loved one is in an assisted living facility.

Does Medicare cover long-term dementia care?

No, Medicare does not pay for long-term dementia care. This kind of care, called custodial care, isn't considered medically necessary from Medicare's perspective because it mainly involves help with everyday tasks such as bathing and eating.

Does Medicare cover nursing home for dementia?

Medicare offers limited coverage for nursing home stays that meet SNF criteria. These criteria include having a medically necessary need for skilled nursing or rehabilitative services.

Additionally, a three-day inpatient hospital stay is often required to qualify for an SNF admission, and this hospitalization must be related to the need for skilled care in the nursing home. Medicare does not cover long-term stays in a nursing home.

Will Medicare cover hospice care for dementia?

Yes, Medicare covers hospice care for dementia. A healthcare provider must certify that the patient has a prognosis of six months or less to live. Hospice care for dementia can include services provided at home, in a hospice facility, or a hospital.

Does Medicare Advantage cover dementia care?

Medicare Advantage (Part C) plans can provide coverage for dementia care. These plans include services related to dementia that are covered by Medicare Parts A and B, such as visits with healthcare providers and hospital stays.

Some Medicare Advantage plans, known as Chronic Condition Special Needs Plans (C-SNPs), provide benefits and support for chronic conditions like dementia.

Some Medicare Advantage plans also offer extra benefits like transportation to medical appointments. But it’s important to remember that Medicare Advantage plan coverage can vary widely.

Caring for someone with dementia can be expensive. While Medicare provides coverage for certain medical aspects of dementia care, out-of-pocket costs for personal care and supervision assistance can quickly add up.

To help cover these significant costs, consider alternatives like Medicaid (income qualifications apply), purchasing long-term care insurance ahead of time, or dipping into personal savings to pay privately for care.

Throughout this journey, remember you're not alone. Seek guidance from dementia care organizations and support groups. They can provide invaluable assistance, both financial and emotional. Navigating dementia care can be challenging, but with knowledge and available resources, you can better address your or your loved ones' needs.