Both Original Medicare and Medicare Advantage help with dementia costs, but the deductibles, copayments, and coinsurance differ between the two programs.
Physical changes in the brain are responsible for dementia, which is a progressive condition. As the symptoms become more severe, a person will need different treatment and care.
Medicare helps pay for some services at every stage of dementia. The areas of coverage include tests to evaluate a person’s thinking skills, home healthcare, prescription drugs, and hospice.
This article explains dementia and examines Medicare coverage from the early to late stages of the condition. The article also identifies the dementia-related services that Medicare does not cover.
Glossary of Medicare terms
We may use a few terms in this article that can be helpful to understand when selecting the best insurance plan:
- Out-of-pocket costs: An out-of-pocket cost is the amount a person must pay for medical care when Medicare does not pay the total cost or offer coverage. These costs can include deductibles, coinsurance, copayments, and premiums.
- Deductible: This is an annual amount a person must spend out of pocket within a certain period before an insurer starts to fund their treatments.
- Coinsurance: This is the percentage of treatment costs that a person must self-fund. For Medicare Part B, this is 20%.
- Copayment: This is a fixed dollar amount a person with insurance pays when receiving certain treatments. For Medicare, this usually applies to prescription drugs.
Medicare provides help with services that a person with dementia needs at every stage of the illness. The chart below shows an overview of Medicare coverage for dementia. More details about the coverage of each part then follow.
| Coverage | |
|---|---|
| Part A | Coverage includes home healthcare, the first 100 days in a nursing home, and hospice care. |
| Part B | Coverage includes preventive services, such as wellness visits, along with medical tests, doctor visits, and equipment. |
| Part D | Coverage includes prescription drugs. |
| Medigap | Coverage includes some or all of Part A’s and Part B’s uncovered costs, which are deductibles, copayments, and coinsurance. |
Original Medicare (Part A and Part B)
Original Medicare includes Part A (hospital Insurance) and Part B (medical Insurance).
It covers inpatient hospital stays, doctor visits, outpatient care, and some preventive services. Prescription drug coverage is not included, so beneficiaries often enroll in a separate Part D plan for medications.
Original Medicare offers coverage for services at different stages of dementia.
Wellness visits
Medicare’s coverage of dementia can begin before the condition starts to develop. A doctor may detect early symptoms of dementia or Alzheimer’s disease during an annual wellness visit.
The wellness visit involves creating a personalized plan to help prevent the condition. A doctor bases the plan on an individual’s health and risk factors after considering the following:
- family and personal medical history
- prescription medications
- height, weight, and blood pressure measurements
- any symptoms or signs of dementia
The personalized plan may include treatment options if some degree of dementia is present. It may also recommend lifestyle practices, such as:
- eating a nutritious diet
- getting regular exercise
- participating in social activities
- engaging in mentally stimulating activities, such as crossword puzzles
Early dementia
During the early stages of dementia, many individuals benefit from being in their own home.
Medicare Part A pays for up to 35 hours per week of home healthcare for people who meet specific criteria, such as those certified as homebound.
This coverage is not indefinite. Once a person’s condition improves, or if they no longer meet the criteria for being homebound, the coverage would end.
Part B covers tests, doctor visits, and medical items.
There is no deductible or coinsurance, but doctor visits, equipment, and other medical tests involve a 20% coinsurance. Also, the annual Part B deductible of $240 applies.
Later dementia
In the later stages of dementia, people are often unable to live at home. At this point, they usually need 24-7 care.
Part A pays for the first 100 days in a skilled nursing facility (SNF). An SNF is a facility that provides medical or nursing care. This care is not the same as a person would receive in a nursing home, where they may receive help with bathing, dressing, or eating but not medical care or therapy services.
This cost does not include a deductible. There is no cost for the coinsurance for days 1–20. From day 21 to day 100, the out of pocket cost is $204 each day. After 100 days, a person is responsible for the full cost.
Medigap is Medicare supplement insurance. Medigap plans help pay for the uncovered costs of Medicare Parts A and B, which include deductibles, copayments, and coinsurance, such as those for skilled nursing care.
End-of-life care
When a doctor determines that a person with dementia has 6 months or less to live, Medicare pays for hospice care.
This coverage includes doctor, nursing, and personal care, along with counseling and prescription drugs. The coverage does not depend on location, and a person is covered whether they are receiving the care at home, in a hospice facility, or in a nursing facility.
This cost does not include a deductible, and the coinsurance is minimal.
Medicare Advantage (Part C) plans are an alternative to Original Medicare, offered by private insurers.
It includes Parts A and B and often bundles in Part D for prescription drugs, along with extra benefits like vision, dental, and hearing coverage.
Part C provides dementia-related services that Medicare Part A and Part B cover. The plans may also include additional benefits, such as rides to doctor appointments. However, the deductibles, copayments, and coinsurance may differ from those in Original Medicare.
One type of Advantage plan, a Special Needs Plan, offers benefits that are tailored to chronic conditions, including dementia.
While Original Medicare coverage tends to be uniform, Medicare Advantage plans can vary widely. A person should carefully read each policy’s explanation of benefits when determining the best option for them.
Although Medicare helps with healthcare costs associated with dementia, coverage does not include everything that a person may need. Services that it does not cover include:
- 24-hour-per-day care at home
- care in a skilled nursing facility beyond the first 100 days
- adult day care
- incontinence supplies
- meal delivery services
- personal care, such as bathing and dressing, when this is the only care that a person needs
- homemaking care, such as laundry and shopping, when this is the only care that a person needs
- nutritional supplements
Medicare resources
For more resources to help guide you through the complex world of medical insurance, visit our Medicare hub.
Medicare coverage for a person with dementia begins with preventive services in the form of annual wellness visits.
If a person develops dementia, the coverage helps with costs throughout the course of the disease. This coverage includes hospice care in the last months of life.
Whether people have Original Medicare or a Medicare Advantage plan, they are eligible for the coverage. However, the two programs have different deductibles, copayments, and coinsurance costs. Anyone who is unsure of the details of their coverage should speak with their plan provider.