Medicare 102: Does the government-sponsored health care program cover dementia care?

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What is medicare?

Medicare is a U.S. government-sponsored health care program for seniors and disabled individuals. A person is eligible for Medicare if they meet the following requirements:[01]

  • They’re under 65 and disabled.
  • They’re over 65 and have worked and paid Medicare taxes for at least 10 years.
  • They’ve been diagnosed with end-stage renal disease.

Medicare includes several plan options and add-ons. These include Parts A, B, C, D, and Medigap, with premiums and deductibles relative to income.

Parts A and B are considered Original Medicare, which is the most basic coverage that all who qualify for Medicare can receive. The following table [02] shows the types of care services covered for both.

 

Medicare Part A

 

 

Medicare Part B

 

Inpatient care Health care provider visits
Home health care Outpatient care
Skilled nursing facility care Preventive care, e.g., annual screenings and vaccinations
Hospice care Medical equipment
Home health care

 

What other Medicare plans and services are there?

  • Part C, also referred to as the Medicare Advantage plan, is offered through private insurance companies and is bundled with Part A and B. These plans offer additional coverage for things like vision, hearing, and dental. Oftentimes, Part C also offers Part D (prescription drug) coverage. Anyone enrolled in a Medicare Advantage plan is automatically ineligible for Medigap.
  • Part D is prescription drug coverage that can be added to Original Medicare or Part C. It’s offered through private insurance companies and it helps cover the cost of many prescription drugs, including recommended shots or vaccines.
  • Medigap, also known as Medicare Supplement Plan, helps those who can afford it fill “gaps” in their Original Medicare plan. It’s offered by private insurance companies to help pay for things like copayments, coinsurance, and deductibles. However, it doesn’t pay for long-term care or private-duty nursing.[03]
  • Medicare Special Needs Plans, also known as SNPs, are for people with a disabling chronic condition (like dementia), people who require institutionalized care, or people who qualify for both Medicare and Medicaid.[04] This plan offers everything that Part C offers with added services for specialized needs.
  • Chronic care management services are offered under Original Medicare to those with at least two chronic conditions that are expected to last at least one year.[05] To receive such services, dementia patients with chronic conditions will work with their doctor on a care plan and health goals, and then sign an agreement.

Does Medicare pay for memory care costs?

Medicare doesn’t cover the cost of room and board in a memory care facility, but it may pay for some home health care service for dementia patients. It also covers some associated costs of memory care in a facility or at home, as described in the table below.[02]

 

Covered

 

 

Not covered

 

Cognitive assessments to confirm a dementia or Alzheimer’s diagnosis The cost of renting a unit in a memory care community or assisted living community
100 days of skilled nursing care followed by a precipitating event, such as a hospital stay Long-term memory care
Care planning to learn about treatment options Assistance with activities of daily living at home or in a memory care or assisted living community
Prescriptions to delay the progression of memory loss Alternative therapies such as acupuncture or herbal medicines
Some custodial care services

Medical expenses can increase during the 12 months before an Alzheimer’s diagnosis.[06] So, an early diagnosis can help you cover medical costs and reduce hospitalizations. A proper diagnosis can help you to take advantage of any services you can bill to Medicare, especially screenings and preventive services.

Does Medicare cover home health care for dementia?

Medicare covers part-time home health care costs for dementia. This is typically defined as care received less than seven days a week or less than eight hours each day over a span of 21 days.[07]

Medicare does sometimes offer exceptions for specific groups or under special circumstances. For instance, if your loved one is a Native American or an Alaska Native, they may be able to receive home health care for their dementia for up to 35 hours per week.[08]

Keep in mind that this coverage is only available for seniors who fit Medicare’s definition of “homebound.” This means they can’t leave home easily without assistance, or that leaving their home isn’t recommended due to their condition.[07]

In addition to skilled nursing care or assistance from a home health aide, Medicare covers medical social services and occupational, physical, and speech therapy. Taking advantage of these services may be helpful if you’re trying to decide where your loved one receives long-term care.

If you’re considering home care, keep in mind that homemaking tasks and assistance with activities of daily living aren’t typically covered by Medicare, if it’s the only care you need. Medicare may sometimes cover custodial care services as long as you also require medical services (like sterile dressings or physical therapy).

 

Does Medicare cover nursing home care for dementia?

Medicare typically doesn’t cover the cost of nursing home care for seniors with dementia. However, Medicare may pay for some skilled nursing home care for up to 100 days under limited circumstances. For example, if a senior with dementia has a qualifying inpatient hospital stay that warrants a limited stay in a skilled nursing facility afterward. Patients must need additional skilled nursing services like intravenous fluids or rehabilitative therapies.[10]

Additionally, seniors may turn to Medicaid in some instances to pay for a nursing home level of care. If your loved one has Medicaid, they would need to live in a Medicaid-approved nursing home to take advantage of this coverage.

 

Are there other payment options and resources for memory care?

Because Medicare doesn’t pay for long-term memory care, families often find different ways to pay for memory care services. There are many surprisingly helpful ways to fund care, including veterans benefits, life insurance, and more.

If you’re not sure whether Medicare or Medicaid covers memory care facilities in your state, speak to someone from Medicare, or view your state’s profile on the Medicaid website.

If you’re already seeking a home care agency or memory care facility, contact a Senior Living Advisor. These experts can provide local guidance and help you find care that fits your loved one’s needs, all at no cost to your family.

This article originally appeared on APlaceForMom and was syndicated by MediaFeed.

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