Dementia Care Costs for Medicare Beneficiaries

The Alzheimer’s Association says that dementia is a general term for the severe mental decline which interferes with daily life. Alzheimer’s is the most common form of dementia, involving parts of the brain that control memory, though, and language.

Dementia can make it difficult to complete daily tasks. Many of those suffering from dementia need constant care. It can be difficult to find help paying for respite care since Medicare doesn’t cover custodial care. It’s important to understand Medicare coverage for dementia as the disease progresses.

Early Stage Dementia

If you’re a Medicare beneficiary with both Medicare Part A (hospital insurance) and Medicare Part B (medical and outpatient insurance), Medicare’s coverage for early stage Dementia includes the following:

Annual Wellness visit and assessment

Part B will cover the costs of your wellness visit, this means that for no cost you can see a doctor that accepts Medicare Assignment.

The yearly physical exam will include a health risk assessment. This is a starting point for identifying symptoms that lead to a diagnosis.

The doctor will go over advance care planning options with you, including an advance directive that will allow you to make decisions for yourself after you’ve lost the ability to make choices.

Diagnostic Radiology testing

Part B of Medicare covers diagnostic tests like MRIs, CT scans, and PET scans when ordered by a physician to confirm or rule out a dementia diagnosis and to see how far the disease has progressed.

You may be responsible for the 20% of the Medicare-approved cost and the Part B deductible if you haven’t reached it for the year. If you get the test done in an outpatient hospital setting, you may be required to pay a copayment.

Hospital, doctor, and mental health services

Part B covers physician services, like doctor visits and follow-up care. Mental health services are covered, including counseling sessions from behavioral health specialists and psychiatrists who accept assignment.

Part B pays 100% of the approved amount for an annual depression screening if your doctor accepts assignment and you receive care in a primary care setting.

These are important benefits because people with dementia may experience depression, anxiety, or frustration, especially as they lose their memory.

If hospital care is needed, Part A provides coverage for inpatient care. Costs vary depending on the services needed, but the cost can include deductibles, copayments and coinsurance.

Prescription Drugs

If you receive drugs in an inpatient hospital setting, they will be covered under your part A of Medicare. Part B offers limited coverage for medications that you won’t be able to give yourself, like infusion drugs.

For Medications that you take at home, you’ll need a Medicare Part D prescription drug plan, these plans are available through Medicare-contracted private insurance companies. Since coverage varies, it’s important to check the plan’s formulary to make sure your medications are covered.

Mid-Stage Dementia Coverage

This is often the stage where patients start exhibiting more intense confusion and increased difficulty communicating with others. If you’re the one providing care, you’ll likely notice big changes in behavior and mood.

Many people need home health aides, adult day care, or assisted living in this stage. Medicare coverage for these services is limited.

Medicare Part B will cover short-term, limited home health coverage in some situations, but this is covered only if the individual is unable to leave home without considerable hardship and needs intermitted skilled nursing care or therapy services (physical or occupational therapy). Medicare won’t cover full-time nursing care.

While Medicare doesn’t cover adult day care or assisted living facilities, there are community programs available in your area that provide elder care services for those who need some assistance but can’t live independently.

Medicare coverage that was initiated in early stages of dementia will continue to be available through the middle and last stages as needed, and as ordered by a physician.

Late Stage Dementia and Medicare Coverage

The late stage of dementia can be exhausting, with extensive care twenty-four hours a day, including personal care assistance.

At this stage, there is profound memory loss, and the patient may no longer be able to communicate verbally, and either will need help walking or can’t walk at all. The patient may have incontinence, anger, or aggressive outbursts.

It’s at this point that many family caregivers can no longer provide the care that is needed. People in the late stage of dementia often require full-time nursing home care.

Medicare doesn’t cover long-term care. Medicare only covers skilled nursing care in certain situations, like during a short-term stay at a skilled nursing facility after a qualifying hospital stay.

If you have limited income, many state Medicaid programs cover long-term care, including nursing home care. This could be an option worth looking into, and you can find out more by contacting your states Medicaid program.

During the final stage, hospice care may be required. Hospice care is covered by Part A, it includes coverage for a variety of services ordered by the hospice physician, including:

  • Durable Medical Equipment (DME supplies)
  • Nursing and therapy services
  • Prescription drugs for symptom control or pain relief only
  • Short term, temporary respite care to relieve family members who are caregivers
  • Hospice aid services
  • Homemaker services
  • Grief counseling

Help to afford Dementia While on Medicare

For those diagnosed with dementia, getting help through additional Medical coverage may be an ideal option.

There are few options available to Medicare beneficiaries with Dementia:

Medicare Supplement Plans

Also referred to as a Medigap policy, Medicare Supplements are offered by private insurance companies and they help pay out-of-pocket expenses for services covered under Medicare Part A and Part B.

Different supplemental plans cover different amounts of those costs; such as copayments, coinsurance and deductibles. Medicare Supplement Plan F will eliminate all out-of-pocket expenses covered by Medicare along with some additional services, like foreign emergency coverage,

Medicare Advantage Plans

Medicare Advantage plans are offered by private insurance companies contracted with Medicare to provide at least the same level of coverage as Original Medicare (except hospice care, which continues to be covered under Medicare Part A).

Medicare Advantage plans allow you to choose Medicare “managed care”, such as:

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

Many Medicare Advantage plans offer additional benefits like routine dental, vision, hearing, or wellness programs. There are also plans available that include creditable prescription drug coverage.

Medicare Advantage Special Needs Plans

There are some locations that have a special needs plan for those with unique needs, specific disease or characteristics. A Medicare Advantage Special Needs Plan for those with Alzheimer’s or Dementia may have special coordination services to help enrollees better manage their condition.

Having some additional coverage is better than no coverage, especially when your health takes a toll and help is needed on a regular basis. Good news is, there’s information out there stating Dementia may be declining among older Americans.

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