Dear wise senior,
What exactly does Medicare cover when it comes to Alzheimer’s disease? My husband was recently diagnosed with early stage Alzheimer’s disease, and we would like to know what is covered and what is not.
– Plan ahead
I’m so sorry to hear of your husband’s diagnosis, but you’ll be happy to know that most medical costs to treat beneficiaries with Alzheimer’s disease are covered by Medicare. Unfortunately, the long-term care costs that most patients eventually need are not. Here’s a breakdown of what Medicare does and doesn’t cover when it comes to Alzheimer’s disease, along with some tips that can help you plan ahead.
Medical care: For the most part, ongoing medical care to diagnose and treat Alzheimer’s disease is covered by Medicare Part B, including visits to primary care physicians and specialists, lab tests, speech and occupational therapy, home health care and outpatient counseling services. Medicare pays 80% of these costs and you will be responsible for the remaining 20% after you reach your Part B annual deductible of $233.
Sixty days of inpatient hospital care is also covered by Medicare Part A after paying a deductible of $1,556. Beyond 60 days, a daily co-insurance is added.
Medications : Most Alzheimer’s drugs are covered by Medicare Part D prescription drug plans, but coverage varies, so check your plan’s formulary. The only exception is Aduhelm, the controversial new drug whose cost is estimated at $28,200 per year. Medicare Part B will only cover this drug if your husband is enrolled in a clinical trial.
Long-term care: It is important to understand that the original health insurance does not cover long term care. This includes nursing home care, assisted living costs and adult day care. However, Medicare pays for some short-term nursing care, but only for up to 100 days after a three-day hospital stay.
Hiring a home helper for bathing, grooming and dressing (this is called custodial care) is also not covered by Medicare, unless your husband is also receiving skilled nursing care or physical or occupational therapy.
To help with these costs you may want to consider purchasing a long term care insurance policy or short term care plan if possible, or if your income and assets are very limited you may qualify. to Medicaid. To explore your financial options for long-term care, go to PayingForSeniorCare.com.
Hospice: In the later stages of illness, Medicare Part A covers nearly all aspects of palliative care, including medical services, nursing care, drugs, medical equipment and supplies, physical and occupational therapy, nursing services, domestic help, counseling and respite care. To qualify, a physician must certify that a patient has six months or less to live.
Other insurance and assistance
If your husband is enrolled in the original Medicare and he doesn’t have a supplemental insurance, also called a Medigap, policy, you should consider getting one for him. A Medigap plan will help pay for things not covered by Medicare like copayments, coinsurance, and deductibles. To find plans in your area, go to Medicare.gov/plan-compare and click “Medigap policy only.”
Or, if you’re enrolled in a Medicare Advantage plan (like an HMO or PPO), their plan must provide at least the same coverage as the original health insurance. Some benefit plans may also provide additional coverage for home care services.
If you can’t afford your Medicare costs or need help with your drug expenses, there are Medicare Savings Programs and the Supplemental Assistance Program. who provide financial assistance for drugs. To learn more, visit Medicare.gov/your-medicare-costs/get-help-paying-costs.
You can also get help through your state health insurance assistance program (see ShipHelp.org or call 877-839-2675), which provides free advice on insurance -sickness and long-term care.
Send your senior questions to: Savvy Senior, PO Box 5443, Norman, OK 73070, or visit SavvySenior.org. Jim Miller is an NBC Today contributor and author of “The Savvy Senior.”