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What Medicare Coverage is Available for Conditions?

If you are living with a medical condition, you may have specific questions about what Medicare will cover and how to best receive treatment. Or you may just want to investigate coverage for a condition you’re concerned about or of which you have a family history.

Here, you’ll find a guide to what Medicare will and will not cover and pay for and how Medicare gets you the tests, diagnoses and treatment you need.

What does Medicare cover for Alzheimer’s disease?

Alzheimer’s disease is a brain disorder that some people may get when they are older. It is a form of dementia. It can make people lose their memory, act differently and have trouble thinking and solving problems.

More than 5 million people in the United States have Alzheimer’s disease. It is the sixth leading cause of death. Alzheimer’s disease patients also may suffer from depression, agitation, anxiety and other health conditions.

Find out what’s covered for Alzheimer’s disease

If you have Alzheimer’s disease, Medicare will help pay for your care for medical and mental health conditions. This may include:

Ongoing hospital care, doctor visits and needed medical items.

This includes care for diagnosis and treatment:

  • Diagnosis: Medicare will help pay for the doctor visit, physical exam and several tests used to diagnose Alzheimer’s disease. Medicare will only cover the costs of PET (Positron Emission Tomography) scans in certain cases for Alzheimer’s disease. PET scanning is a medical test that can diagnose Alzheimer’s disease in its early stages.
  • Treatment: Medicare also helps pay when you see your doctor to treat and manage Alzheimer’s disease. It will pay if your doctor asks another doctor to see you. Medicare also will pay if your doctor oversees your home health or hospice care.

Mental health services

Sometimes, people with Alzheimer’s disease need mental health services too. Medicare provides a mental health benefit that lets you see psychiatrists, clinical psychologists or social workers. Medicare will cover 80% (in 2014) of the amount it approves for a mental health service.

Medical social services

A social worker can visit you at home to counsel you and help you deal with the social and emotional side of Alzheimer’s disease. Your doctor must order these services.

Medical supplies

Your doctor may include orders for certain medical equipment and supplies if you need this equipment to live at home. This includes a walker, wheelchair or oxygen equipment.

Prescription drugs

All Medicare drug plans must include certain types of prescription drugs used to treat Alzheimer’s disease. Each plan must cover at least 2 drugs in 2 categories that: Raise the levels of brain chemicals to aid memory and judgment, called cholinesterase inhibitors; and help improve memory, attention, reason and language, called memantine.

Find out more about drugs covered by Part D prescription drug plans. Learn about prescription coverage.

Medicare does not cover these types of care for Alzheimer’s disease:

  • Long-term care: This includes long-term nursing home stays beyond 100 days, the costs of assisted living facilities and adult day care.
  • Personal care, also called custodial care: This includes paying another person to help you bathe, dress, fix meals and do other daily activities. People with Alzheimer’s disease often need more and more custodial services as times goes on.

Medicare will cover custodial care, both at home and during a brief stay in a skilled nursing facility, but only when you also need and get skilled care.

People with Alzheimer’s disease often need other types of care that Medicare does not cover. Alzheimer’s disease patients and their families often must pay for these services if they do not qualify for Medicaid or long-term care insurance.

Contact the Alzheimer’s Association at www.alz.org or 1-800-272-3900 // TDD: 1-866-403-3073.

What does Medicare cover for cancer?

Cancer starts when abnormal cells in the body grow out of control. There are many kinds of cancer. Different cancers act differently, and treatments can vary. Cancer is named for the part of the body it started in.

Cancer is the second leading cause of death in the United States. But millions of people today either are living with cancer or have had it. Generally, the sooner cancer is found and treated, the better your chances are for survival.

Find out what’s covered for cancer

Cancer treatment can cost a lot. But Medicare will help pay to diagnose medical and mental health conditions you face. Medicare covers these services:

  • Doctor visits
  • Certain medical items
  • Ongoing medical treatment for your cancer diagnosis
  • Hospital care
  • Second opinions on surgery
  • Chemotherapy or drugs you take by mouth or by vein
  • Radiation
  • Medical treatment for other health conditions and side effects of your cancer treatment
  • Prescription drugs for chemotherapy and to treat side effects such as nausea
  • Healthcare services at home, such as a visiting nurse or rehabilitation therapist and home health aides
  • Care to help you do daily tasks, called rehabilitative care
  • Mental health services
  • Experimental treatments in clinical trials
  • Short-term nursing home care
  • Hospice or end-of-life care

Medicare may not pay for everything you need. Medicare often does not cover these services:

  • Services that help you bathe, eat and do other activities of daily living that do not require skilled care
  • Nutritional supplements
  • Stays in assisted living facilities
  • Adult day care
  • Long-term nursing home care

How do I find a cancer treatment center?

To get the best medical care possible for your cancer, choose your treatment center carefully. You may not be able to choose which hospital treats you in an emergency but you can choose a center for your regular care.

The government has named some hospitals and healthcare organizations as excelling in treating certain conditions. These are called Centers of Excellence. The National Cancer Institute (NCI) has named the top centers treating cancer in the United States. These are called NCI-designated cancer centers.

Which drugs does Medicare Part B cover?

It can be hard to understand why Medicare covers some drugs under Part B and others under Part D. But it is important to know the difference. How you get your drugs and what you pay will differ if Medicare Part B or Part D covers your drugs.

Medicare Part B covers most of the drugs to treat your cancer that are given as a shot, through an IV tube or by mouth. These are called chemotherapy drugs. Your doctor or treatment center gets the drugs. Then your doctor or a nurse puts them in your veins or gives you a pill or liquid to swallow.

Many chemotherapy drugs can cause nausea and vomiting. You will get anti-nausea drugs when you get your chemotherapy.

Which oral cancer drugs does Part B cover?

Medicare Part B covers cancer drugs that you have put in your veins or can take by mouth. If your drug is only made to be taken by mouth, your Medicare Part D plan should cover it.

How does Medicare cover anti-nausea drugs?

It covers them the same way Medicare covers cancer drugs. If you can take your anti-nausea drug by mouth or in your veins, then Medicare Part B will cover either one. But your doctor must give it to you within 48 hours of your cancer treatment. Otherwise, your Medicare Part D plan should cover it.

Which part of Medicare covers radiation therapy?

Medicare Part B covers your radiation if you are an outpatient or in a freestanding facility. You will pay 20% coinsurance of the amount Medicare approves for the doctor visit. Medicare will pay the remaining 80%.

Medicare Part A covers your radiation therapy while you are a hospital inpatient.

If I want a second opinion, will Medicare cover the visit?

After you get your doctor’s diagnosis and cancer treatment plan, it is a good idea to get another cancer doctor’s advice before you start treatment. This is especially true if your doctor suggests surgery. This is called a second opinion.

Medicare covers most of the cost of a second opinion before surgery. A second opinion might tell you to follow your first doctor’s treatment plan. Or it can suggest that you change the plan. A second opinion can make you feel better that you have explored your treatment options. It also will give you a chance to get all your questions answered.

Contact the American Cancer Society www.cancer.org 1-800-ACS-2345 (1-800-227-2345) OR National Cancer Institute www.cancer.gov 1-800-4-CANCER (1-800-422-6237) // TTY: 1-800-332-8615

What does Medicare cover for diabetes?

If you have diabetes, your body does not make enough insulin or it does not respond to insulin like it should. Insulin is a hormone that changes sugar, starches and other food into the energy you need to live. If you do not have enough insulin, your blood sugar will be too high. A high blood sugar level is bad for your health.

If you have diabetes but do not treat it, you can have serious health problems. Nearly 29 million Americans have diabetes. Of these, 7 million do not even know they have it. One of every 4 individuals age 65 and older has diabetes. Diabetes is the seventh leading cause of death in the United States.

There is good news. If you find and treat diabetes early, you can prevent or delay many of the health problems diabetes brings on. Eating right, being active and taking new diabetes drugs can help.

Find out what’s covered for diabetes

If you have diabetes or are at risk for it, Medicare can help. Medicare covers:

  • Tests to tell if you have diabetes
  • Drugs and supplies you will need if you have diabetes
  • Services that can help you manage your diabetes and stay healthy

Medicare Part B covers up to 2 diabetes screenings each year, if you are at risk for diabetes. It also covers many of the supplies and services you may need to control your diabetes.

Medicare Part D is Medicare’s prescription drug benefit. It covers insulin, diabetes drugs and certain supplies. There are times when Medicare Part D does not cover insulin, diabetes drugs and supplies. For example, Medicare Part B, not D, covers external insulin pumps and the insulin used in them.

You must join a Medicare Part D drug plan to get the prescription drug coverage. Learn more about Medicare’s Part D drug benefit.

What does Medicare NOT cover?

If you have diabetes or are at risk, Medicare offers a lot of coverage. Medicare can help you manage your condition. It also can help prevent severe health problems that go along with diabetes. But Medicare does not cover everything. Here are some services people with diabetes commonly need that Medicare does not cover:

  • Eye exams for glasses. These are called eye refraction exams.
    • Note: There is a special type of eye exam that Medicare will cover for people with diabetes. This exam, called a dilated exam, checks for damage to your eyes. If not controlled, diabetes can cause serious problems to your vision. Medicare will cover this exam once every 12 months.
  • Routine physical exams. These are exams beyond the one-time “Welcome to Medicare” physical exam. However, starting in 2011, Medicare will cover an Annual Wellness visit every 12 months.
  • Weight-loss programs

You must also follow Medicare rules. For example, you must get a doctor’s prescription for certain services or get care from certain professionals. Paying close attention to these rules will save you money. If you do not follow them, you may have to pay the full cost for a certain treatment, service or product.

What products and supplies does Medicare cover?

Medicare covers a range of supplies to help you keep your blood sugar levels under control. This can help prevent damage to your blood vessels, eyes, kidneys and nerves from your diabetes.

Medicare covers:

  • Equipment that lets you test your blood sugar
  • Medical supplies that help you take insulin
  • Specialized orthopedic footwear
    • A foot doctor, or podiatrist, or other qualified doctor must prescribe the shoes or inserts. A doctor or someone else who is qualified must fit you for the shoes and give them to you.

Medicare Part B covers some of this equipment. Medicare Part D covers other drugs and the supplies to use in taking those drugs. It is important to understand the differences. This way, you can get your supplies on time and save money.

How do I get supplies and equipment to test blood sugar and take insulin?

Your doctor must give you a prescription for your blood sugar self-testing equipment and supplies.

You can:

  • Order and pick up your supplies at your drugstore
  • Order supplies from a medical equipment supplier. A supplier is a company, person or agency that offers them outside of a hospital or skilled nursing facility.

You must place this order yourself, using your doctor’s prescription. Your doctor cannot order supplies for you.

Make sure to ask if your drugstore or supplier is enrolled in Medicare. If it is not, you will have to pay the whole cost for any supplies.

What preventive services does Medicare cover for people with diabetes?

If you have diabetes, Medicare covers certain services for you. Your doctor must write an order or referral for you to get some of them, including:

  • Tests to see if you have diabetes, called diabetes screening
  • Training to help you manage your diabetes
  • Advice on what to eat, called medical nutrition therapy services
  • Blood sugar tests, called hemoglobin A1c tests
  • Special eye exams

You do not need an order or referral for these:

  • Foot exams and treatment
  • Eye exams to test for glaucoma
  • Shots for flu and pneumonia
  • “Welcome to Medicare” physical exam
  • Annual Wellness Visit

Contact the American Association of Diabetes Educators (AADE) www.diabeteseducator.org 1-800-338-3633 OR American Diabetes Association www.diabetes.org 1-800-DIABETES (1-800-342-2383)

Next Steps:

Learn About Part C  or  Learn About Costs