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Medicare Coverage and Costs

Someone who has Alzheimer's may need different kinds of care over time. Medicare can help cover some of the costs of care for medical and mental health conditions you may face.

What does Medicare cover?

If you have Alzheimer’s, 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. Medicare will only cover the costs of PET (Positron Emission Tomography) scans in certain cases for Alzheimer’s. PET scanning is a medical test that can diagnose Alzheimer’s in its early stages.
    • Treatment: Medicare also helps pay when you see your doctor to treat and manage your Alzheimer’s. 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
  • Home health care
  • Rehabilitative care
  • Skilled nursing care services
  • Home care
  • Prescription drugs
  • Hospice, or end-of-life care

What does Medicare NOT cover?

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

  • 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 often need more and more custodial services as times goes on.

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

Learn more from the Alzheimer’s Association about Medicaid and ways to help cover these costs.

Myths and facts about Medicare and Alzheimer’s

Myth: Medicare does not cover people with Alzheimer’s.

Fact: Medicare does cover people with Alzheimer’s. It gives them medical and mental health coverage, just as it does for other medical conditions.

Myth: Medicare does not cover home care, certain therapies, and even some medical care for Alzheimer’s patients. The reason is Alzheimer’s gets worse over time and does not have a cure.

Fact: A long time ago, Medicare did deny coverage for these reasons. But Medicare has since changed its policy. That’s because research shows some therapies can help people with Alzheimer’s and dementia. These include drug, physical, occupational, speech-language, and other therapies that can help delay the worst effects of Alzheimer’s.

Make sure you understand Medicare rules about what it will cover or not cover. This can help you get you or your loved one’s medical needs met. It also can save you money.

What will it cost?

Medicare pays for most of the costs of services and items it covers. But benefits vary. You may have to pay some of the cost, depending on what services you get.

Knowing how much Medicare covers will help you save money and help reduce fraud and abuse in Medicare.

How do I pay for services Medicare does not cover?

When you need services and Medicare does not pay for them, you have three options:

  • Pay for them on your own.
  • Use long-term care insurance, if you bought a policy before you were diagnosed with Alzheimer’s.
  • See if Medicaid will pay. Medicaid is a government health program for people with low incomes. If you have questions, you may be able to get personal help.

Mental health coverage

Medicare does not view Alzheimer’s disease as a mental illness. It is a medical illness. Knowing this can help you understand Medicare coverage.

When a doctor treats you for Alzheimer’s, Medicare usually pays 80% of the doctor’s bill. This is because Medicare sees it as a medical service.

Sometimes, people with Alzheimer’s need mental health services too. Medicare provides a mental health benefit that lets you see psychiatrists, clinical psychologists, or social workers. Medicare will cover 65% (in 2013) of the amount it approves for a mental health service.

If you seek a diagnosis or treatment for Alzheimer’s from a mental health professional, Medicare will pay either 80% or 65% of the fee (in 2013). How much depends on the type of visit.

Example #1: Mr. Jones is showing signs of Alzheimer’s. He visits his psychiatrist to get a diagnosis. This service will be billed as a medical service because it involves a diagnosis of Alzheimer’s. Medicare will cover 80% of the fee. Mr. Jones will have to pay for 20%.

Example #2: In 2013, Mr. Smith seeks psychotherapy treatment for his bipolar depression. He does not suffer from Alzheimer’s. This is billed as a mental health service. Since he is getting treatment, he will pay 35% of the amount Medicare approves, and any remaining portion of his Medicare Part B deductible.

Note: If your mental health provider sees you briefly, just to check on your drugs, Medicare should cover 80% of the cost of your visit.

Medicare also covers services you get as an inpatient in a psychiatric hospital. Medicare only pays up to 190 days during your lifetime for such care. Usually you pay the hospital deductible when you are admitted and daily copayments after day 60 in the hospital.

NEXT: Home Health Care

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