Does Medicare cover dementia care?

Does Medicare cover Alzheimer’s drugs?

Medicare Part D covers many medications that people with dementia and Alzheimer’s disease take. All Medicare Part D plans must cover at least two cholinesterase inhibitors in their formularies, according to the Alzheimer’s Association.

These medications are prescribed to treat symptoms related to judgment, language, memory and other thought processes. They help prevent the breakdown of acetylcholine, a chemical messenger important for learning and memory, and support communication among nerve cells.

Be sure to compare costs for your medications for plans available in your area during open enrollment each year. Also check if a plan has restrictions on coverage for the drug, such as requiring prior authorization or step therapy. 

Medicare covers some drugs for patients with Alzheimer’s or dementia under Part B if a health care provider administers them intravenously. It covers Alzheimer’s treatments that have full, traditional FDA approval but not those that have gone through accelerated FDA approval or are available via other special provisions. That limits the Alzheimer’s drugs covered, especially newer types of Alzheimer’s medications that can help slow the progression of the disease.

Now that the FDA has given full approval to Leqembi, Medicare will cover the medication under Part B. The drug is subject to the 20 percent Part B coinsurance, which could be covered by a Medigap policy or other supplemental plan.

But before Medicare covers Leqembi, you must first meet certain requirements:

• Be diagnosed with mild cognitive impairment or mild Alzheimer’s disease dementia and have documented evidence of beta-amyloid plaque on the brain.

• Use a physician who participates in a qualifying registry, which collects information from providers and has an appropriate clinical team and follow-up care.

Centers for Medicare and Medicaid Services actuaries estimate that Leqembi could cost the original Medicare program about $550 million in 2024, with the potential for costs to rise to $3.5 billion for original Medicare and Medicare Advantage in 2025.

Does Medicare cover nursing home care for dementia?

No. This is one of the big gaps in Medicare.

Medicare doesn’t cover custodial care — help with the activities of daily living, such as bathing, dressing and eating — in a nursing home, assisted living center or memory care unit if that’s the only care you need. It provides coverage for up to 100 days in a skilled nursing facility for rehabilitation after a three-day inpatient hospital stay if you need daily skilled nursing, occupational therapy or physical therapy related to the hospital stay.

But Medicare won’t cover the long-term care that many Alzheimer’s and dementia patients need as their condition progresses. 

Medicare provides limited home care coverage if you meet specific requirements. To qualify, a doctor must certify that the person is homebound and requires skilled therapies or intermittent skilled nursing. A Medicare-certified home health agency under the doctor’s plan of treatment must provide the care.

Does Medicare cover hospice care for dementia?

Yes. Medicare covers end-of-life hospice care for people with dementia or Alzheimer’s disease. A doctor must certify that you have a life expectancy of six months or less.

You can receive hospice care at home or at an inpatient hospice center or a nursing home or other facility. It provides comfort rather than treatment for the illness.

If you qualify and choose to receive hospice care, Medicare will cover most everything you need for comfort care, including doctor services and nursing care, drugs to help control your pain, medical equipment and support for your caregivers. However, when you are on hospice, Medicare will not pay for treatment that is intended to cure your illness. 

Be aware that palliative care, another name for pain and symptom management, is totally covered when you’re enrolled in hospice. If you’re not in a hospice program, the palliative care services of physicians and other licensed practitioners may be covered under Part B and subject to the deductible and 20 percent copayment.

Keep in mind

If you choose a private Medicare Advantage plan, sometimes known as Medicare Part C, rather than original Medicare, you’ll have the same coverage as Medicare Part A and Part B but with different out-of-pocket costs. You may also have additional prior authorization requirements before receiving certain services or medications. The Medicare Advantage plan may provide additional coverage, such as meal delivery and transportation to doctor’s appointments. Some plans also provide caregiving support and in-home support services for activities of daily living and housekeeping tasks that you may have trouble continuing to do. 

Medicare Advantage plans usually have a provider network, which means you may not have coverage or you may have to pay more if you use any out-of-network doctors or facilities. Make sure your neurologist and other doctors are covered in the plan’s network and check on the plan’s coverage for your medications. 

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