Alzheimer’s and Medicare: Understanding Coverage

What is Medicare?

Medicare is a federal health insurance program for people who are 65 or older (or for people who have been receiving social security disability payments for at least two years). Everyone should apply for Medicare three months before their 65th birthday.

What does Medicare cover?

Medicare’s coverage is similar to that of private medical insurance: it covers doctor’s visits, hospital care, prescription drugs, etc. As with most medical insurance, though, you have to pay deductibles, copays, and coinsurance as well as a monthly premium.

Medicare will cover the diagnosis of Alzheimer’s and the costs of its treatments (medicines and therapies) as long as they are approved (not experimental) and certified by your doctor as medically necessary.

What doesn’t Medicare cover?

The most important thing to know about Medicare, when you’re planning around Alzheimer’s, is that Medicare does not cover long-term (custodial) nursing home care. Also, be aware that Medicare has no out-of-pocket yearly maximum. Medicare also does not cover assistance with activities of daily living (ADLs) such as dressing and personal hygiene.

How can you fill the gaps in your Medicare coverage?

Medicaid is a government program that provides health coverage to low-income Americans. If you are 65 and your income is low, you may be eligible for Medicare and Medicaid at the same time, which supplement each other.

Medicaid will pay for long-term nursing home care, but only if your income and assets are below a certain level.

You can also buy a private supplementary policy (Medigap) to cover the copays, deductibles, and coinsurance that come with Medicare.

Another option is to sign up for a Medicare Advantage Plan instead of straight Medicare. A Medicare Advantage Plan is insurance from a private company that contracts with Medicare to provide you with benefits. Medicare Advantage Plans vary in terms of premiums, coverage, and copays, deductibles, and coinsurance costs, as well as access to specific doctors and other practitioners. All Medicare Advantage Plans have an out-of-pocket maximum.