Does Medicare Cover Dementia Care?
Key takeaways:
Medicare covers care for dementia, including cognitive assessments, physical therapy, and hospital care.
For enrollees with dementia, Medicare does not cover adult day care. But it may cover some home healthcare if you qualify.
Some Medicare dementia care resources can greatly increase services while reducing out-of-pocket costs. This includes the Medicare Special Needs Plan (a type of Medicare Advantage plan) and the Program of All-Inclusive Care for the Elderly, known as PACE.
Table of contents
Navigating the complexities of dementia can be overwhelming for people with the condition and their caregivers. Fortunately, Medicare covers some aspects of dementia care.
For the millions of people in the U.S. with dementia conditions, including Alzheimer’s disease, Medicare covers medical treatment and some home healthcare.
Home healthcare for dementia is covered only if skilled nursing services are required for other needs. And Medicare does not cover long-term care.
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Medicare Special Needs Plans, a type of Medicare Advantage plan, offer more benefits than original Medicare. Understanding what your Medicare plan covers and does not cover can save you from unexpected expenses. Dementia, for example, often requires specialized care over the long term.
Does Medicare cover dementia care?
Original Medicare covers several aspects of dementia-related care, including:
Inpatient hospital care, including medications during a hospital stay
Outpatient hospital care, such as the intravenous (IV) infusion of medications
Positron emission tomograpy (PET) scans for diagnosing Alzheimer’s and prescribing new medications
Physical therapy
Physician services
Limited home healthcare for people certified as homebound
Medicare Advantage Special Needs Plans and special programs, such as PACE, offer expanded Medicare coverage for people with dementia.
Early onset Alzheimer’s
Although 65 is the typical age of Medicare eligibility, someone younger who is diagnosed with early onset Alzheimer’s can qualify for Medicare coverage. You are eligible if you have been receiving Social Security Disability Insurance, known as SSDI, for 24 months.
What dementia conditions are covered under Medicare?
Medicare covers the care for all primary forms of dementia. Here are the most common types:
Alzheimer’s disease: This condition deteriorates memory and cognitive function. It accounts for at least two-thirds of dementia cases in people 65 and older.
Vascular dementia: This is the second most-common type of dementia. This condition is caused by impaired blood flow to the brain. It affects thinking and physical coordination.
Lewy body dementia: This condition is characterized by abnormal protein deposits in the brain. It affects behavior, movement, and mood.
Frontotemporal dementia: This condition affects the frontal and temporal lobes of the brain. It leads to personality changes and language difficulties.
Mixed dementia: A person with this condition has symptoms of more than one type of dementia.
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Does Medicare cover long-term care or home care for dementia?
Medicare covers medically necessary home healthcare that requires skilled nursing or therapy services. Palliative care and hospice are also covered for individuals with dementia.
Medicare does not cover long-term care, such as assisted living, nursing homes, and memory care. But it may cover some services provided in these facilities.
Program of All-Inclusive Care for the Elderly
The Program for All-Inclusive Care of the Elderly, known as PACE, provides medical and social services to older adults living at home. Most PACE participants are eligible for both Medicare and Medicaid. Almost half have been diagnosed with dementia.
A team of healthcare professionals provides coordinated care. This delays or prevents an individual’s transition to a long-term care facility. (About five percent of PACE participants already live in nursing homes.)
You can enroll if:
You are age 55 or older.
You live in the service area of a PACE organization.
Your state certifies that you need nursing home-level care.
You would be able to live safely at home with the help of PACE services.
Medicare and Medicaid covers PACE services and care. Anything your healthcare team determines you need is covered. This includes prescription medications.
There is never a deductible or copay. There is no coverage gap for covered services approved by your healthcare team.
PACE for dementia care includes:
Adult day care programs
Family and caregiver support services
Home care services
Home health services
Rehabilitation services
You cannot access PACE if you’re enrolled in a Medicare Advantage plan or a Medicare Part D prescription plan. Even if you don’t have Medicare or Medicaid, you can pay for PACE out of pocket if you qualify. If you are not eligible for Medicaid and you move to a nursing home for the long term, you could be charged monthly premiums to cover the Medicaid long-term-care benefit. These premiums are $4,000 to $5,000 a month, on average. At that point, you will also need to pay the premiums for your Medicare Part D plan.
There are more than 160 PACE organizations and more than 300 PACE centers nationwide. You can use this PACE search tool or this PACE program locator to find out if there is an organization near you.
What aspects of dementia care does each part of Medicare cover?
Here’s a breakdown of what each part of Medicare covers for dementia care:
Part A
Medicare Part A covers hospital stays and treatment related to your dementia diagnosis. It also covers skilled nursing care. You are responsible for all costs after day 100 of each benefit period, which begins when you’re admitted. Your benefit period ends when you haven’t received inpatient care for 60 days in a row.
Part A also covers home healthcare. It provides limited coverage for respite care or substitute care in a Medicare-approved inpatient setting, so unpaid caregivers can take a break.
Part B
Medicare Part B covers outpatient services, including doctor visits, diagnostic tests, and therapy. Part B also covers outpatient treatments, such as Leqembi, if your physician participates in a registry. Aduhelm will be covered until the IV treatment is discontinued at the end of 2024.
Medicare Advantage (Part C)
Medicare Advantage plans are private alternatives to original Medicare. Medicare Advantage plans must meet the benefits offered by original Medicare. There are also Medicare Special Needs Plans, which provide extra benefits and care coordination to people with specific conditions or needs. A person with dementia would qualify for a Chronic Condition Special Needs Plan.
PACE and dual eligibles
PACE provides comprehensive community-based care to individuals with dementia. Most PACE participants are “dual eligibles,” which means they qualify for Medicare and Medicaid.
Part D
Part D covers prescription medications for managing dementia symptoms and slowing disease progression.
Medigap
If you have original Medicare, Medigap offers supplemental insurance plans. These help cover out-of-pocket costs, such as copays and deductibles.
GUIDE pilot program
Guiding an Improved Dementia Experience, known as GUIDE, is an 8-year pilot program that begins on July 1, 2024. It’s designed to provide services for Medicare enrollees diagnosed with dementia and their unpaid caregivers. This voluntary model can be offered in all states, the District of Columbia, and U.S. territories.
Through care coordination and caregiver services, the model aims to:
Improve the quality of life for people living with dementia
Reduce strain and burden on caregivers
Prevent or delay nursing home care
What dementia care is not covered by Medicare?
Certain items and services related to dementia care are not covered by Medicare. These include:
Adult day care
Incontinence supplies
Medical alert systems
Over-the-counter vitamins and supplements
If you have a Medicare Advantage plan or a Medicare Special Needs Plan, or have enrolled in the PACE program, some of the items and services listed above may be covered.
What other resources can help you pay for dementia care?
You may be eligible for dementia care services from faith organizations and other community resources. The U.S. Department of Veterans Affairs (VA) offers dementia care services for qualified individuals.
VA healthcare services for dementia care include:
Nursing home care in various settings
The bottom line
Medicare provides dementia care support covering a range of medical services and treatments. This includes cognitive screenings, care plan services, hospital care, positron emission tomography (PET) scans for diagnosing and treating Alzheimer’s disease, and limited home healthcare.
For people with dementia, Medicare also has expanded options for coordinated care. The Medicare Advantage Special Needs Plan is a type of Medicare Advantage plan for people with special conditions and needs, including dementia. The Program for All-Inclusive Care of the Elderly, known as PACE, has comprehensive medical and social services that allow people with dementia to continue living in their homes and delay or avoid their transfer to nursing homes.
In addition, people under 65 who are diagnosed with early onset Alzheimer’s can qualify for Medicare coverage after 24 months of receiving Social Security Disability Insurance.
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