Does Medicare Cover Home Health Care For Dementia? – Dementia is a condition in which one’s memory, thinking, and decision-making ability become impaired and interfere with their day-to-day activities. In 2017 the Journal of the American Geriatric Society estimated that the lifetime cost for someone living with dementia is $184,500, with 86% of the overall expenses taken on by the families. The cost is likely to increase with inflation. If any of your family members are living with dementia, then it is important to know how much home health care costs will federal programs like Medicaid, Medicare, or other forms of insurance cover.
Fortunately, the federal health insurance program Medicare covers a few aspects of dementia care. These include inpatient stays, diagnostic tests, and home healthcare. Medigap and Medicare Special Needs Plans may also work with Medicaid to help you. In this article we will provide all ins and outs on the most frequent question among people: ‘Does Medicare cover home health care for dementia’ and will help you explain what your Medicare plan covers and does not cover when it comes to receiving dementia-related services.
Highlights of this Post
Key Takeaways
- Medicare partially covers dementia care costs, including home healthcare, inpatient stays, diagnostic tests, and hospice care. This can alleviate some of the financial burden families face, which on average can reach up to $184,500 over a lifetime for a dementia patient.
- Medicare provides coverage for several common types of dementia including Alzheimer’s Disease, Vascular Dementia, Lewy Body Dementia, Frontotemporal Dementia, and Mixed Dementia.
- Medicare does not cover long-term custodial care, which includes assistance with daily activities like eating and dressing. However, it does cover medically necessary home health care involving skilled nursing or therapy services.
- For comprehensive coverage, other resources such as Medicaid, the Program of All-Inclusive Care for the Elderly (PACE), and long-term care insurance policies may offer additional support for custodial and long-term care needs.
- Understanding the eligibility criteria and the required documentation can significantly streamline the process of applying for Medicare and other supportive programs, ensuring that those with dementia receive the care they need without undue financial stress.
What Is Dementia?
Dementia is a condition when one loses cognitive abilities like thinking, memory, and decision-making. Alzheimer’s disease is the most common type of dementia.
As per the 2018 research, around 5.7 million people in America have Alzheimer’s disease or other types of dementia, and nearly 96% of these individuals are 65 years of age or older. A person living with dementia has to face the following difficulties:
- Staying organized
- Solving problems
- Communicating or finding the right words
- Recalling memories from people or directions
- Controlling your emotions and paying attention
- Getting out day-to-day tasks independently.
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What Is The Monthly Cost Of Caring For A Patient With Dementia?
The cost of caring for a person living with dementia per month may vary depending on the level of care that the person needs as well as the place from where they are receiving the care. According to the Journal Of Managed Care the cost of treating Alzheimer’s disease and other types of dementia was $132 billion in 2022.
On average, the monthly cost of getting residential memory care in an assisted living facility in America is $6160. The median monthly in-home dementia care costs for 44 hours in a week is $4957.
If the dementia progresses and additional care is required, then the person living with dementia in the memory care may need to be transferred to a nursing home, where the median monthly cost is $7908 for a shared room and $9034 for a private room. Medicaid may cover most of this cost for eligible nursing home residents.
Does Medicare Cover Dementia Care?
The Medicare covers some but not all causes related to dementia care, including the following:
- Home healthcare
- Inpatients stay at facilities like skilled nursing facilities and hospital assessments.
- Hospice care
- Tests needed for dementia diagnosis and treatment
- Prescription drugs or Medicare Part D.
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What Dementia Conditions Are Covered Under the Medicare Program?
The Medicare program offers coverage for primary forms of dementia. The following is the list of most common types of dementia that can be covered through your Medicare program.
- Alzheimer’s Disease: The condition deteriorates cognitive and memory function and accounts for at least two-thirds of overall dementia cases in senior citizens who are 65 or older.
- Vascular Dementia: Vascular dementia is the second most common type of dementia that is caused by impaired blood flow to your brain and affects physical coordination and thinking ability.
- Lewy Body Dementia: The condition is caused by abnormal protein deposits in the brain and affects movement, behavior, and mood.
- Frontotemporal Dementia: The condition affects the temporal and frontal lobes of the brain and causes personality changes as well as language difficulty.
- Mixed Dementia: This is a combination of two or more types of dementia.
Does Medicare Cover Long-Term Care for Dementia?
A lot of people living with dementia may need long-term care, such as custodial care that involves assistance with daily activities like dressing, eating, and using the toilet. The Medicare program doesn’t cover long-term care or custodial care.
However, other resources, such as Medicaid, The Program of All-Inclusive Care For The Elderly (PACE), and other long-term care insurance policies, may help you get coverage for long-term and custodial care for dementia patients.
Medicare covers only medically necessary home healthcare that needs skilled nursing or therapy services, including palliative care. The long-term cares that are not covered by Medicaid are memory care, nursing homes, and assisted living.
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Does Medicare Cover Home Care for Dementia Patients?
The Medicare program covers skilled nursing or health services provided at your home, through Part A&B plan. The services that are generally coordinated by an expert home health agency include the following:
- Physical therapy
- Part-time skilled nursing care
- Occupational therapy
- Medical social services
- Speech language therapy
- Positron Emission Tomography (PET) scans for diagnosing Alzheimer’s disease and prescribing new medicines
- Cognitive assessment and care plan services
- Inpatient hospital care like medicines during hospital stay
- Outpatient hospital care like intravenous infusion of medicines
- Limited home healthcare for those certified as homebound.
The Medicare program covers home health services, so if you need medical equipment like a hospital bed or wheelchair, you can get it for 20% of the cost. Medicare Advantage Special Needs Plans and other programs like PACE provide expanded Medicaid coverage for those living with dementia.
Does Medicare Cover Facility or Inpatient Care For Dementia?
The Medicare Part A plan covers inpatient stays at both the hospitals and SNFs. Let’s take a look at the facility or inpatient care services covered by Medicare for dementia.
Hospitals
The Medicare Part A program covers inpatient hospital stays, and this comprises stays in facilities like acute care hospitals, long-term care hospitals, and inpatient rehabilitation hospitals. Following are the few services that are covered:
- Semi-private room
- General nursing care
- Meals
- Additional hospital care or supplies
Medications that are part of your dementia treatment
For an inpatient hospital stay, the Medicare Part A plan covers all costs for the initial 60 days.
For 61 through 90 days, you need to pay coinsurance worth $408.
Inpatient hospital stay for 91 to 150 days comes with coinsurance of $816 per day.
After 151 days you need to be responsible for all the costs as an inpatient. If you get doctor services in the hospital, then you can get coverage by Medicare Part B.
SNFs
The Medicare Part A covers inpatient stay at Skilled Nursing Facilities (SNFs). These facilities offer skilled healthcare to dementia patients through expert professionals like doctors, physical therapists, and registered nurses. If your healthcare professional decides that you need skilled care after hospitalization, then they will recommend you for SNFs.
For the initial 20 days in SNF, Medicare Part A will cover all the costs, and after 20 days you have to pay coinsurance worth $204. For more than 400 days, you have to pay the entire cost.
Medicare does not cover custodial care such as bathing, dressing, and eating in an assisted living center, nursing home, or memory care unit. The program offers coverage for up to 100 days in a skilled nursing facility for rehabilitation after a three-day inpatient hospital stay if you need daily occupational therapy, skilled nursing, or physical therapy related to hospital staff.
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Does Medicare Cover Testing for Dementia?
The Medicare Part B program covers two types of wellness visits: a welcome to Medicare visit that gets completed within the initial 12 months after your enrollment and an annual wellness visit once every 12 months in all subsequent years.
All these visits come with cognitive impairment assessments that help the doctor look for signs of dementia. For this, your doctor uses a validated cognitive assessment tool, reports or concerns from yourself or your family members, and direct observation of your behavior, appearance, and responses. The Medicare Part B covers tests that are deemed necessary to diagnose dementia, like blood tests and brain imaging like MRI scans and CT Scans.
Does Medicare Cover Hospice Care for Dementia?
For those who are wondering: does Medicare cover palliative care for dementia, would be pleased to note that Medicare covers end-of-life hospice care or palliative care for those with dementia or Alzheimer’s disease.
A type of care given to people who are at the end of their life due to their health condition is hospice care. This level of care is managed by an expert hospice team that includes the following services:.
- Medical equipment such as wheelchairs and walkers
- Medications to ease symptoms
- Doctor services as well as nursing care
- Supplies like catheters and bandages
- Short-term respite care or a short inpatient stay to allow your primary caregiver to rest
- Grief counseling for you or your family.
If you or someone you know is living with dementia, then the Medicare will cover hospice care only if you fulfill the following conditions:
- Your healthcare professional has determined that you have a life expectancy of six months or less.
- You have agreed to accept hospice care that offers symptom relief and comfort instead of care to cure your health condition.
- You have signed a statement that indicates you have selected hospice care instead of Medicare-covered interventions.
- The Medicare program will provide coverage for all costs of hospice care apart from room and board. You can be responsible for a small co-payment for medicines prescribed to relieve your symptoms.
What Parts Of Medicare Cover Dementia Care?
The Medicare program provides services and benefits that someone with dementia may need at each stage of their illness. Following is an overview of Medicare provision for dementia coverage.
Medicare Part A
Medicare Part A (hospital insurance) covers home health care, hospice care, and the first 100 days of caring for a nursing home, including inpatient stays at hospitals. It also offers limited coverage for respite care in Medicare-approved inpatient settings.
Medicare Part B
Medicare Part B (medical insurance) provides preventive services like medical equipment, doctor services, or services necessary to diagnose/ treat your medical condition. Aduhelm will be covered by Medicare Part B until IV treatment is discontinued at the end of 2024.
Medicare Part C
Medicare Part C, also known as Medicare Advantage, offers benefits of both the Medicare Part A and Part B plans, including additional benefits like vision, dental, and prescription drug coverage, or Part D.
The Medicare Special Needs Plan offers additional benefits and care to those with specific conditions or needs. If you’re living with dementia, you can qualify for a Chronic Condition Special Needs Plan.
Medicare Part D
Medicare Part D is a prescription drug coverage that covers prescribed medications for treating dementia.
Medigap
Medicare or the Medicare Supplement Program helps to pay for things that are not covered by Medicare Part A&B, such as co-insurance, deductibles, and co-pay.
GUIDE Pilot Program
GUIDE stands for Guiding an Improved Dementia Experience, which is an 8-year pilot program that started on July 1, 2024, and is designed to offer services and care for Medicare recipients or those diagnosed with dementia and their unpaid caregivers.
The voluntary model is provided in all U.S. states, including U.S. states and the District of Columbia. The Medicare dementia care model through caregiver services and care coordination aims to reduce the financial burden on caregivers, improve the overall quality of life for those living with dementia, and delay or prevent nursing home care.
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Which Dementia Services Are NOT covered by Medicare?
Even though the Medicare program helps people to cover healthcare costs related to dementia. The program doesn’t include the following services:
- Round the clock or 24 hour per day care at home
- Adult daycare
- Meal delivery services
- Incontinence supplies
- Care in a skilled nursing facility beyond the initial 100 days
- Nutritional supplements
- Personal care like bathing and dressing
Who Is Eligible For Medicare Coverage For Dementia Care?
Now that you know the answer to the question, ‘Does Medicare cover home health care for dementia’, it is important to meet the following general eligibility criteria.
- You are 65 years old or older.
- You are at any age but living with a disability.
- You are at any age and live with end-stage renal disease.
Following are some specific Medicare plans for someone diagnosed with dementia.
- Special Needs Plan (SNP): Medicare SNP dementia refers to a special group of Medicare Advantage plans that address the particular needs of people living with specific health conditions, like dementia or stroke. This requires coordination of care.
- Chronic Care Management (CCM) Services: Individuals who have dementia along with other chronic conditions can be eligible for Chronic Care Management (CCM), which includes coordinating care, developing care plans, medications, and 24/7 access to healthcare professionals for meeting health needs.
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What Other Resources Help Pay For Dementia Care?
As you know, Medicare does not provide long-term care like assisted living community care and nursing homes for those living with disabilities. Let’s take a look at the best alternatives of the Medicare program that can help you with long-term care or home care.
Medicaid
Medicaid pays for home healthcare for those with dementia and can meet the eligibility criteria, such as being in need of nursing home-level care. The program covers memory care units in nursing homes that have specialized staff to care for those with dementia.
To apply for Medicaid, you must contact your local Department of Welfare, or the Department of Health & Human Services. You can also visit the Health Insurance Marketplace to see if you qualify based on your income.
The US Department of Veterans Affairs (VA)
Veterans, military members, or family members of eligible veterans and military members can get dementia care services from the US Department of Veterans Affairs. VA covers home health care for Alzheimer’s patients or dementia, such as the following:
- Caregiver support
- Adult day healthcare
- Homemaker and home health aide care
- Nursing home care in different settings
- Respite care
- Home-based primary care.
Program Of All Inclusive Care For The Elderly (PACE)
PACE offers social as well as medical services to senior citizens living at home. A team of expert healthcare professionals will offer coordinated care that prevents or delays your transition to a long-term care facility. You can enroll in the program if you fulfill the following criteria:
- You were 55 years old or older.
- You’re living in a PACE-eligible service area.
- You can leave safely at home with PACE services.
- Your state confirms that you need nursing home-level care.
PACE for dementia provides coverage for home care services, adult daycare programs, family and caregiver support services, rehabilitation services, and home health services. Medicare and Medicaid covers PACE services and care.
However, you cannot access PACE if you’re enrolled in the Medicare Part D Prescription plan or the Medicare Advantage plan. Those who are not eligible for Medicaid and move to a nursing home for long-term care would be charged a monthly premium ranging between $4000 and $5000 on average.You can use PACE program locator or PACE search tool to find an organization near you.
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Conclusion
To sum up, if you are wondering: ‘Does Medicare cover Home Health Care For Dementia’, then you would be happy to note that the program covers a few parts of dementia care, such as home health care, inpatient stays at skilled nursing homes, and medically necessary dementia diagnostic tests. Additionally, those living with dementia can be eligible for Medicare plans that are tailored for their health condition, like chronic care management services and special needs plans. People with dementia may need long-term care for their health condition; however, Medicare generally does not provide coverage for long-term care, but other programs like Medicaid can help you offset the cost of long-term care for dementia. We hope Medicare coverage for dementia patients clarified in this guide has been helpful for you.
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Frequently Asked Questions
How Much Does Medicare Pay For Alzheimer’s Care?
Medicare covers an average amount of $21,973 every year for patients with Alzheimer’s or other dementia. This amount is $7918 for those without Alzheimer’s or other dementia.
How Long Does Medicaid Cover Home Health Care For Dementia?
Medicare covers 35 hours of home healthcare every week for people with dementia who are certified as homebound.
Can A Dementia Patient Be Cared For At Home?
A lot of people with dementia continue to live at home if their condition progresses through the end of life. However, this may not be the right choice for everyone.
What Benefits Is A Person With Dementia Entitled To?
People with dementia are entitled to get a number of benefits such as retirement benefits, workplace pension, disability benefits and the benefits check up.
Does Medicare Pay For Nursing Home Care For The Elderly?
No, Original Medicare does not cover nursing home care or custodial care. But it covers skilled nursing home care or home health care for 100 days in a skilled nursing facility during every benefit period.
