Medicare largely covers services focused on helping beneficiaries recover from acute illnesses or injuries. As a result, beneficiaries with Alzheimer’s disease and related dementias who have significant chronic care needs may not qualify for some benefits.
Although Medicare will cover for the diagnosis, evaluation and some treatment of Alzheimer’s disease, including inpatient hospital care and portions of the doctor’s fees, Medicare will not cover:
- Prescription drugs: There’s a special prohibition on certain drugs often prescribed to cope with mental health issues, even with a physician's prescription. The only coverage Medicare provides for at-home medications is through a Part D prescription drug plan.
- Over-the-counter nutritional supplements.
- Adult day care: Medicare considers this “custodial care” as opposed to medical care.
- Respite care (except as described under the Part A hospice benefit).
- Personal aid assistance (except as provided under the home health care benefit).
- Long-term care in a nursing home: Medicare may pay for up to 100 days of care in a skilled nursing facility. It will cover 100 percent of the first 20 days. For 21-100 days, the beneficiary pays a daily coinsurance amount.
- Assisted living costs: These are not generally covered by Medicare, but the program may pay for short-term services such as physical and other therapies.
- Incontinence supplies.
- Experimental treatments.
Medicare may cover the following medical treatments, though it may sometimes deny payment for them. If these services are ordered by a doctor and provided by an appropriate provider, but Medicare refuses to pay for them, the beneficiary may appeal Medicare’s decision.
- Home health care: Home care coverage under Medicare is only available only if a patient is confined to the home and requires physical, occupation or speech therapy, or skilled nursing care, which will be provided from a home health agency under a doctor’s plan of treatment. Medicare might deny a claim for home health care because Medicare has determined that the beneficiary is not confined to the home.
- Rehabilitation care including physical, occupational, or speech therapy: Medicare might deny a claim for therapy if it is not shown that the beneficiary can benefit from the therapy.
- Mental health services: Part B can cover physical, occupational and speech therapy, as well as psychological counseling if prescribed by a doctor. The counseling must be provided by a Medicare-certified therapist or mental health provider. As with rehabilitation therapy, Medicare might deny a claim for mental health therapy if it is not demonstrated that the beneficiary will benefit from the mental health services.
- Hospice coverage: Medicare coverage is available for Part A beneficiaries, if a physician certifies that the patient is terminally ill (with a life expectancy is six months or less), and if the beneficiary chooses to receive hospice care.
Does Medicare Cover Long-Term Care, Skilled Nursing Facility Care and Nursing Home Care?
What Services Are Not Covered by Medicare?
What Does Part B Cover?
What Does Part A Cover?