Medicare and Alzheimer’s Disease

The Hawaii SHIP is repeatedly asked this question, “Does Medicare cover Alzheimer’s Disease?” Medicare’s coverage is based on “medically necessary” procedures, not disease diagnosis. For example, if I go to my doctor and he orders blood to be drawn to see if my medication is at a therapeutic level, Medicare would pay for both the doctor’s visit and the visit to the lab. A doctor’s examination and laboratory tests are covered whether the patient has Alzheimer’s disease (AD), cancer, epilepsy or other diseases.

Does Medicare cover…

HOME HEALTHCARE? This benefit is based on a prescription from your physician for a medical reason and it is not for 24-hour care. If you just need someone to keep an eye on Mom while you are at work, it is not a medical need and it would not be covered by Medicare. If Mom fell and broke her leg and was in a non-weight bearing cast, she might need home care for a short time to assist with bathing or physical therapy in the home. These services would be covered whether Mom has AD or not.

LONG-TERM CARE? Not covered by Medicare. Medicare has a “skilled nursing facility care” benefit, but it is again based on medical necessity. Eligible skilled care must follow a hopital stay of three or more days–that is admission to an inpatient hospital, and care must be at a skilled level. Your doctor must certify that you need the daily services that can only be provided by licensed nursing or therapy personnel.

PRESCRIPTIONS? Medications that are needed to assist in the treatment of AD will be covered under Medicare Part D (or through your Medicare Health Plan if it includes Part D). We suggest that you always take your Part D plan formulary booklet with you to your physician visit to make sure that the drug that is prescribed is under your plan formulary. If the medication is not covered by the plan and your physician says that it is medically necessary, you and your physician can appeal to the plan and ask them to cover it for you. There are five levels of appeals (so “no” does not mean “no” until the fifth level).

Medicare Health plans are required to cover all the Medicare A & B benefits, but may have different co-pays and added benefits. Be sure to study your “annual explanation of benefits” that you receive each fall from your plan.

The answer is that Medicare covers medical needs and medication. Custodial care and longterm care sometimes required for AD and patients with other chronic diseases are not covered. Whenever you have questions on Medicare coverage, Hawaii SHIP has the answers

HAWAI‘I SHIP (State Health Insurance Assistance Program) 1-888-875-9229 | 808-586-7299 help@hawaiiship.org | www.hawaiiship.org facebook.com: Hawaii SHIP

This SHIP project was supported, in part, by grant number 90SA0004-02-00 from the U.S. Administration for Community Living, Department of Health and Human Services, Washington, D.C., 20201. Grantees undertaking projects under government sponsorship are encouraged to express freely their findings and conclusions. Points of view or opinions do not, therefore, necessarily represent official Administration for Community Living policy.