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Medicare

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If the person with Alzheimer's or dementia is a Medicare beneficiary, Medicare will pay for some, but not all, care costs.


About Medicare

Medicare is a federal health insurance program generally for people age 65 or older who are receiving Social Security retirement benefits or who are younger than 65 and received Social Security disability benefits for at least 24 months.

  • Medicare covers inpatient hospital care and some of the doctors' fees and other medical items for people with Alzheimer's or dementia who are age 65 or older. Medicare Part D also covers many prescription drugs.
  • Medicare will pay for up to 100 days of skilled nursing home care under limited circumstances. However, custodial long-term nursing home care is not covered.
  • Medicare will pay for hospice care delivered in the home, a nursing facility or an inpatient hospice facility for people with dementia who are determined by a doctor to be near the end of life.

Learn more: Medicare's website has information about eligibility and benefits.

Medicare updates: Changes in 2013

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During Medicare's annual open enrollment, we outline important Medicare changes that affect beneficiaries with dementia.

Changes in cost-sharing during the coverage gap under Part D
When your total prescription drug costs reach $2,970, your Medicare plan reduces the amount it pays for beneficiaries’ prescription drugs. This “coverage gap” (donut hole) is being phased out by 2020. In 2013, Medicare will pay 52.5 percent for brand drugs and 21 percent for generic drugs that are covered by the Part D plan. Some Part D plans provide additional payment in the coverage gap for drugs on its formulary.

Cost-sharing changes for mental health services
Beginning January 1, Medicare beneficiaries in original fee-for-service Medicare will pay 35% for outpatient mental health treatment. Medicare will pay 65% of the approved amount. Medicare’s payment for mental health services is being increased annually until 2014, when Medicare will pay 80% for these services, as it does for other Part B services.

New notice of non-coverage of Part D drugs at pharmacy
Beginning March 2013, the pharmacy must provide a Medicare beneficiary a written notice if the Part D plan denies payment of the drug. The notice will inform the beneficiary that the claim was denied and that the beneficiary should contact the Part D plan to request a coverage determination or to request an exception.

Special enrollment opportunity for “5-star” quality plans
From December 8, 2011 to November 30, 2013, Medicare beneficiaries will again have a one-time opportunity to enroll in a prescription drug plan or a Medicare Advantage plan that has received an overall 5-star (excellent) rating of quality from CMS, if a 5-star plan is available in the beneficiary’s state. The plan quality ratings can be found on the Medicare Plan Finder on the Medicare website. For the chart showing which Medicare national plans cover Alzheimer's drugs, click here.

Nineteen plans have received 5-star ratings for 2013. They are marked on the Medicare Plan Finder with a “gold star” icon. Eleven are Medicare Advantage (MA-PD) plans, four are Medicare Advantage-only plans, and four are stand-alone prescription drug (PDPs) plans.

Special Enrollment for beneficiaries affected by Hurricane Sandy
Many Medicare beneficiaries, and people who assist them, were affected by Hurricane Sandy and were unable to take advantage of the annual Open Enrollment Period to  make enrollment decisions for Part C and D for 2013. For that reason, CMS announced that individuals affected by Hurricane Sandy who were unable to make a plan selection by December 7 can still enroll in a health and prescription drug plan for 2013 by calling 1-800-MEDICARE (1-800-633-4227).

New Summary of Benefits Notices for Medicare
Medicare redesigned its “Medicare Summary Notices” (MSN) of benefits Medicare covered during the quarter. This new easy-to-read notice includes a list of all services covered under Part A and B during the quarter. It also includes information on how much the beneficiary is responsible to pay, how to appeal a decision and how to report possible fraud. The new notice is available online and by mail.

Reminder: Medicare covers an Annual Wellness Visit and Health Risk Assessment
Medicare pays for an Annual Wellness Visit once every 12 months. Prior to or during an annual wellness visit appointment, a Medicare beneficiary (or caregiver) will be asked by his or her doctor or health professional to complete a Health Risk Assessment (HRA).  The HRA includes some questions about the beneficiary’s health which may provide important information to discuss with the health professional during the annual wellness visit.

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Medigap

Medicare coverage can be supplemented with Medigap, a private insurance policy that covers copayments and deductibles required by Medicare. The more expensive Medigap policies may cover additional items.

Learn more: Medigap's website

Medicare managed care

Medicare Advantage (also called Part C) allows you to choose Medicare "managed care" in lieu of traditional Medicare, such as:

  • Medicare health maintenance organization (HMO)
  • Preferred provider organization (PPO)
  • Point of service (POS) plan

Medicare Advantage plans are offered by private companies approved by Medicare. These Medicare plans may provide services (such as dental and vision) not covered by traditional Medicare and usually have limits on which hospitals, doctors and other health care providers you can use.

Read each plan carefully. Learn about the many Medicare options and whether they are right for the person with dementia. You can also contact your State Health Insurance Assistance Program (SHIP) for free one-on-one help and publications.

Learn more: Medicare's website has information about Medicare managed care.

Special Needs Plans (SNP) for Alzheimer's disease

For 2013, there are two Medicare Special Needs Plans (SNPs) for individuals with dementia, including Alzheimer’s disease. SNPs are Medicare Advantage plans that specialize in care and coverage for beneficiaries with dementia. Only Medicare beneficiaries with dementia can enroll in these plans. They are:

  • Universal Health Care: Universal Secure Choice, an HMO available in 21 counties in Florida
  • Medica Complete Solution – Dementia, an HMO available in 22 counties in Minnesota

Help Is Available

Medicare.gov provides information about Medicare, open enrollment, benefits and how to find Medicare plans, facilities or providers. You also can call Medicare at 800.633.4227.

Ask Medicare is Medicare's site to help family caregivers access and use valuable health care information, services and resources.

Medicare Basics for Caregivers  is an online version of Medicare's booklet, "Medicare Basics: A Guide for Families and Friends of People with Medicare."

BenefitsCheckUp is an online tool that shows whether you are eligible for a variety of governmental programs.

Medicaid.gov provides information about Medicaid, including what it is and who qualifies for it.

Shiptalk.org offers information about the State Health Insurance Assistance Program (SHIP) in your state.

Medicare Rights Center is an independent, non-profit group that provides information and assistance for people with Medicare.

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