What Caregivers Should Know About Medicare and Alzheimer’s

by Mary Jane Stern

When my husband and I were living in New England we met a wonderful couple, Morley and Ruthie.  At that time, Morley was 94 and Ruthie was 78, a second marriage for both. Morley was a dedicated husband and took wonderful care of Ruthie who had Alzheimer’s disease.

Of course both were on Medicare, but during this time Medicare did not cover any type of mental health services, home healthcare or even hospice care when a person was diagnosed with Alzheimer’s disease.  Most people with this disease were denied coverage.

During 2001 a new policy went into effect and became public during 2002 where Medicare covers “reasonable and necessary” doctors’ visits; physical, occupational or speech therapy, psychotherapy or behavioral management therapy by a mental health professional, and skilled home-care services for nursing, speech or physical therapy.

Alzheimer’s experts believe this rule helps people with this disease stay at home longer.  But, for caretakers it can be extremely worrisome and exhausting and there isn’t any coverage for adult day care or room and board at assisted living facilities.

If you are a caregiver you need to understand that the program doesn’t have a special category of coverage for Alzheimer’s, like they do for Diabetes.  It doesn’t pay for long-term care, whether they are in a nursing home, assisted-living facility or at home.  There has been no expansion of coverage since 2001. Here is a list of items they will cover under Part A, B and D.

• Evaluation and diagnosis – Medicare Part B
• Doctors’ visits for treatment of Alzheimer’s - Make sure the doctor’s office uses code 331 (Alzheimer’s disease) versus code 290 (pre-senile dementia).  The difference is Medicare will only cover 50% of the charge for code 290, but Code 331 is the 80/20 payment.
• Psychiatric services – Generally they will not cover counseling for Alzheimer’s disease, but they will cover some of the psychological conditions that are associated with the disease like depression, aggression, and agitation.
• Prescription drugs - This is covered under Part D and all Part D drug plans are required to have at least two cholinesterase inhibitors and the drug memantine on their list of covered drugs.
• Physical therapy - They will pay for physical therapy as long as it is “reasonable and necessary.” This must be a written plan of treatment from a skilled therapist, and if Medicare doesn’t think the therapy is working, the therapy can be terminated.  But you can appeal.
• Home health care – Pays for skilled nursing care. The program doesn’t cover home care unless a person is housebound.
• Caregiver training – This type of training may be useful for any caregiver looking for ways to make day-to-day activities less stressful.
• Hospice. Medicare does cover hospice care for anyone expected to die within six months.

Medicare really doesn’t pay too much for this disease and it’s up to the family to pitch in and be the caregivers. The Alzheimer’s Association continues to advocate for expanded Medicare coverage for Alzheimer’s disease and they believe with increased home care it could actually save money in the long run .

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