As we age, occasional forgetfulness is natural, but significant memory issues might signal dementia, a serious condition that isn’t a normal part of aging.

What is Dementia?

Dr. Ronald C. Petersen, Director of the Mayo Clinic Alzheimer’s Disease Research Center, explains, “Dementia is a set of symptoms that manifest as cognitive changes severe enough to impact daily activities and functioning.”

Dementia is increasingly prevalent in the U.S., with projections suggesting 14 million cases by 2060. Alzheimer’s disease, the most common type, accounts for 60-80% of dementia cases. The Alzheimer’s Association estimates that in 2024, around 6.9 million Americans aged 65 and older were living with Alzheimer’s, representing 10.9% of this age group.

Types of Dementia

• Alzheimer’s Disease: Caused by amyloid plaques in the brain, it affects memory and thinking.
• Lewy Body Dementia: Characterized by abnormal protein deposits known as Lewy bodies.
• Vascular Dementia: Results from conditions that damage blood vessels in the brain.
• Mixed Dementia: A combination of multiple types of dementia.

Medicare Coverage for Dementia

Medicare provides some coverage for dementia, particularly starting from diagnosis.

Diagnosing Dementia

Medicare covers annual wellness visits, including cognitive assessments. If concerns arise, a more detailed clinical assessment may follow, covered under Medicare Part B. Dr. Petersen notes that these assessments include a detailed history and cognitive tests to evaluate memory, thinking, and functional abilities.

Dementia Care Planning

Following a diagnosis, creating a comprehensive care plan is crucial as symptoms worsen over time. Since 2017, Medicare Part B has covered standalone visits for developing dementia care plans. These plans include treatment recommendations, safety tips, caregiving support, and end-of-life planning.

Medications for Dementia

Though there is no cure for dementia, certain medications can alleviate symptoms. Medicare drug plans must cover cholinesterase inhibitors, which help improve cognitive functions. Additionally, recent FDA-approved drugs like Leqembi (lecanemab) and Kisunla (donanemab) are covered by Medicare Part B for patients confirmed to have amyloid plaques in the brain.

Costs and Coverage: Leqembi costs around $26,500 annually, while Kisunla costs about $32,000 per year. Beneficiaries are required to pay a 20% co-pay. From 2025, the Inflation Reduction Act will cap out-of-pocket Part D medication costs at $2,000 annually.

Long-Term and Personal Care

Unfortunately, Medicare does not cover most long-term and personal care services essential for dementia patients, such as:

• Long-term care: Stays in assisted living, adult daycare, and extended nursing home stays.
• Personal care: Assistance with daily activities like meal preparation and personal hygiene.

Medicare does cover certain skilled nursing care and therapies under specific conditions. Patients eligible for both Medicare and Medicaid may receive additional coverage for services and out-of-pocket costs not covered by Medicare.

Hospice Care

Medicare does cover hospice care for dementia patients in the final stages of the disease, providing critical end-of-life support.

Also read: How to Appeal a Denied Medicare Claim: A Comprehensive Guide

New Support Initiatives

The Biden Administration’s Executive Order 14095 and the National Plan to Address Alzheimer’s Disease aim to enhance support for dementia patients. Launched on July 1, 2024, the GUIDE model is a Medicare pilot program designed to help patients and caregivers navigate healthcare and social support systems more effectively. This program expands Medicare coverage to include care coordination, caregiver education, and respite services.

Conclusion

Navigating dementia care can be challenging, but understanding Medicare’s role and leveraging available resources can make a significant difference. For more detailed information and assistance, visit Clarah.co.

Please Note: This article aims to provide a comprehensive overview of dementia care coverage under Medicare. For personalized advice, consult a healthcare professional or a Medicare advisor.