As dementia progresses to its middle stages, a person’s need for care increases. Individuals with dementia may need help with activities of daily living, such as dressing, hygiene, meal planning, and the management of medication.

If you are the caregiver of an individual with dementia, you may be trying to keep your loved one in their home and community for as long as possible. But, as the caregiving demands increase, so does your need to bring in help. You may wonder if Medicare is a good starting place; does it pay for at-home professional dementia care?

Medicare Types and Coverage

There are four parts of Medicare: Part A, Part B, Part C, and Part D. Here are the covered expenses for each part which may occur in dementia care:

Medicare Part A (Hospital Insurance)

Includes limited home health care, hospice care, hospital inpatient stays, mental health inpatient stays, and skilled nursing facility stays.

Medicare Part B (Medical Insurance)

Includes doctor services, outpatient therapy, durable medical equipment (Dme), clinical laboratory services, home health services, outpatient mental health services, and partial hospitalization mental health services.

Medicare Part C (Medicare Advantage)

Provides coverage for Medicare Parts A and B, as well as extended services that are helpful for dementia patients, such as rides to doctor’s appointments, safety updates in the home, devices for mobility, limited non-medical home care, adult daycare, and some parts of living in a memory care facility.

Medicare Part D (Prescription Drug Coverage)

Covers most outpatient prescription drugs, including vaccines.

Medicare-covered services are paid at various rates depending upon the deductible due, coinsurance, and premiums that vary per plan.

Some dementia patients may qualify for a special needs plan (SNP) which is designed to provide targeted care and can cover some of the areas of need that Medicare Parts A-C does not cover.

Medigap is a resource that may cover costs where Medicare leaves off. A Medigap policy is health insurance sold by private insurance companies that can pay some of the costs that an Original Medicare Plan does not cover.

What Medicare Covers for Dementia Patients

Medicare does pay a portion of the medical expenses for dementia patients, but there are limitations. Here are some of the aspects of dementia care that Medicare will cover.

Medical, Physician, and Mental Care Services and Stays

Medicare covers inpatient care and doctor’s visits. It also pays for dementia screenings, cognitive testing, and other tests necessary for dementia diagnosis. Health laws in the United States require physicians to cover cognitive function screenings during the patient’s annual wellness visit.

Inpatient care includes stays and services provided while the patient is in the hospital or a skilled nursing home facility. There is no set time limitation for a hospital stay, but Medicare coverage for a skilled nursing home stay is limited to 100 days.

Individuals with dementia can experience mood changes, depression, or anxiety, which may be helped by mental health inpatient and outpatient services which are covered by Original Medicare (Medicare Part A and Part B).

Physical, occupational, and speech therapy can be beneficial to the well-being of a person with dementia and it is covered by Medicare Part B.

Home Safety

Home safety in any stage of dementia is important to the individual’s life protection. Part B Medicare covers home safety assessments when the evaluation is ordered by the patient’s primary care physician.

Advance Care Planning

Voluntary advance care planning is covered by Medicare Part B. This service includes discussions between the physician and the patient about end-of-life care options and wishes, and advance directives.

Intermittent Skilled Nursing Care

At-home intermittent skilled nursing care is covered up to 35 hours a week by some Medicare plans. The attending physician must coordinate with a certified home health agency, and the patient must be declared ‘homebound.’ The patient must be receiving home care under a plan that is regularly reviewed and updated by the physician.

The patient may be physically able to leave the home but may still qualify as homebound when they are psychologically unable to function outside of the home.

Hospice Services

Hospice is covered by Medicare when the patient’s physician certifies that they have six months or less to live.

Hospice care brings relief to both the patient and the caregiver in the late stages of dementia.

What Medicare Does Not Cover for Dementia Patients

In summary, Medicare does not cover:

  • Respite care (except for the adult daycare or intermittent skilled nursing care services mentioned above)
  • Custodial or non-medical care (such as cleaning, cooking, dressing, bathing, laundry, household rent, or shopping)
  • Long-term around-the-clock care (except for approved at-home intermittent skilled nursing care services for up to 35 hours per week, or care provided in hospitals and skilled nursing facilities – with a 100-day limitation)

Planning for Long-Term Care

We understand that planning long-term dementia care for your loved one can feel overwhelming, and the process can be exhausting.

Whether you are wondering At What Point Do You Need 24 Hour Care With Dementia?, or if you are in the Austin, Texas area and are looking for help with memory care options, we are here to assist you.

If you are in or plan to be in the Round Rock or North Austin, Texas area, we would love to help you with your questions! Contact us online or schedule a virtual tour online or call us at 512-399-5080.

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