Does Medicare cover dementia care?

Kimberly Lankford,

AARP

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En español

Published August 01, 2023

/ Updated July 04, 2024

Yes, Medicare covers many dementia-related expenses, but coverage for care and treatment vary.

Medicare covers some types of screening and medical care for people with dementia and Alzheimer’s disease. And with restrictions, Medicare also covers several dementia medications and some newer drugs that can help slow the progression of Alzheimer’s.

But as the disease progresses, it doesn’t cover custodial care — the bathing, cleaning, cooking, dressing and walking assistance you may require to live life in the best health and with the most dignity possible.

Dementia refers to several types of neurological conditions that affect the brain and worsen over time. Alzheimer’s disease is the most common form of dementia, representing 60 to 80 percent of cases. But dementia comes in several other forms, too, such as frontotemporal dementia, Lewy body dementia and vascular dementia.

Does Medicare cover Alzheimer’s screening?

Since January 2011, Medicare has covered cognitive assessments as part of its annual Medicare wellness visit, which is a free preventive service not subject to the Part B deductible or coinsurance. During this exam, the doctor assesses your cognitive function through direct observation, discussion and often a memory test.

If your doctor finds anything out of the ordinary during that visit, rest assured that Medicare Part B also covers a separate visit with your regular doctor or specialist to review your cognitive function, confirm a diagnosis and establish a care plan. That secondary visit is subject to the Part B deductible and 20 percent coinsurance.

No single test can determine if a person is living with Alzheimer’s or another form of dementia. Doctors use diagnostic tools combined with medical history and other information — including blood or cerebrospinal fluid tests; brain imaging such as computed tomography (CT), magnetic resonance imaging (MRI) and positron emission tomography (PET) scans; cognitive and functional assessments; and neurological exams — to diagnose Alzheimer’s, according to the Alzheimer’s Association.

Medicare Part B usually covers diagnostic testing, which is subject to a deductible and 20 percent coinsurance. But it may require you to meet additional conditions before it will cover the tests.

For example, a PET scan can help show if beta-amyloid plaques or tau tangles are present in the brain, a marker of Alzheimer’s. Previously, Medicare only covered one brain amyloid PET scan per lifetime for those enrolled in a clinical trial, but the Centers for Medicare & Medicaid Services (CMS) eliminated those limits in October 2023.

This rule change is significant because Medicare requires patients to show evidence of amyloid plaques before covering some of the newer Alzheimer’s medications, such as Leqembi, which received full FDA approval in July 2023.

Medicare also covers care planning with a medical professional for people who have cognitive impairment, a change that started in 2017. Care planning provides Medicare beneficiaries and their caregivers information about medical and nonmedical treatments, clinical trials and support services available within the community.

People who receive proper care planning are shown to have fewer hospitalizations and emergency room visits and better medication management, the Alzheimer’s Association says.

Does Medicare cover Alzheimer’s drugs?

Medicare Part D covers many medications that people with dementia and Alzheimer’s disease take. All Medicare Part D plans must cover at least two cholinesterase inhibitors in their formularies, according to the Alzheimer’s Association.

These medications are prescribed to treat symptoms related to judgment, language, memory and other thought processes. They help prevent the breakdown of acetylcholine, a chemical messenger important for learning and memory, and support communication among nerve cells.

Be sure to compare costs for your medications for plans available in your area during open enrollment each year. Also check if a plan has restrictions on coverage for the drug, such as requiring prior authorization or step therapy.

Medicare covers some drugs for patients with Alzheimer’s or dementia under Part B if a health care provider administers them intravenously. It covers Alzheimer’s treatments that have full, traditional FDA approval but not those that have gone through accelerated FDA approval or are available via other special provisions. That limits the Alzheimer’s drugs covered, especially newer types of Alzheimer’s medications that can help slow the progression of the disease.

Now that the FDA has given full approval to Leqembi (lecanemab) and Kisunla (donanemab), Medicare will cover those medications under Part B. The drugs are subject to the 20 percent Part B coinsurance, which could be covered by a Medigap policy or other supplemental plan.

But before Medicare covers Leqembi and Kisunla, you must first meet certain requirements:

Be diagnosed with mild cognitive impairment or mild Alzheimer’s disease dementia and have documented evidence of beta-amyloid plaque on the brain.

Use a physician who participates in a qualifying registry, which collects information from providers and has an appropriate clinical team and follow-up care.

Centers for Medicare and Medicaid Services actuaries estimate that Leqembi could cost the original Medicare program about $550 million in 2024, with the potential for costs to rise to $3.5 billion for original Medicare and Medicare Advantage in 2025.

Does Medicare cover nursing home care for dementia?

No. This is one of the big gaps in Medicare.

Medicare doesn’t cover custodial care — help with the activities of daily living, such as bathing, dressing and eating — in a nursing home, assisted living center or memory care unit if that’s the only care you need. It provides coverage for up to 100 days in a skilled nursing facility for rehabilitation after a three-day inpatient hospital stay if you need daily skilled nursing, occupational therapy or physical therapy related to the hospital stay.

But Medicare won’t cover the long-term care that many Alzheimer’s and dementia patients need as their condition progresses.

Medicare provides limited home care coverage if you meet specific requirements. To qualify, a doctor must certify that the person is homebound and requires skilled therapies or intermittent skilled nursing. A Medicare-certified home health agency under the doctor’s plan of treatment must provide the care.

Does Medicare cover hospice care for dementia?

Yes. Medicare covers end-of-life hospice care for people with dementia or Alzheimer’s disease. A doctor must certify that you have a life expectancy of six months or less.

You can receive hospice care at home or at an inpatient hospice center or a nursing home or other facility. It provides comfort rather than treatment for the illness.

If you qualify and choose to receive hospice care, Medicare will cover most everything you need for comfort care, including doctor services and nursing care, drugs to help control your pain, medical equipment and support for your caregivers. However, when you are on hospice, Medicare will not pay for treatment that is intended to cure your illness.

Be aware that palliative care, another name for pain and symptom management, is totally covered when you’re enrolled in hospice. If you’re not in a hospice program, the palliative care services of physicians and other licensed practitioners may be covered under Part B and subject to the deductible and 20 percent copayment.

Keep in mind

If you choose a private Medicare Advantage plan, sometimes known as Medicare Part C, rather than original Medicare, you’ll have the same coverage as Medicare Part A and Part B but with different out-of-pocket costs. You may also have additional prior authorization requirements before receiving certain services or medications. The Medicare Advantage plan may provide additional coverage, such as meal delivery and transportation to doctor’s appointments. Some plans also provide caregiving support and in-home support services for activities of daily living and housekeeping tasks that you may have trouble continuing to do.

Medicare Advantage plans usually have a provider network, which means you may not have coverage or you may have to pay more if you use any out-of-network doctors or facilities. Make sure your neurologist and other doctors are covered in the plan’s network and check on the plan’s coverage for your medications.

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Kimberly Lankford is a contributing writer who covers Medicare and personal finance. She wrote about insurance, Medicare, retirement and taxes for more than 20 years at Kiplinger’s Personal Finance and has written for The Washington Post and Boston Globe. She received the personal finance Best in Business award from the Society of American Business Editors and Writers and the New York State Society of CPAs’ excellence in financial journalism award for her guide to Medicare.