Does Medicare cowl dementia care?

“Dementia is a set of symptoms that show up as cognitive changes of sufficient severity to affect your daily activities, your daily function so you can no longer do what you formerly did because of your thinking skills,” says Dr. Ronald C. Petersen, PhD, MD, Director of the Mayo Clinic Alzheimer’s Disease Research Center and the Mayo Clinic Study of Aging, in Rochester, MN.

Dementia is on the rise in the U.S., with 14 million projected cases by 2060. Alzheimer’s is the most common form of dementia, representing 60-80% of all diagnoses. According to the Alzheimer’s Association, approximately 6.9 million Americans age 65 and older had Alzheimer’s in 2024, or 10.9% of those 65 and older.

Alzheimer’s, which affects memory and thinking skills, occurs when amyloids, naturally occurring proteins in the body, clump together to create amyloid plaques in the brain.

Other types of dementia that affect those over 65 include Lewy body dementia, brought on by abnormal deposits of the protein alpha-synuclein known as Lewy bodies, vascular dementia, created by conditions that damage blood vessels in the brain or interrupt the flow of oxygen and blood to the brain, and mixed dementia, a combination of at least two types of dementia.

Dementia patients have a variety of medical issues. “In addition to symptoms related to dementia, the overwhelming majority of dementia patients have one or more chronic health conditions,” says Matthew Baumgart, Vice President of Health Policy, at the Alzheimer’s Association.

Medicare (and Medicare Advantage) provide some coverage for dementia, beginning with the diagnosis, says Baumgart.

Diagnosing dementia

The annual Medicare wellness visit, free of charge to Medicare enrollees, includes cognitive assessments. If the doctor has any concerns, you may be referred to a specialist or another visit with your doctor for a clinical assessment to determine if you have a cognitive impairment. This appointment is covered under Medicare Part B, and a co-pay and/or deductible may apply.

During the assessment, “a doctor takes a history from the patient, as well as someone who knows the person well, to see if there’s been a change in memory, thinking, behavior, or function,” says Petersen. “The doctor will also conduct a mental status exam, which might include exercises asking the patient to remember words, do calculations, name the current president, draw a box, etc., to get a rough assessment of a person’s cognitive function,” he says. “If necessary, the doctor can do additional cognitive testing to get a closer look at memory, attention, language, visual-spatial skills. Then all of that information is put together and an assessment is made,” Petersen says.

Dementia care planning

Once a diagnosis of dementia is made, patients can live for many years, says Petersen. Over time, the symptoms will get worse, he says, which is why it’s important to create a care plan.

The Alzheimer’s Association was a strong advocate for Medicare dementia care planning coverage, and since 2017, Medicare Part B has paid for a standalone visit to a physician or specialist to create a care plan for those diagnosed with dementia.

A Dementia Care Plan can include recommended treatments and therapies for dementia symptoms and other health conditions, safety recommendations, caregiving support, end-of-life planning, and more.

Medications for dementia

While there is no cure for any type of dementia, medications may help lessen symptoms and/or prevent further cognitive diminishment.

All Medicare drug plans are required to cover at least two types of prescription medications known as cholinesterase inhibitors. These drugs treat Alzheimer’s disease by helping improve memory, attention, reason, and language and increasing the levels of brain chemicals to aid memory and judgment.

In 2023, lecanemab, sold under the brand name Leqembi, was approved by the FDA to treat mild cognitive impairment and mild Alzheimer’s disease. “The drug is intravenously infused into the veins, circulates into the blood, and goes into the brain and activates the immune system, to remove some of the amyloid plaques from the brain,” says Petersen.

Leqembi is covered by Medicare Part B, with the condition that a PET scan has confirmed the presence of amyloid plaques in the brain and that the patient is enrolled in a registry. The registry is a collection of evidence about how drugs work in the real world, which clinicians submit through a nationwide portal.

The cost of the PET scan, when used specifically to determine this condition, is covered by Medicare Part B, as of late 2023. Prior to this decision, Medicare only covered cerebrospinal fluid tests, which require a lumbar puncture, to determine amyloid plaque in the brain. Co-pays for diagnostic testing under Medicare are generally 20% of the cost, after the annual deductible.

In July 2024, donanemab, sold under the brand name Kisunla, received FDA approval. It is also an intravenous medication and is covered by Medicare with a PET scan confirmation of amyloid plaques in the brain, as well as enrollment by the patient in a registry.

Both Leqembi and Kisunla are covered by Medicare Part B, which means that Medicare beneficiaries do not have to enroll in Medicare Part D to have coverage of these prescriptions. enrollees still need to pay the 20% co-pay, and both medications are expensive. Leqembi’s cost, listed by its manufacturer, is $26,500 per year. The 12-month treatment cost of Kisunla, listed by its manufacturer, is $32,000.

The Inflation Reduction Act of 2022 may provide some relief. Beginning in 2025, the law will cap out-of-pocket Part D medication costs at $2,000. 

Medicare coverage of dementia-related long-term and personal care

“Sadly, Medicare doesn’t cover some critical services for dementia patients, including long-term care and personal care,” says Baumgart. Long-term care includes stays at assisted living facilities, adult daycare, and nursing home stays of more than 100 days, he says. Personal care includes help with activities of daily living, including making meals, and help with bathing and getting dressed.

“Medicare does provide skilled nursing home care coverage of specific skilled therapies, such as physical, occupational, or speech therapy, or occasional skilled nursing,” says Baumgart. A doctor must certify that the patient is homebound and needs this help, and it must be provided by a Medicare-approved home health agency, he says. 

If a dementia patient is enrolled in both Medicare and Medicaid, Medicaid may pay for some or all of the services not covered by Medicare. Medicaid may also pay for some or all of the premiums, co-pays, and deductibles of Medicare.

“Medicare does cover the very end stage of dementia—hospice care,” says Baumgart.

A new program that helps dementia patients

The government has two initiatives that are jumpstarting efforts to provide additional aid to dementia patients. These include the Biden Administration’s April 2023 Executive Order 14095 on Increasing Access to High-Quality Care and Supporting Caregivers and the National Plan to Address Alzheimer’s Disease,

One program that checks the boxes for both initiatives is the GUIDE model, which launched on July 1, 2024, as a Medicare pilot program.

“We’re excited about this,” says Baumgart. “It provides dementia patients and their caregivers with the ability to more seamlessly navigate the health care and social support systems,” he says.

The program will provide additional Medicare coverage of care coordination and care management, caregiver education and support, and respite services.

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