What It Is
Medical services and care for patients with Alzheimer's disease
Medicare doesn't have a special category of coverage for Alzheimer's disease. And the single most important thing to understand about Medicare coverage for Alzheimer's patients is that Medicare doesn't pay for long-term care, whether in a nursing home, assisted-living facility, or at home. However, Medicare does cover some medical services of particular help to Alzheimer's patients. These include:
Therapeutic services. Medicare Part B covers outpatient physical, occupational, and speech therapy for an Alzheimer's patient. The treatment has to be prescribed by the patient's physician and be provided by a Medicare-certified therapist.
Psychological or disease-management counseling. Counseling by nonphysicians is not technically medical care, and normally Medicare doesn't cover it. But some Alzheimer's care specialists are clinical psychologists or medical social workers rather than physicians. Medicare Part B covers outpatient counseling concerning the management of Alzheimer's either from a physician or from a Medicare-certified psychologist, medical social worker, or other nonphysician provider. If the treatment is provided by a nonphysician, it must be prescribed by the Alzheimer's patient's doctor.
If you have a Medicare Part C Medicare Advantage plan: Medicare Part C Medicare Advantage plans, also called Medicare Advantage plans, must cover everything that's included in original Medicare Part A and Part B coverage. But sometimes a Part C plan covers more, with extra services or an expanded amount of coverage. (Co-payments for Part C plans may also be different than those for Part A or Part B plans.) To find out whether your plan provides extra coverage or requires different co-payments for Alzheimer's care, contact the plan directly.
If you have a Medicare Part D prescription drug plan: Medicare Part B doesn't cover drugs prescribed by a physician for outpatient use to manage symptoms of Alzheimer's. But if you're enrolled in a Medicare Part D prescription drug plan, such drugs are likely to be covered by that plan. For details of coverage and co-payments, check directly with the Part D plan itself.
What Medicare Pays
For outpatient physical, speech, or occupational therapy -- or for outpatient counseling services -- Medicare pays 80 percent of the Medicare-approved amount. For physical and speech therapy, there's a combined yearly cap of $1,810 on how much Medicare Part B will pay. For occupational therapy, there's a separate cap of $1,810.
Warning: The yearly caps on outpatient physical, speech, and occupational therapy don't apply if a patient receives the therapy at a hospital outpatient clinic rather than in a therapist's office or at home.
Important: Regardless of the rules regarding any particular type of care, in order for Medicare Part A, Medicare Part B, or a Medicare Part C plan to provide coverage, the care must meet two basic requirements:
The care must be "medically necessary." This means that it must be ordered or prescribed by a licensed physician or other authorized medical provider, and that Medicare (or a Medicare Part C plan) agrees that the care is necessary and proper. For help getting your care covered, see FAQ: How Can I Increase the Odds That Medicare Will Cover My Medical Service?
The care must be performed or delivered by a healthcare provider who participates in Medicare.