Healthcare Watch: Preparing for the price of Alzheimer’s disease
For seniors and their families, Alzheimer’s disease and its hefty price tag are an increasingly scary prospect.
About 5.4 million Americans are affected by Alzheimer’s disease, making it the sixth leading cause of death in the United States. Because of growing life expectancies and aging baby boomers, that number is expected to triple by 2050.
Alayna Tillman’s mother and aunt both have Alzheimer’s disease and live with Tillman, her husband and two sons in Lake View Terrace.
Tillman says Medicare pays for many of the medical costs her mom and aunt incur. But other services, such as home care or adult day care, are left to the family to pay. “Unless you can afford to pay $90 a day for adult day care, there’s nothing for them to do during the day,” she says.
An in-home worker to help her aunt get dressed in the morning costs $50 to $200 a day. “Every penny of her Social Security check goes to the home care agency,” Tillman says.
A recent study by the Alzheimer’s Assn. estimates that the cost of the disease per patient is nearly $57,000 a year, 60% of which falls on a family’s shoulders. Given that roughly 90% of all Alzheimer’s patients are over 65, they and their families rely on Medicare and other insurance to cover costs.
So it’s vital for patients and their families to understand what Medicare does and doesn’t pay for as a part of long-term financial planning. Experts offer some guidance and suggestions about common pitfalls to avoid.
•Doctor visits and other outpatient medical services are covered. Visits to primary care doctors and specialists, physical and speech therapists, lab tests and more generally are paid for by Medicare Part B. That includes an entitlement under the health reform law for a free annual wellness visit, which includes a medical evaluation of changes in a person’s thinking abilities.
With traditional Medicare, patients pay 20% of the cost of outpatient visits, says Fred Riccardi, director of programs and outreach with the Medicare Rights Center in New York. Supplemental insurance, such as Medigap plans, can help cover that extra cost.
If you have Medicare Advantage, which typically covers hospitalization, outpatient care and prescription drugs under one plan, make sure your doctors are in your insurer’s network to avoid excess costs. Also find out whether you need a referral or prior authorization before getting care.
•Drugs usually are included. Most medications for people with Alzheimer’s are covered by Medicare Part D prescription drug plans.
People should make sure the drug their doctor wants them to take is covered by their insurance and that they know the co-payment, says Judith Stein, executive director of the Center for Medicare Advocacy, a Connecticut-based education and advocacy organization.
Also, know your plan’s rules regarding pre-approval, and make sure your local pharmacy is in the plan’s network.
If you or your loved one take a lot of medications, the challenge is to find the plan that covers the majority of them, says Beth Kallmyer, vice president of constituent services with the Alzheimer’s Assn.
And be sure to review the plan’s list of covered drugs every year as policies change. “It is something that adult children or other family members can do to help make the right choices based on medications,” Kallmyer says.
You can compare Part D drug plans and their costs by using the Medicare Plan Finder tool at https://www.medicare.gov/find-a-plan. The Alzheimer’s Assn. also offers a coverage guide for common Alzheimer’s drugs at https://www.alz.org.
•Medicare won’t pay for long-term nursing home care. Families are often dismayed to learn that they must shoulder the cost of a long-term stay in a nursing home, Kallmyer says.
“The thing about Medicare is it does not provide custodial services, which is really what people with Alzheimer’s disease or dementia require,” she says. Custodial services include help getting dressed, bathing and eating.
Medicare will pay for some shorter-term nursing home care, but only up to 100 days following a three-day inpatient hospital stay.
Be careful, Stein says: A common practice is to hospitalize patients for several nights in what’s called an observation unit, which is considered outpatient care. Unless you’re hospitalized as an inpatient, you won’t qualify for needed nursing home care after your hospital stay.
Also available is long-term-care insurance, but a policy must be purchased before you become ill. You can find an insurance agent to help you with your long-term-care insurance options by visiting the website of the National Assn. of Health Underwriters, at www.nahu.org.
•Medically necessary services provided in your home are sometimes covered. Also a surprise is that at-home care can be available on a long-term basis. “Medicare would have you believe that the home care benefit is short-term, but that’s not true. With home care, there are no time constraints,” Stein says.
At-home care doesn’t need to occur every day, but it does need to be scheduled on a regular basis — even once a week can be enough to get coverage. The key is whether skilled healthcare workers, such as a nurse or therapist, are needed.
However, Stein says, people with Alzheimer’s often don’t need a nurse and so are unable to get financial assistance for the help they need to stay at home.
•Help is available. For more information about Medicare benefits for Alzheimer’s disease, check with the State Health Insurance Assistance Program in your state for free and unbiased help. (California’s programs can be found at https://www.aging.ca.gov/hicap.) Find your local program by visiting the Medicare Helpful Contacts page at https://www.medicare.gov/contacts or by calling (800) MEDICARE ([800] 633-4227).
The Alzheimer’s Assn., the Medicare Rights Center and the Center for Medicare Advocacy all provide information about Alzheimer’s and other long-term conditions.
The best defense is understanding your benefits and preparing for the future possibility of illness, Riccardi says. “People are often surprised by the sheer expense of paying for care when it’s not covered by Medicare or when they haven’t planned for later on in life.”
Zamosky writes about healthcare and health insurance.
