Medicare Advantage Plans changed dramatically beginning in 2020 and these changes have benefited people who have Alzheimer’s disease or another form of dementia. The Chronic Care Act, passed by Congress in 2018, makes private insurance companies that provide Medicare Advantage plans to expand their definitions of “supplemental benefits.”
Coverage for supplemental benefits used to be minimal, with things like eyeglasses and hearing aids being covered. There were no benefits for home improvement upgrades that prevent accidents. That means that items, like grab bars in a shower used to prevent a fall, would have to be paid out of pocket by the individual. That sort of inefficiency in the program is representative of what is changing. Preventing an accident costs less than treating a broken bone in the emergency room because of falling.
In 2020 new coverage options like meal delivery and preventative health help like humidifiers for the home. Medicare Advantage will even cover the costs of carpet shampooing for people with asthma, which reduces irritants in the air.
This is beneficial news to people with Alzheimer’s because they require more assistance than simply medical care. Adult daycare, in-home help with daily living activities like dressing and cleaning, palliative (pain-relief) care, installation of safety devices like grab bars and wheelchair ramps, and rides to doctor appointments are all potential benefits of Medicare Advantage plans. Assisted living residents, including people with dementia in memory care, are more and more finding that their communities can partner with healthcare providers to maximize the benefits under Medicare Advantage.
Since becoming law two decades ago, Medicare Advantage (also known as Medicare Part C) includes all the services offered by traditional Medicare but additionally covers emergency services and coverage for vision, hearing, and dental needs. Medicare Advantage is provided through the Medicare program by a private insurer working with the government. As of 2023, about half of Medicare enrollees use Medicare Advantage, and that number continues to increase annually.
There have traditionally been six different types of Medicare Advantage Plans. They are:
1. Health Maintenance Organization (HMO), which sets the monthly or annual fee while limiting coverage to doctors under an HMO contract.
2. Preferred Provider Organization (PPO) costs less if you use doctors and services within a plan’s network, and costs more for going outside the network.
3. HMO Point of Service (HMOPOS) allows flexibility to seek doctors outside an HMO network under specific circumstances. Medical care is coordinated through a primary care physician.
4. Private Fee-For-Service (PFFS) sets the costs paid by the insurer and the patient ahead of time.
5. Medical Savings Account (MSA) combines high-deductible plans with a special savings account.
6. Special Needs Plan (SNP) is designed for targeted care for persons with special needs. Special needs plans may be the best option for someone with Alzheimer’s disease, which the Centers for Medicaid and Medicare Services (CMS) includes among its “chronic diseases.” SNPs can establish long-term goals for care, including prescription drug coverage, and may be most applicable for people who reside in assisted living or memory care communities. For more, see Institutional Special Needs Plans below.
As Medicare Advantage continues expanding some newer models are being developed and unrolled across the country:
The Value-Based Insurance Design or V-BID is a Medicare Advantage program that began in 2020. These are health plans designed to further reduce costs by making it easier to access innovative services for seniors with chronic health conditions including dementia. Enrollees see their health plans tailored very specifically, from the start, to include the classic benefits of Medicare but also go further into benefits like meal delivery, transportation, and even devices to improve the home environment, such as humidifiers and cleaning to remove allergens. V-BID plans emphasize efficiency, aligning costs with services and comparing options so enrollees know that they are not overpaying. Insurance companies working with Medicare are incentivized to look at healthcare in innovative ways in terms of the care provided and cost.
As of 2023, V-BID plans are available in 49 states plus the District of Columbia and Puerto Rico. The program has continued to weigh the economic status of enrollees heavily, so someone who has a harder time affording care (including “dual-eligible” enrollees of both Medicare and Medicaid) receives a broader range of assistance. Wellness and healthcare planning, which encourage habits that prevent expensive medical treatments will also be more broadly defined and covered. For more information, click here.
As these programs become increasingly available, assisted living communities are getting in on the innovations. Institutional Special Needs Plans (I-SNP) have traditionally been offered in nursing homes, where Medicare Advantage has customized care through the residence to pay for services that prevent costly hospital visits. As with other types of Medicare Advantage programs the definition of I-SNP is expanding. An example of this is that memory care and nursing communities are providing this new version of care management services in their facilities. Local care teams work with individuals in these communities to fill their specific needs. This partnership between the residence, insurance provider, and the government is becoming a model in assisted living nationwide. As of 2023, there are 1,284 I-SNP plans offered nationwide covering a little less than 5 million Americans.
Under the new changes in Medicare Advantage, there are more practical improvements that benefit the quality of life of dementia patients. The Centers for Medicaid and Medicare Services (CMS) say that Medicare Advantage will cover Special Supplemental Benefits For Chronically Ill (SSBCI) enrollees if the item or service “has a reasonable expectation of improving or maintaining the health or overall function of the enrollee as it relates to their chronic disease.” This can be interpreted broadly, but it is meant specifically for sufferers of long-term illnesses like Alzheimer’s and other dementias. For years, home health care and caregivers have only been available outside Medicare, but Advantage plans have changed to reflect these needs. Hot meals, rides to doctor appointments, and around-the-house safety improvements can also be covered. This enables your loved one to continue living in their homes instead of being placed in a nursing home.
An easy way to improve the quality of life of your loved one with dementia is to make their home safer as memory, coordination, and balance worsen. Medicare Advantage Plans can cover home modifications such as:
– Updates to the bathroom, like transfer benches, bath steps, rail grabs, or a converted walk-in bath.
– Updates in the kitchen, like easy-grip cutlery and non-return straws.
– Devices for moving more comfortably, like walking sticks or wheelchairs.
– Identifiers, like signage and extra lighting that make it easier to get around and maintain bearings.
Companionship is something that all humans need but is not deemed medically necessary. This is especially true for someone with dementia. This can be someone around for supervision, recreation, and conversation. It can also be more personal help, like a professional who bathes, dresses, helps with using the bathroom, eating, or exercising. And it can also be a homemaker, who handles chores like tidying up and preparing meals. These services can now be an option with Medicare Advantage plans.
Additionally, nutritionists are covered because a smarter diet can contribute to improved health. And housekeeping matters as well; if your loved one has issues in the house that may affect well-being, like the need for an air humidifier or pest control, these would be considered covered long-term wellness expenses. As Medicare Advantage plans expand, enrollees are encouraged to expand their ideas about what steps can make a home healthier.
Adult daycare is beneficial for both caregivers and patients. Caregivers get a much-needed break to alleviate the symptoms of caregiver stress (mood swings, headaches, trouble concentrating or sleeping), and the person with Alzheimer’s or dementia gets a safe environment with counseling, healthy meals, activities, and behavior management. CMS directors have said the updates to Advantage will allow a plan to cover adult daycare services. As of 2023, there are 1,091 plans offering coverage for home support services like adult daycare in 43 states plus the District of Columbia and Puerto Rico.
Memory care is an assisted living community with extra emphasis on supporting Alzheimer’s and dementia patients. Memory care combines housing, support, and medical care, with staff specifically trained to help people with severely impaired cognition. Memory care communities are supervised 24 hours per day and monitored with safety devices (like locks and alarms) that prevent residents from being dangerous to themselves. Medications are carefully managed in memory care. Assisted living or memory care residences can be officially designated by Medicare Advantage as a person’s “home.” That means that while Medicare Advantage won’t cover the entire cost of staying in an assisted living or memory care community, it can potentially save a good deal of money on the overall cost by paying for small parts of living in one of these residences.
No, not all new Medicare Advantage plans will have these benefits. Medicare Advantage plans have the option to cover different things for someone who has Alzheimer’s or dementia. The individual plans differ because they are offered through private companies. Specifics can be fluid, so check with an insurer in your area about what options are available. Further complicating matters is the two-year rollout of the new Medicare Advantage and its updated interpretation of “supplemental benefits” that began in 2020. While the mandate to expand the definition of what MA covers has passed into law, it will unroll slowly, so check for updates on what is covered through Medicare Advantage.
Age – the basic requirement for any Medicare plan is that an enrollee must be 65 or older and enroll in Medicare Parts A and B.
Citizenship – persons must be U.S. citizens or legal residents for at least five years.
Geographic – there are no geographic restrictions but to receive an insurer’s Advantage plan, a person must live in an area that provides those benefits.
Financial – applicants cannot be denied coverage based on their income and assets. However, they must be able to afford their plan’s monthly premiums. Remember that the newer Value-Based Insurance Design (see above) is intended to find a low-cost/efficiency balance and help lower-income people get affordable options.
Health Status – by law, eligibility is not affected by the applicant’s health
The period for enrollment in Medicare is three months before to three months after turning 65. Miss this window, and there may be a penalty for late enrollment. Each year, there is also an open enrollment period starting in October and ending in December. It is easy to find a Medicare Advantage plan using the federal government’s Medicare website.
Medicare Advantage policyholders pay their standard Part B premium, which is $164.90 per month in 2023 and they pay their private insurance for the additional coverage. The additional average cost was $18, even though there can be free and more costly options that go up to $200 per month. In general, the greater the benefits cause the cost to rise, so one should assume that Medicare Advantage plans that cover the additional non-medical benefits discussed in this article will cost several hundred dollars per month. The costs will vary based on state, and private insurers may change the cost once per year.