Medicare Advantage Plans with Benefits Designed for Alzheimer’s & Dementia

Article Summary

Medicare Advantage Plans are changing dramatically for 2020 and 2021, and these changes are beneficial for persons who suffer the symptoms of Alzheimer’s disease or other dementias such as those that result from Parkinson’s or Huntington’s Diseases. The Chronic Care Act, passed by Congress in 2018, says private insurers who work with Medicare to provide healthcare through Medicare Advantage plans are legally required to expand their definitions of “supplemental benefits.”

Supplemental benefits used to be narrower in scope, such as eyeglasses or hearing aids, but did not include something like shower grab bars to prevent a fall. The expensive emergency room visit to put a cast on a broken bone following a fall would be covered by the plan, but the inexpensive grab bar that could have prevented the fall was not covered. That sort of inefficiency in the program is representative of what’s changing.

In 2020, options like meal delivery are becoming available, and enrollees can get money for preventative health help like humidifiers for the home. Medicare Advantage will even cover the costs of something like carpet shampooing for people with asthma, to reduce irritants in the air.

This is welcome news in the Alzheimer’s world where individuals require so much more assistance than simply medical care. Adult day care, 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 new 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. This makes it easier than ever to cater benefits to address specific needs.

What are Medicare Advantage Plans?

Since becoming law two decades ago, Medicare Advantage (also known as Medicare Part C) includes all the services offered by original Medicare, but supplements original Medicare with benefits including 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. About one-third of Medicare enrollees use Medicare Advantage, and that number continues to increase annually.
There have traditionally been six different types of Medicare Advantage Plans.

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, include 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:

Value-Based Insurance Design

A Medicare Advantage program being unrolled slowly beginning in 2020 is the Value-Based Insurance Design, or V-BID. 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 aren’t overpaying. Insurance companies working with Medicare are incentivized to look at healthcare in ways that are innovative both in care provided and cost.

V-BID plans are available in 30 states in 2020, and will continue expanding nationwide. Further, in 2021 the program will expand to weigh the economic status of enrollees more heavily, so someone who has a harder time affording care (including “dual-eligible” enrollees of both Medicare and Medicaid) would receive a broader range of assistance. Wellness and healthcare planning, to encourage habits which might prevent expensive medical needs down the road, will also be more broadly defined and covered. For more information, click here.

Institutional Special Needs Plans

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 expensive hospital visits. As with other types of Medicare Advantage programs, however, the definition of I-SNP is expanding.

In Minneapolis/St. Paul, for instance, almost 80 assisted living, memory care, and nursing communities are providing this new version of care management services through assisted living and memory care residences. Local care teams work with individuals in these communities to fill their specific needs. This partnership between the residence, insurance provider, and government could become a model in assisted living throughout the country. Already, the number of I-SNP plans offered nationwide have grown about 30 percent from year-to-year between 2018 and 2020.

Benefits of the New Medicare Advantage Plans for Alzheimer’s

Under the changes, Medicare Advantage becomes more about practical improvements to the lives of Alzheimer’s sufferers. The Centers for Medicaid and Medicare Services (CMS) says 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 the new Advantage is changing to reflect these needs. Hot meals, rides to doctor appointments, and around-the-house safety improvements should also be covered and can keep people living in their homes longer instead of being placed in nursing homes.

Home Modifications

An effective way to improve the life of a senior with Alzheimer’s or dementia is to make their home safer as memory, coordination, and balance become increasingly worse. The new 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.

Non-Medical Home Care

Something essential for a person with Alzheimer’s, but not necessarily medical, is companionship. This can be someone around simply for supervision, recreation, and conversation. It can also be more personal help, like a professional who bathes, dresses, and helps with using the bathroom or eating or exercising. And it can also be a homemaker, who handles chores like tidying up and preparing meals. These services will now be an option under Medicare Advantage.

Further, nutritionists are being covered, because of course 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 wellbeing, like the need for an air humidifier or pest control, these would count as long-term wellness expenses under Medicare Advantage. As MA expands, enrollees are encouraged to expand their own ideas about what steps can make a home healthier.

Adult Day Care

Adult day care is a win-win. Caregivers for people with dementia 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 counselling, healthy meals, activities, behavior management, and more. CMS directors have said the updates to Advantage will allow a plan to cover adult day care services.

Memory Care / Assisted Living

Memory care is an assisted living community with extra emphasis on helping persons with the unique challenges of advanced Alzheimer’s or dementia. 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 fortified 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.

Do All New Plans Have These Benefits?

No, not all new Medicare Advantage plans will have these benefits. Medicare Advantage plans have the option to cover these aspects of life with Alzheimer’s or dementia, but specifics of the 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 it’s updating interpretation of “supplemental benefits.” 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 can be paid for through Medicare Advantage.

Medicare Advantage Eligibility Requirements

Age – the basic requirements 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 a U.S. citizen or legal resident 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. One can find a Medicare Advantage plan using the federal government’s Medicare website.

Cost of a Medicare Advantage Plan

Medicare Advantage policyholders pay their standard Part B premium ($144.60 per month in 2020) and they pay their private insurance for the additional coverage. The additional coverage costs between $0 – $300 per month. The greater the benefits, the greater the costs, 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.