New Medicare Advantage Rules Increase Benefits for Alzheimer’s and Dementia Care

Last Updated: March 26, 2019

Article Summary

Medicare Advantage Plans are changing dramatically for 2019 and 2020, 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.

Much of the care that now can be provided under Medicare Advantage programs is decidedly non-medical and 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.


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, 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 are 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 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.


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 now cover supplemental benefits 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.

 Crucially, if a person with Alzheimer’s or dementia moves into assisted living or memory care, many of the new Medicare Advantage benefits will move with them.


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.


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 however 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.
Health Status – by law, eligibility is not affected by the applicant’s health


 By law, eligibility is not affected by health, therefore someone who has Alzheimer’s or other dementia cannot be denied access to Medicare Advantage for that reason.


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 ($135.50 per month in 2019) 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.