Age-related memory loss is common, but more serious memory problems can be a sign of it. dementiawhich is not a normal part of aging.
“Dementia is a set of symptoms that manifest as cognitive changes that are severe enough to affect your daily activities, your daily functioning, so that you can no longer do things that you used to do because of your thinking skills,” says Ronald C. Petersen, PhD, MD, director of the Mayo Clinic Mayo Clinic Alzheimer’s Disease Research Center and Study of Aging, Rochester, Minnesota.
Dementia is on the rise in the United States, with 14 million cases expected by 2060. Alzheimer’s disease is the most common form of dementia, accounting for 60 to 80% of all diagnoses. According to the Alzheimer’s Association, approximately 6.9 million Americans people aged 65 and over had Alzheimer’s disease in 2024, or 10.9% of people aged 65 and over.
Alzheimer’s disease, which affects memory and thinking skills, occurs when amyloidsproteins naturally present in the body clump together to create amyloid plaques in the brain.
Other types of dementia that affect people over 65 include Lewy body dementiacaused by abnormal deposits of the alpha-synuclein protein known as Lewy bodies, vascular dementiacreated by conditions that damage blood vessels in the brain or interrupt the flow of oxygen and blood to the brain, and mixed dementiaa combination of at least two types of dementia.
Patients with dementia have a variety of medical issues. “In addition to dementia-related symptoms, the vast majority of patients with dementia have one or more chronic health conditions,” says Matthew Baumgart, vice president of health policy at the Alzheimer’s Association.
Health insurance (and Medicare Advantage) offer some coverage for dementia, starting with diagnosis, Baumgart says.
Diagnosing dementia
The annual Medicare wellness visit, which is free for Medicare enrollees, includes cognitive assessments. If the doctor has concerns, you may be referred to a specialist or have another visit with your doctor for a clinical assessment to determine if you have cognitive impairment. This appointment is covered by Medicare Part Band a co-payment and/or deductible may apply.
During the assessment, “a doctor takes a history from the patient and asks someone who knows the patient well to check for changes in memory, thinking, behavior, or functioning,” Petersen says. “The doctor also does a mental status exam, which may include tasks that ask the patient to recall words, do math, name the current president, draw a picture frame, etc., to get a rough assessment of a person’s cognitive function,” he says. “If needed, the doctor may do additional cognitive testing to look more closely at memory, attention, language, and visual-spatial skills. Then all of this information is put together and an assessment is done,” Petersen says.
Care planning for people with dementia
Once diagnosed, patients can live for many years, Petersen says. Over time, symptoms worsen, making it important to have a care plan.
The Alzheimer’s Association is a strong advocate for Medicare to cover dementia care planning, and since 2017, Medicare Part B has paid for a stand-alone visit to a doctor or specialist to create a care plan for people diagnosed with dementia.
A Care plan for people with dementia may include recommended treatments and therapies for symptoms of dementia and other health conditions, safety recommendations, caregiving support, end-of-life planning, and more.
Drugs for dementia
Although there is no cure for any type of dementia, medications can help ease symptoms and/or prevent further cognitive decline.
All Medicare drug plans are required to cover at least two types of prescription drugs called cholinesterase inhibitorsThese drugs treat Alzheimer’s disease by helping to improve memory, attention, reasoning, and language and by increasing levels of chemicals in the brain to aid in memory and judgment.
In 2023, lecanemab, marketed as Leqembi, was approved by the FDA to treat mild cognitive impairment and mild Alzheimer’s disease. “The drug is injected intravenously into the veins, circulates in the bloodstream, and enters the brain to activate the immune system, to clear some of the amyloid plaques in the brain,” Petersen explains.
Leqembi is covered by Medicare Part B, provided a PET scan has confirmed the presence of amyloid plaques in the brain and the patient is enrolled in a program registrationThe registry is a collection of evidence about how drugs work in the real world, which clinicians submit through a national portal.
The cost of PET scanning, when used specifically to determine this condition, is covered by Medicare Part B, starting in late 2023. Prior to this decision, Medicare only covered cerebrospinal fluid tests, which require a lumbar punctureto determine amyloid plaque in the brain. Copayments for diagnostic tests under Medicare are typically 20% of the cost, after the annual deductible.
In July 2024, donanemab, sold under the brand name Kisunla, received FDA approval. It is also an intravenous drug and covered by Medicare with confirmation by PET scan of the presence of amyloid plaques in the brain, as well as the registration of the patient in a registry.
Both Leqembi and Kisunla are covered by Medicare Part B, meaning Medicare beneficiaries do not need to enroll Medicare Part D To qualify for coverage for these drugs, enrollees must still pay the 20 percent copayment, and both drugs are expensive. The cost of Leqembi, as listed by its manufacturer, is $26,500 per year. The cost of Kisunla for a 12-month course, as listed by its manufacturer, is $32,000.
THE Inflation Reduction Act of 2022 could provide some relief. Starting in 2025, the law will cap Part D drug costs at $2,000.
Medicare Coverage for Dementia-Related Personal and Long-Term Care
“Unfortunately, Medicare does not cover some essential services for dementia patients, including long-term care and personal care,” Baumgart says. Long-term care includes stays in assisted living facilities, adult day centers and nursing home stays of more than 100 days, he says. Personal care includes assistance with activities of daily living, including meal preparation, bathing and dressing.
“Medicare provides coverage for skilled nursing care in nursing homes for specific specialty therapies, such as physical, occupational or speech therapy, or occasional skilled nursing care,” Baumgart says. A doctor must certify that the patient is homebound and needs this assistance, and it must be provided by a Medicare-approved home health agency, he says.
If a patient with dementia is enrolled in both Medicare and Medical aidMedicaid may pay for some or all of the services not covered by Medicare. Medicaid may also pay for some or all of the Medicare premiums, copayments, and deductibles.
“Medicare covers the end stage of dementia: palliative care,” Baumgart says.
New program helps dementia patients
The government has launched two initiatives that jumpstart efforts to provide additional help to dementia patients. These include the Biden administration’s April 2023 proposal Executive Order 14095 on improving access to quality care and supporting caregivers and National plan to combat Alzheimer’s disease,
A program that ticks both boxes of initiatives is the GUIDE MODELlaunched on July 1, 2024 as a Medicare pilot program.
“We are excited about this initiative,” says Baumgart. “It provides dementia patients and their caregivers with the ability to more easily navigate health care and social support systems,” he adds.
THE program will provide additional Medicare coverage for care coordination and management, caregiver education and support, and respite services.
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