Does Marketplace health insurance cover Alzheimer’s disease?

What is Alzheimer’s disease?

Symptoms of Alzheimer’s include memory loss, confusion, difficulty with familiar activities, and trouble finding words. The person with Alzheimer’s may forget information they just read and may experience mood changes, such as becoming quickly upset in common situations. As Alzheimer’s disease progresses, symptoms worsen, and the affected person may lose the ability to care for themselves, communicate, recognize loved ones, and function independently.³

There is no single, definitive test that can diagnose Alzheimer’s disease. Instead, a comprehensive medical workup is required for an accurate diagnosis.

What is early-onset Alzheimer’s disease?

While most cases arise after age 65, a much less common form⁴ called early-onset Alzheimer’s affects people in their 40s and 50s.⁵ And because early-onset Alzheimer’s is unusual, symptoms of memory loss and cognitive changes may initially be incorrectly attributed to high stress or other medical conditions

In some cases, early-onset Alzheimer’s results from rare inherited genetic mutations – known as familial Alzheimer’s disease. People who develop Alzheimer’s due to genetic mutations often begin experiencing cognitive symptoms in their 30s, 40s, or 50s, and multiple relatives across generations may be affected.

Regardless of the cause, individuals with early-onset Alzheimer’s can be in any stage of the disease, such as early, middle, or late stage. Each stage is characterized by varying degrees of cognitive decline and functional impairment.⁵

How do Marketplace health plans cover care of Alzheimer’s disease?

Under ACA, Marketplace health plans must cover the 10 essential health benefits. These include medical care that patients may need in various stages of the disease. Here are some examples of how Marketplace plans cover Alzheimer’s disease:⁶

• Office visits for medical evaluation and management are generally covered as essential health benefits under ACA-compliant plans. For example, a primary care physician can conduct an initial assessment of symptoms like memory loss and confusion. The physician may also coordinate referrals to specialists, such as neurologists, psychiatrists, or psychologists, for further evaluation.⁷ While Marketplace plans would generally cover these services, a policyholder’s out-of-pocket costs (deductible, copayment, and coinsurance) will vary based on the plan.
• Medically necessary diagnostic tests to evaluate and diagnose Alzheimer’s disease are also covered under Marketplace plans. These may include brain imaging studies like magnetic resonance imaging (MRI) and computed tomography (CT) scans. Cognitive and neuropsychological assessments and blood tests would also be considered essential health benefits under the Mental Health and Substance Use Disorder Services and Laboratory Services categories.⁸ Keep in mind some plans may require a prior authorization for diagnostic tests, and medical necessity criteria may have to be met for coverage.
• While there’s no cure for Alzheimer’s, many FDA-approved drugs can manage symptoms or slow the progression of the disease.⁹ Prescription medications are one of the essential health benefits covered by Marketplace insurance plans. Some ACA-compliant plans may cover additional Alzheimer’s medications based on the state’s benchmark plan, which serves as a model to determine the minimum coverage requirements within a state. Individual and small group Marketplace plans must cover at least one medication in every drug category and class, including the three classes of antidementia medications. Each plan has a list of approved medications, called a formulary, so it’s important to check whether your plan covers your medications. Health plans may categorize the same Alzheimer’s medication in different tiers, which means out-of-pocket costs may vary between plans.
• Inpatient hospitalization is included as an essential health benefit. If a patient requires hospitalization for medical reasons or to manage behavioral symptoms, hospitalization would be covered under ACA-compliant Marketplace plans. However, the specifics of coverage and out-of-pocket costs vary by plan.
• Essential health benefits include rehabilitative and habilitative services, such as physical therapy and occupational therapy. These services can help people in any stage of Alzheimer’s disease maintain mobility and perform activities of daily living for as long as possible.¹⁰ Depending on the state in which a policyholder lives, there may be variations in the number of visits and the type of services covered under the list of essential health benefits.
• ACA-compliant plans will generally cover medically necessary care received in a skilled nursing facility, such as for rehabilitation after a hospitalization. Plans also cover some home health services (skilled nursing care, but generally not custodial care for assistance with activities of daily living), and hospice care. The term custodial care refers to help with activities of daily living, such as bathing, dressing, and eating, which is not considered medical care.¹¹ But, similar to rehabilitative services, the number of visits or number of days covered vary with each plan.

Does Marketplace insurance cover care for early-onset Alzheimer's disease?

Health plans, including ACA-compliant individual market plans, generally cover medical care costs related to Alzheimer’s disease, whether early-onset or late-onset Alzheimer’s. Medically necessary office visits, medications, lab work and imaging are included in the essential health benefits and are thus covered by all Marketplace plans.

The specifics of the coverage will depend on the type of care the patient needs, the state in which they live, and the plan details. However, coverage of long-term care – which involves non-medical services, either at home or in a facility – is generally excluded. And unfortunately, custodial care tends to be the largest expense for people with Alzheimers.¹²

Here are some key points to keep in mind:

• The Affordable Care Act (ACA), commonly referred to as Obamacare, requires all ACA-compliant health plans – purchased through the Marketplace or off-exchange – to cover 10 essential health benefits (EHB) categories. These include outpatient care, hospitalization, prescription medications, mental health services, and more. For example, visits with medical professionals, hospital stays, and some prescription medications used to manage early-onset Alzheimer’s would be included in the essential health benefits.
• Coverage for services can vary between states. States decide the details of what’s covered within the 10 essential health benefit categories. They base this on a “benchmark” plan. Some states mandate benefits beyond the EHB, while some may limit the number of covered services.¹³ For example, a state can decide how many physical or occupational therapy visits a plan must cover per year.
• Under the ACA, Marketplace plans are required to cover pre-existing medical conditions. This means that no ACA-compliant plan can deny coverage, charge extra, or refuse to cover essential health benefits for any pre-existing condition (a medical condition the policyholder had before applying for insurance coverage). Additionally, after enrollment, the plan cannot deny coverage or increase premiums based only on the enrollee’s health condition.¹⁴ This applies to conditions like Alzheimer’s disease and early-onset Alzheimer’s disease.

What Alzheimer’s care is not covered under Marketplace plans?

Under the ACA, any Alzheimer’s care that isn’t defined as an essential health benefit or is not considered medically necessary is typically not covered.

For example, memory care facilities provide specialized dementia care, activities, and a safe environment to support people living with Alzheimer’s disease or other types of dementia. However, the care is largely custodial rather than medical. Custodial care, which primarily involves assistance with activities of daily living, is generally not considered medically necessary or classified as an EHB under the ACA, which means it is generally not covered under Marketplace plans.¹⁵ The same is true for custodial care received in an assisted living, nursing home, or long-term care facility, or at the patient’s home.

ACA-compliant plans generally don’t cover adult daycare. Adult daycare centers provide structured programs, activities, and supervision for people with Alzheimer’s who need daytime support and engagement and are not defined as medically necessary under the ACA.¹⁶

Certain specialty Alzheimer’s medications may not be included in an ACA plan’s formulary, meaning the drugs may not be covered by the insurance. This can happen if the plan determines that there are other more cost-effective drug options available or if the medication is so new that it hasn’t been added to the plan’s formulary yet. In this case, a policyholder may be able to contact the insurance plan directly to ask for a formulary exception.

A formulary exception is a decision by the insurance company to cover a medication that is not on its drug-covered list. The prescribing provider will typically need to write a letter of medical necessity to the carrier explaining why the medication is needed. If the formulary exception is denied, the policyholder has the right to appeal, asking the health plan to reconsider its decision. Contact the health plan to ask about its appeal process requirements, including the timeline for filing an appeal.

Working with the prescribing doctor to find alternative medications covered in the plan’s formulary is another approach.

Contacting the drug manufacturer directly is also an option. Some pharmaceutical companies offer patient assistance programs or coupons that help reduce the cost of medications.

Do Marketplace health plans cover memory care?

Marketplace plans do not include coverage for memory care services, which provides specialized care and support for individuals with Alzheimer’s or other forms of dementia. However, there are financial relief options for those who need these services:

• Individuals who meet certain criteria can apply for Medicaid to help with memory care expenses. Income limits apply (and asset limits if you’re 65 or older), and the extent of coverage varies based on state rules.¹⁷ If a Medicaid enrollee is 55 or older and receiving Medicaid-covered long-term care services, federal rules require the Medicaid program to recoup the cost of that care from the person’s estate after they die, if possible.¹⁸
• Veterans and their spouses 65 and older may access the Aid and Attendance Benefit, a monthly financial assistance program provided by the Department of Veteran Affairs (VA), to help pay for long-term expenses, including memory care.¹⁹
• Private long-term care insurance helps cover custodial care costs – including memory care – when a condition such as Alzheimer’s disease leaves you unable to care for yourself. These policies have to be purchased prior to diagnosis.²⁰
• Life insurance policies with long-term care riders may be an option. A long-term care rider is a feature added to a life insurance policy that allows you to access part of the death benefit while you’re still alive. This fund can be used to cover long-term care costs, such as memory care.²¹

Can I get Medicare if I have early-onset Alzheimer’s disease?

Yes, you may qualify for Medicare before age 65, without ESRD or ALS, if you have early-onset Alzheimer’s disease. However, you must meet certain eligibility requirements.²²

To receive Medicare benefits before age 65 (or without ESRD or ALS), you must have been receiving Social Security disability benefits for 24 months. In this case, if you have early-onset Alzheimer’s, you can apply for Social Security disability income (SSDI). If approved for SSDI, after a 24-month qualifying period, you would become eligible for Medicare even if you’re under 65 years old.²²

Medicare provides many benefits for people with Alzheimer’s disease, including coverage for healthcare provider office visits, hospitalizations, and diagnostic tests.

Medicare Part B covers certain durable medical equipment a person with Alzheimer’s disease might need, such as a commode chair or a walker. Prescription medications for managing Alzheimer’s symptoms can be paid through a separate Medicare Part D plan.

It’s worth noting that Medicare does not cover long-term care or custodial care. But if a Medicare beneficiary is also eligible for Medicaid (meaning their income and asset/resource levels are within their state’s eligibility limits), the Medicaid coverage can be used for custodial care.