(Alzheimer’s Foundation of America) The AFA was founded by a consortium of organizations to fill the gap that existed on a national level to assure quality of care and excellence in service to individuals with Alzheimer’s disease and related illnesses, and to their caregivers and families.
This post describes the government programs and resources that can help persons with Alzheimer’s disease and their caregivers:
- Medicare Prescription Drug Coverage Benefit
- Compassionate Allowance
- Affordable Care Act
- Government Programs
Medicare Prescription Drug Coverage Benefit
Medicare provides prescription drug benefits to Medicare beneficiaries and those currently covered under Medicaid. The Medicare Part D Prescription Drug Coverage Benefit began in January 2006 under the Medicare Modernization Act of 2003.
Here are some important points for you to know:
Eligibility
Everyone with Medicare (Medicare Part A, Part B, and Medicare Advantage Plans) is entitled to the new prescription drug benefit. Individuals currently receiving drug coverage through Medicaid have been automatically enrolled, but others must sign up.
Enrollment
Enroll by calling 1.800.MEDICARE (1.800.633.4227) or visiting www.medicare.gov.
The open season for enrollment in the Medicare Part D prescription drug program runs from October 15 to December 7 of each year and takes effect on January 1 of the following year. This applies to newly eligible Medicare beneficiaries and current beneficiaries who are considering changes to their Medicare Part D plan.
Coverage begins on the first day of the month following the month you join.
Plans
Medicare has approved a variety of drug plans so it is important to explore your options and choose a plan that best fits your needs. The plans differ in terms of:
- Brand name and generic drugs covered
- Pharmacies and/or mail order companies that can fill prescriptions under the plan
- Costs, including premiums, deductibles and co-payments (see section on cost)
In addition, you can join a Medicare prescription drug plan, which covers only prescription drugs, or you can enroll in a Medicare Advantage Plan, which provides coverage for hospitals and doctors in addition to prescription drugs.
The number of available plans varies by state. In some states, a large number of plans have been approved; in other states, there are only a few options. In every state, each person will be offered a choice of at least two plans.
Cost
Enrollees pay a monthly premium, and the cost varies by plan. The average premium is $37 per month per person.
In addition, beneficiaries are responsible for:
- A co-payment—a dollar amount you pay to the pharmacy when you pick up your medication.
- A deductible —a portion of the cost of medications that are not covered by the prescription plan provider. Beneficiaries typically pay the deductible at the start of the year. Once you have paid the deductible, the benefits of the policy apply.
- Other cost sharing amounts—depending on the plan, some beneficiaries will be responsible for a portion of their medication costs when payments by the insurer reach a specific amount.
All of these amounts vary depending on the plan you chose. For instance, some plans cover more drugs, but have a higher premium.
Medicare will subsidize low-income beneficiaries. If you meet specific income and other requirements, you may qualify for a reduced premium or no premium at all, and you may not be responsible for any deductible.
Approved Medications
Formularies are a list of approved medications that are covered by the drug plan. It is important to review a plan to be sure your current medications will be covered.
The formulary must include at least two drugs in the categories and classes of the most commonly prescribed drugs to people with Medicare.
Some formularies will not cover all medications prescribed for Alzheimer’s disease, although each plan will cover at least two types.
There are procedures in place to ensure access to prescription drugs that a physician deems medically necessary, even if they are not covered under your prescription drug plan. If your doctor believes you need to take your current prescription and should not switch to a drug covered under your plan, you or your doctor can contact your plan and ask it to give you an “exception,” which means the plan agrees to pay for your current drug. If the plan refuses to give you an exception, you can appeal the plan’s decision. Your Medicare drug plan will send you information about its appeal procedures when you enroll.
To find a plan in your area that matches your required drug list, visit the Medicare Formulary Finder Web site; this tool allows you to review formularies by state and specific medication:
http://formularyfinder.medicare.gov/formularyfinder/selectstate.asp
Questions? Concerns? Ready to enroll? Here are some helpful links:
The Center for Medicare and Medicaid Services (CMS)
www.medicare.gov
1.800.MEDICARE (1.800.633.4227)
Medicare Today
www.medicaretoday.org
Medicare RX Education Network
www.medicarerxeducation.org
U.S. Social Security Administration
www.ssa.gov/organizations/medicareoutreach2
Access to Benefits Coalition
www.accesstobenefits.org
Kaiser Family Foundation
www.kff.org/medicare/rxdrugscalculator.cfm
Compassionate Allowance
The Social Security Administration’s (SSA) Compassionate Allowance process is a way of quickly identifying diseases and other medical conditions that clearly qualify for Social Security and Supplemental Security Income disability benefits. It allows the agency to electronically target and make speedy decisions for individuals with specific diseases or conditions who meet qualification criteria.
Effective March 1, 2010, SSA added early-onset Alzheimer’s disease (also known as young onset) to its Compassionate Allowance list. According to the SSA, this action will enable qualified individuals to be approved for disability benefits “in a matter of days, rather than months and years.”
It also added 37 other medical conditions, bringing the list to a total of 88 conditions or diseases. The Compassionate Allowance list now includes these dementia-related illnesses:
- Creutzfeldt-Jakob disease
- early-onset Alzheimer’s disease
- Frontotemporal-Dementia (FTD)-Picks Disease Type A
- mixed dementia
- primary progressive aphasia
While having a diagnosis of early-onset Alzheimer’s disease or one of the other conditions on the list will speed up the application process, it is important to note that:
- applicants must still meet additional criteria to be designated as a Compassionate Allowance case and qualify for disability benefits, and
- this list does not apply to individuals who are receiving full Social Security retirement benefits.
SSA manages two programs that provide income to people who are unable to work because of a disability: 1) the Social Security Disability Insurance (SSDI) program and 2) the Supplemental Security Income (SSI) program.
Social Security Disability Insurance (SSDI) provides income to disabled individuals under the age of 65 who are considered “insured”—meaning that the disabled individuals, their spouses or parents worked long enough in jobs covered by Social Security and, therefore, paid Social Security taxes. Monthly payments are based on the worker’s lifetime average earnings covered by Social Security and provide an annual cost of living increase. For people receiving SSA disability benefits, their spouse, divorced spouse and their children (under 18, students, disabled) may also qualify for disability benefits.
Supplemental Security Income (SSI) provides payments to aged (65 or older), blind or disabled individuals who have limited income and resources. This benefit can be applied for once an individual is determined disabled due to a condition such as early-onset Alzheimer’s disease. Payments are based on the Federal Benefit Rate (FBR) and a person’s living arrangements, such as living alone or in another person’s household. Some states supplement the federal benefit with an additional monthly payment.
Note:
Many persons are eligible for disability benefits under both the SSDI and SSI programs at the same time. Applicants for SSDI are often required to concurrently apply for SSI and vice versa.
Here are some important things to know about disability benefits versus health care coverage:
- SSI and SSDI are income benefits, not medical insurance benefits.
- According to the Department of Labor, if a person receives SSA disability benefits, any COBRA benefits may be extended from 18 to 29 months.
- Individuals can apply for Medicaid if they meet the income guidelines as determined by each state. In most states, individuals who receive SSI benefits are eligible for Medicaid. After receiving SSDI benefits for 24 months, beneficiaries are eligible for Medicare, including Part A (hospital benefits), Part B (medical benefits) and Part D (drug benefits).
Resources
- To contact SSA to apply for benefits, click here or call 1-800-772-1213. For individuals who are deaf or hard of hearing call the toll-free TTY number, 1-800-325-0778.
- For more information on SSI, click here.
- For more information on SSDI, click here.
- For more information on Compassionate Allowances, click here.
- To estimate potential benefit amounts, click here.
- To learn more about Medicare or Medicaid , click here.
- If you need assistance with applying for disability benefits, click here to contact your local office of the aging or call 1- 800-677-1116 and ask for a benefits counselor.
- Each state bar association has additional information on disability programs. To find your state bar association, click here.
Affordable Care Act
The Patient Protection and Affordable Care Act, also known as “Health Care Reform,” signed into law in 2010 makes a few upgrades to Medicare with a focus on prevention and early detection.
The Facts:
- Starting in January 2011, Medicare will now pay for a wellness exam once every 12 months for beneficiaries.
- There are no deductibles or co-payments for this visit.
- The exam includes the creation or update of a personalized prevention plan based on your current health and risk factors.
- The exam also includes the detection of any cognitive impairment.
- The visit may be performed by a doctor or any other healthcare provider recognized by Medicare.
More Details About the Detection of Any Cognitive Impairment:
- Your doctor may do an assessment of your cognitive function through direct observation while also taking into consideration any concerns raised by you, your family, caregivers or others.
- The detection of a cognitive impairment is not necessarily a diagnosis of Alzheimer’s disease. Some memory problems can be readily treated, such as those caused by vitamin deficiencies or thyroid problems. Other memory problems might result from causes that are not currently reversible, such as Alzheimer’s disease. If your practitioner suspects a problem, additional tests can be run to more accurately determine the cause of the impairment.
- If you have questions or concerns about your memory, don’t hesitate to ask your doctor or other healthcare professional during this visit or at any other time.
What Else to Expect During the Visit:
- A review of your personal medical and family history, current health conditions and medical concerns, and current prescription drugs, over-the-counter drugs, vitamins and supplements.
- A check of your blood pressure, vision, weight and height to establish a baseline for future comparison.
- Discussion of the status of your cancer screenings, shots and other preventive screenings and services.
- Recommendations for further tests, depending on your general health and medical and family history. Note: Further tests or doctors’ visits not included in the annual wellness exam may require some out-of-pocket costs. Ask your doctor or Medicare if you have questions about coverage.
- Creation or updating of a personalized prevention plan, including a checklist of suggested screenings, immunizations and other preventive services.
Preparing for the Visit:
- Bring your medical records, including immunization records, and your family medical history, which can help your doctor determine suggested screenings.
- Bring a list of any prescription drugs, over-the-counter drugs, vitamins and supplements that you currently take, noting the conditions they related to, dosage and any side effects. Also consider bringing the actual pill bottles.
- Notify your doctor if you have exhibited any of the following symptoms of dementia or prepare a list of your own concerns:
-Memory loss, especially of recent events, names, placement of objects and other new information
-Confusion about time and place
-Struggling to complete familiar actions, such as brushing teeth or getting dressed
-Trouble finding the appropriate words, completing sentences and following directions and conversation
-Changes in mood and personality, such as increased suspicion, rapid and persistent mood swings, withdrawal and disinterest in usual activities
-Difficulty with complex mental assignments, such as balancing a checkbook or other tasks involving numbers
In Order to Qualify for the Visit:
- You must have been receiving Medicare Part B benefits for at least 12 months.
- If you have had your initial, one-time “Welcome to Medicare” physical exam within the past 12 months, you will be eligible for your first annual wellness exam one year from the date of that initial visit.
- You are eligible for a wellness exam once every 12 months.
To learn more about Medicare, click here.
Government Programs
A.D.E.A.R.
Alzheimer’s Disease Education & Referral Center
PO Box 8250
Silver Spring , MD 20907
Phone: 1-800-438-4380
http://www.nia.nih.gov/Alzheimers/AlzheimersInformation/GeneralInfo/
Center for Medicare & Medicaid Services
7500 Security Boulevard
Baltimore , MD 21244
www.cms.gov
Department of Health & Human Services
200 Independence Avenue, SW
Washington , DC 20201
Phone: 1-877-696-6775
www.hhs.gov
U.S. Department of Veterans Affairs
810 Vermont Avenue, NW
Washington , DC 20420
1-800-827-1000
www.va.gov
Eldercare Locator
61 Medford Street
Somerville , MA 02143
Phone: 1-800-677-1116
www.eldercare.gov
Employee Benefits Services Administration,
U.S. Department of Labor
Frances Perkins Building
200 Constitution Avenue, NW
Room 5625
Washington , DC 20210
Phone: 1-866-444-EBSA (1-866-444-3272)
www.dol.gov/ebsa
FDA for Older Persons
5600 Fishers Lane
Rockville , MD 20857
Phone: 1-888-463-6332
http://www.fda.gov/oc/seniors
USDA Food and Nutrition Service
3101 Park Center Drive , Room 926
Alexandria , VA 22302
Phone: 1-703-305-2052
www.fns.usda.gov
Low Income Home Energy Assistance Program
370 L’Enfant Promenade, SW
Washington , DC 20447
Phone: 1-406-494-8662
www.acf.hhs.gov/programs/liheap
National Institute on Aging
Building 31, Room 5C27
31 Center Drive , MSC 2292
Bethesda , MD 20892
www.nia.nih.gov
U.S. Administration of Aging
Washington , DC 20201
Phone: 1-202-619-0724
www.aoa.gov
U.S. Social Security Administration
6401 Security Blvd.
Baltimore , MD 21235
Phone: 1-800-772-1213
www.ssa.gov
U.S. Senate Special Committee on Aging
G31 Dirksen Senate Office Building
Washington , DC 20510
Phone: 1-202-224-5364
www.aging.senate.gov
For more information, connect with the Alzheimer’s Foundation of America’s licensed social workers. Click here or call 866.232.8484. Real People. Real Care.
http://www.alzfdn.org/EducationandCare/strategiesforsuccess.html
http://www.alzfdn.org/Medicare/wellness_exam.html
©2016 Alzheimer’s Foundation of America. All rights reserved.