Medicare Advantage Isn't Always an Advantage for Alzheimer's

People with Alzheimer's are having trouble with Medicare Advantage plans. How is the Advantage Plan different from regular Medicare?

 This has become a significant issue for people with Alzheimer's disease, especially those receiving newer anti-amyloid treatments like Leqembi and Kisunla.

The biggest difference is this:

• Original Medicare is administered directly by the federal government.

• Medicare Advantage (Part C) is administered by private insurance companies (UnitedHealthcare, Humana, Aetna, Kaiser, etc.) that contract with Medicare. They must cover everything Original Medicare covers, but they can impose additional rules on how and when you receive care.

Here's how they compare.

Original Medicare

Medicare Advantage

Government pays claims directly

Private insurance company manages your care

Usually no prior authorization for most Part B services

Prior authorization is often required

See any doctor or hospital that accepts Medicare

Usually limited to a provider network

Usually no referrals to specialists

Referrals may be required, depending on the plan

Can buy a Medigap Plan G to cover most out-of-pocket costs

Cannot use Medigap with an Advantage plan

Separate Part D drug plan important for IQLIK

Usually includes Part D drug coverage

Why Alzheimer's Patients Are Having Problems

Leqembi and Kisunla require more than simply prescribing a drug. Patients often need:

• Amyloid confirmation (PET scan or cerebrospinal fluid test)

• MRI scans before and during treatment

• Infusion appointments

• Neurologist follow-up

• Monitoring for ARIA (brain swelling or bleeding)

Under Original Medicare, once the treatment meets Medicare's national coverage requirements, there are generally fewer administrative hurdles for these services.

With Medicare Advantage, the plan may require:

• Prior authorization before treatment starts

• Reauthorization during treatment

• Review of MRI schedules

• Approval for PET scans

• Use of in-network infusion centers and neurologists

Even though the treatment is covered, these extra administrative steps can delay care.

Why This Matters

For Alzheimer's disease, time matters.

Leqembi and Kisunla work best before large numbers of neurons have died. Delays of several months while waiting for approvals can mean additional disease progression that cannot be reversed.

This has become a major concern among neurologists and Alzheimer's advocacy organizations because every month of delay may allow more tau pathology and neuronal loss to occur.

Why Many Neurologists Prefer Original Medicare

Many dementia specialists prefer that eligible patients have:

• Original Medicare

• Medigap Plan G (or similar)

• A separate Part D drug plan

The reasons are straightforward:

• Fewer administrative barriers

• Greater freedom to choose Alzheimer's specialists

• Access to major memory centers nationwide

• Less risk of treatment delays due to insurance approvals

The trade-off is that this combination usually has higher monthly premiums than many Medicare Advantage plans, although it often provides greater flexibility for people with complex medical conditions.

Given my own experience with Original Medicare plus Blue Shield Plan G, I’ve benefited from exactly this flexibility. It has allowed me to receive Leqembi infusions without being constrained by a Medicare Advantage network: one reason many Alzheimer's specialists recommend Original Medicare with a Medigap supplement for patients who may need advanced neurological care. However, Blue Shield Plan G is expensive and costs more as you age. But compared to the total costs of MRIs, Pet Scans and blood tests, paying 20% of those costs should be figured in to your decision.