Does Medicare Pay for Dementia Nursing Home?

Understanding healthcare costs, especially for long-term care, is a significant challenge for many families. Medicare, a federal health insurance program, is often a first point of inquiry for coverage options. A common question concerns Medicare’s role in covering conditions like dementia, particularly when nursing home care is needed.

Medicare’s Skilled Nursing Facility Coverage

Medicare Part A covers skilled nursing facility (SNF) care under specific conditions. To qualify, an individual must have a medically necessary inpatient hospital stay of at least three consecutive days. Admission to a Medicare-certified SNF is required within 30 days of hospital discharge.

SNF care must be for a daily skilled nursing need or rehabilitative therapy, such as physical, occupational, or speech therapy, prescribed by a doctor. This care is considered skilled if it requires the expertise of licensed healthcare professionals. Medicare covers 100% of costs for the first 20 days of a covered SNF stay.

For days 21 through 100, a daily coinsurance amount applies. In 2025, this coinsurance is $209.50 per day. After day 100, Medicare coverage for SNF care ceases, and the individual is responsible for all costs. A new benefit period begins when an individual has not received inpatient hospital care or skilled care in a SNF for 60 consecutive days.

Dementia Care in Skilled Nursing Facilities

Medicare’s coverage for individuals with dementia in a skilled nursing facility is tied to the need for skilled medical services, not the dementia diagnosis itself. While Medicare covers skilled care, it does not cover long-term “custodial care.” Custodial care primarily involves assistance with activities of daily living (ADLs) like bathing, dressing, or eating, and does not require the specialized skills of licensed professionals.

If a person with dementia requires medically necessary skilled nursing or therapy services, Medicare will cover the SNF stay for that skilled component. For example, if a person with dementia has a fall and needs physical therapy or wound care, Medicare Part A would cover the SNF stay if all other eligibility criteria are met. The dementia itself, or the need for supervision due to cognitive impairment, does not trigger SNF coverage when skilled medical needs are absent.

Once the skilled medical need ends, Medicare coverage for the SNF stay ceases, even if the individual continues to require custodial care due to dementia. Medicare’s SNF benefit is designed for short-term rehabilitation, not for ongoing long-term care where the primary need is personal care or supervision. Many people with dementia will eventually need long-term care that includes custodial services, which Medicare typically does not cover.

Other Medicare Benefits for Dementia

While Medicare does not typically cover direct long-term nursing home care for dementia, it provides coverage for various other services. Medicare Part B covers medically necessary doctor visits, including those with neurologists and psychiatrists, and diagnostic tests like MRI or CT scans to help diagnose dementia. These services are subject to deductibles and coinsurance.

Medicare Part D, the prescription drug coverage, helps cover the costs of medications used to manage dementia symptoms. Coverage and costs vary based on the specific plan chosen. Medicare Part A also covers hospital stays for acute conditions a person with dementia might experience, such as pneumonia or a fall.

Certain home health services are covered by Medicare if an individual is homebound and requires skilled care. These services include skilled nursing care, physical therapy, occupational therapy, and speech therapy provided at home. This coverage does not extend to ongoing personal care or assistance with ADLs if that is the only care needed. For individuals with dementia who meet terminal illness criteria, Medicare also covers hospice care, which can be provided in various settings, focusing on comfort and support.

Funding Dementia Nursing Home Care Beyond Medicare

Given Medicare’s limited role in covering long-term nursing home care for dementia, exploring alternative funding sources is necessary for many families. Medicaid is a joint federal and state program providing healthcare coverage, including long-term custodial care in nursing homes, for individuals meeting specific financial and medical eligibility criteria. Eligibility is based on strict income and asset limits, which vary by state but are typically low, such as around $2,000 in countable assets for a single individual.

Medicaid also has a “look-back period,” commonly 60 months (five years), reviewing financial transactions to ensure assets were not transferred to qualify for benefits. Violations can result in a penalty period of ineligibility. Long-term care insurance is another option, designed to cover services like nursing home care, assisted living, and home care. These policies typically have an “elimination period,” a waiting period (e.g., 30, 60, 90, or 100 days) during which the policyholder pays for care out-of-pocket before benefits begin.

Private pay, using personal savings, investments, or pension income, is a common method for covering long-term care costs. The annual cost for a nursing home stay can range significantly, often exceeding $95,000 for a semi-private room. Some Veterans and their surviving spouses may be eligible for benefits like the Aid and Attendance pension. This pension provides monetary assistance for long-term care, including nursing home care, for those meeting service, medical, and financial requirements and needing assistance with daily living activities.