Medicare covers some nursing home costs for dementia, but only under specific conditions and for limited time
Medicare will pay for a nursing home stay if you have dementia and meet two requirements: you must have been in a hospital for at least three consecutive days (not counting the day you leave), and a doctor must order the nursing home care as part of your recovery from that hospital stay. Medicare calls this a skilled nursing facility stay, and it covers the full cost of the facility, meals, and basic care for the first 20 days. After that, you pay a daily amount (which changes each year) for days 21 through 100. After day 100 in the same benefit period, Medicare stops paying entirely.
The catch is that Medicare does not cover a nursing home stay straightforward because you have dementia and need help with daily living. It only covers care that is medically necessary and related to the condition that sent you to the hospital. If you go to a nursing home directly from home without a hospital stay first, or if the nursing home care is mainly for supervision and information with eating, bathing, and dressing (called custodial care), Medicare will not pay.
Key Takeaways
- Medicare covers nursing home care only after a three-day hospital stay and only when a doctor orders it as part of recovery from that hospital stay.
- Medicare pays all costs for the first 20 days, then you pay a daily copay for days 21 through 100; after day 100, you pay all costs yourself.
- If you enter a nursing home directly from home without a hospital stay, Medicare will not pay, even if you have dementia.
- Medicaid, not Medicare, is the program that typically covers long-term custodial nursing home care for people with dementia who have limited income and assets.
- You should ask the hospital social worker about your coverage before you leave the hospital, because the rules are strict and coverage can end quickly.
When Medicare will and will not pay
Medicare will pay for a nursing home stay only when all three of these are true: you spent at least three consecutive nights in a hospital (the night you are admitted counts, but the night you leave does not), a doctor wrote an order saying you need skilled nursing care, and that care is related to the condition you were treated for in the hospital. The nursing home must also be a Medicare-approved skilled nursing facility, which most are.
Medicare will not pay if you go straight from home to a nursing home, even if a doctor thinks you need care. It will not pay if you were in the hospital for fewer than three nights. It will not pay for custodial care — help with bathing, dressing, toileting, and eating — unless that care is part of recovery from a medical event. For someone with dementia who needs supervision and help with daily living but is not recovering from a recent hospital stay, Medicare does not cover the cost.
How long Medicare will pay and what you pay
Your Medicare coverage in a skilled nursing facility lasts up to 100 days in each benefit period (a benefit period starts when you enter the hospital and ends 60 days after you leave the nursing home). For days 1 through 20, Medicare pays 100 percent of the cost. For days 21 through 100, you pay a daily copay amount; in 2024, that amount is $200 per day, but it changes each year. After day 100, you pay all costs yourself.
The clock resets if you leave the nursing home for 60 days or more and then return to the hospital. If you leave the nursing home for fewer than 60 days and then return, the days you already used count toward your 100-day limit.
The difference between Medicare and Medicaid for nursing home care
Medicaid, not Medicare, is the program that pays for long-term nursing home care for people with dementia who have limited income and assets. Medicaid will pay for custodial care — the day-to-day help with bathing, dressing, eating, and toileting that most people with dementia eventually need. Medicaid has no day limit; it can pay for years of care. However, Medicaid has strict rules about how much money and property you can own, and those rules vary by state.
If you have dementia and are worried about long-term nursing home costs, Medicaid is usually the program that will help. Medicare is designed for short-term skilled care after a hospital stay. A social worker at the hospital or nursing home can tell you whether you may be able to use Medicaid and what the income and asset limits are in your state.
What happens when your Medicare coverage ends
When Medicare stops paying — either because you have used 100 days or because you no longer need skilled care — you have three main options. You can pay out of pocket if you have savings. You can look into Medicaid if your income and assets are low enough. Or you can go home and receive care there, either from family or through home health services (Medicare may cover some home health care if a doctor orders it).
Some nursing homes will let you stay and switch to private pay or Medicaid once Medicare ends. Others may ask you to leave. Before you enter a nursing home, ask the admissions staff what happens when Medicare coverage ends and whether the facility accepts Medicaid. This conversation can save you from a crisis later.
How to find out what Medicare will cover before you leave the hospital
Before you are discharged from the hospital, ask to speak with the hospital social worker or discharge planner. Tell them you have dementia or are concerned about dementia care. Ask them directly: "Will Medicare pay for my nursing home stay, and if so, for how long?" Ask them to put the answer in writing. Ask them to explain what you will owe after Medicare coverage ends.
If the hospital is recommending a specific nursing home, ask whether it is Medicare-approved and whether the social worker can call ahead to confirm that Medicare will cover your stay there. If you have questions you do not understand, ask the social worker to explain again. This is their job, and they are used to repeating themselves.
What to do if you need nursing home care but do not have a hospital stay
If you have dementia and need nursing home care but have not been in the hospital for three days, Medicare will not pay. In this situation, your options are to pay privately, to look into Medicaid, or to explore other care options such as assisted living, adult day programs, or in-home care.
Some people with dementia can stay at home longer with the help of family, hired caregivers, or adult day programs. Others move to assisted living facilities, which are less expensive than nursing homes but provide more help than living alone. A social worker, your doctor, or your local Area Agency on Aging can help you think through what might work for your situation and budget.
Frequently Asked Questions
Does Medicare cover memory care units in nursing homes?
Medicare covers a memory care unit the same way it covers any other nursing home: only after a three-day hospital stay and only for skilled care related to recovery from that hospital stay. The unit itself does not change the rules. If you are admitted to a memory care unit directly from home, Medicare will not pay.
What if my doctor says I need a nursing home but I have not been in the hospital?
Medicare will not pay. You would need to pay privately, look into Medicaid if you may have access to, or explore other options such as assisted living or in-home care. Talk to your doctor or a social worker about what might work for your situation.
Can I use my Medigap or Medicare Advantage plan to cover nursing home costs?
Most Medigap plans cover the daily copay you owe on days 21 through 100 of a skilled nursing facility stay, but they do not change the basic rules about when Medicare pays. Medicare Advantage plans vary; some cover additional days or services. Call your plan to ask what nursing home coverage it includes.
What if I run out of Medicare coverage while I am still in the nursing home?
You will owe the full daily cost of the nursing home. Some facilities will work with you on payment plans or will help you explore for Medicaid. Talk to the nursing home billing department and social worker as soon as you know your Medicare coverage is ending.
Is there any way to get Medicare to pay for long-term nursing home care?
No. Medicare is designed for short-term skilled care after a hospital stay, with a maximum of 100 days per benefit period. For long-term care, Medicaid is the federal program that pays. Some people also use long-term care insurance if they bought it before they became ill.