Medicare's Coverage for Nursing Home Care in Dementia

Medicare covers some nursing home costs, but only under specific conditions — and dementia alone does not automatically may have access to you. Medicare pays for skilled nursing care, which means care that requires a nurse or therapist to deliver it. Dementia is a memory and thinking condition; it does not automatically need skilled nursing. Medicare will pay if you need skilled care because of another condition — a recent hospital stay, a stroke, a broken hip, or an infection — and you happen to have dementia as well.

If you need a nursing home purely because of dementia and no recent medical event, Medicare does not cover it. In that case, you would pay out of pocket, use Medicaid (which does cover long-term dementia care), or both. Understanding which path applies to you depends on what brought you to the nursing home and how long you have been there.

Key Takeaways

  • Medicare covers nursing home care only if you had a hospital stay of at least three days and need skilled nursing or therapy — not custodial care for dementia alone.
  • Medicare pays for up to 100 days in a nursing home per benefit period, but only days 1–20 are fully covered; days 21–100 require a daily copay.
  • Medicaid, not Medicare, covers long-term nursing home care for dementia when skilled care is no longer needed.
  • You must enter the nursing home within 30 days of leaving the hospital for Medicare to cover it.
  • The nursing home must be Medicare-certified, and your doctor must order the care in writing.

When Medicare Will Pay for Nursing Home Care

Medicare covers a nursing home stay only if all of these conditions are met: you spent at least three consecutive days in a hospital (not counting the day you were discharged), your doctor ordered nursing home care as part of your discharge plan, you enter the nursing home within 30 days of leaving the hospital, and the care you need is skilled care — meaning a registered nurse, licensed practical nurse, or physical or occupational therapist must provide it or supervise it daily.

Skilled care includes wound care that requires a nurse, physical therapy after a stroke or surgery, intravenous medications, catheter management, or speech therapy after a swallowing problem. If you are in a nursing home because you cannot remember to take your medications or cannot bathe yourself — even if you have dementia — that is custodial care, and Medicare does not cover it. The difference matters because it determines who pays and for how long.

If you had a hospital stay and now need skilled care, dementia does not disqualify you. Medicare will cover the nursing home stay as long as the skilled care requirement is met. Once you no longer need skilled care — once your wound heals, your therapy ends, or your condition stabilizes — Medicare coverage stops, even if you remain in the nursing home.

How Long Medicare Pays and What You Pay

Medicare covers up to 100 days in a nursing home per benefit period (which runs from October 1 to September 30 each year). The payment structure changes after day 20. Days 1 through 20 are fully covered by Medicare; you pay nothing. Days 21 through 100 require you to pay a daily copay, which changes each year. In 2024, the copay is $200 per day, but confirm the current amount with your nursing home or Medicare.

After day 100, Medicare stops paying entirely. If you still need nursing home care, you must pay out of pocket or switch to Medicaid if you meet its income and asset limits. Many people exhaust their Medicare coverage and then transition to Medicaid for the remainder of their stay. Your nursing home's social worker can help you understand when this transition will happen and what paperwork you need to file.

The 100-day limit resets each benefit period. If you leave the nursing home and return to the hospital, then return to a nursing home within 60 days, your days do not reset — you continue counting from where you left off. If you stay out of the hospital for more than 60 days, a new benefit period begins and your count resets to zero.

Medicaid Coverage When Medicare Ends

Medicaid is the program that covers long-term nursing home care for dementia when skilled care is no longer needed. Unlike Medicare, Medicaid does not require a hospital stay first, and it covers custodial care — the day-to-day help with bathing, dressing, meals, and supervision that people with dementia often need. Medicaid will pay for as long as you remain in the nursing home and meet its income and asset rules.

Income and asset limits vary by state. Some states allow you to keep a small amount of savings (often $2,000 to $3,000) and a small monthly income before Medicaid stops paying. Others are stricter. If you have significant savings or income, you may need to spend down your assets to Medicaid's limit before the program begins paying. This is called "spending down," and it is a legal way to become Medicaid-may be able to access.

Many people use Medicare first (for the 100 days of skilled care coverage) and then switch to Medicaid for ongoing care. Your nursing home's social worker or a Medicaid specialist can walk you through the spending-down process and help you file the Medicaid process. Starting this conversation early — before your Medicare coverage ends — prevents gaps in payment and keeps you from being discharged.

What to Ask Your Doctor and Nursing Home

Before or just after admission, ask your doctor: "Will Medicare cover this nursing home stay, and for how long?" and "What skilled care do I need, and when do you expect that to end?" Ask your nursing home: "Are you Medicare-certified?" (if not, Medicare will not pay), "What is my expected discharge date?" and "When should we start talking about Medicaid?"

Also ask: "What is my daily copay for days 21 through 100?" and "What happens on day 101 if I still need care?" Request a written summary of your Medicare coverage and the expected end date. This protects you from surprises and gives you time to plan. If you disagree with the nursing home's assessment of when skilled care ends, you have the right to appeal to Medicare.

When to Seek Help or Appeal

If your nursing home says Medicare coverage is ending but you believe you still need skilled care, you can appeal. Ask the nursing home for a written notice of the end of coverage (called a Notice of Non-Coverage). You have the right to request a Utilization Review — an independent review by a nurse who works for Medicare — within 24 hours of receiving the notice. This review is free and can overturn the nursing home's decision.

Contact your State Health Insurance information Program (SHIP) if you have questions about Medicare coverage or need help with an appeal. SHIP is free and staffed by counselors who know Medicare rules. You can find your state's SHIP by calling 1-800-MEDICARE or visiting Medicare.gov. If you cannot afford the copays on days 21–100, ask your nursing home about financial aid programs or contact your local Area Agency on Aging.

Frequently Asked Questions

Does Medicare cover nursing home care for dementia alone?

No. Medicare covers nursing home care only if you need skilled nursing or therapy — not custodial care. If dementia is your only condition and you do not need skilled care, Medicare will not pay. Medicaid covers long-term dementia care in a nursing home, but you must meet its income and asset limits.

What if I did not have a three-day hospital stay before entering the nursing home?

Medicare will not cover your nursing home stay. You would need to pay out of pocket or use Medicaid if you meet its rules. Some states have programs that help pay for nursing home care without a hospital stay; ask your nursing home social worker or call your local Area Agency on Aging.

Can I stay in the nursing home after my 100 Medicare days end?

Yes, but you or another payer must cover the cost. Many people transition to Medicaid at day 101 if they meet the income and asset limits. You can also pay privately, use long-term care insurance if you have it, or ask family to help. Your nursing home cannot discharge you solely because Medicare coverage ended.

What is the difference between skilled care and custodial care?

Skilled care requires a nurse or therapist to deliver it — wound care, physical therapy, or medication management. Custodial care is help with daily living — bathing, dressing, meals, and supervision. Medicare covers skilled care; Medicaid covers custodial care. Many people need both at different times during their stay.

How do I know if my nursing home is Medicare-certified?

Ask the nursing home directly, or search the Medicare Care Compare tool at Medicare.gov. You can also call 1-800-MEDICARE. If the nursing home is not certified, Medicare will not pay for your stay, even if you meet all other requirements.