Medicare Coverage for Skilled Nursing Facility Rehab
Medicare's rules for covering rehabilitation for dementia are specific and tied to skilled care needs, not the dementia diagnosis itself. It is crucial to understand these rules to avoid unexpected out-of-pocket costs, as Medicare does not cover long-term custodial care.
The 100-Day Skilled Nursing Facility (SNF) Benefit
Medicare Part A provides coverage for up to 100 days of skilled nursing facility (SNF) care per benefit period. This coverage is intended for short-term rehabilitation, not for indefinite, long-term stays. For a dementia patient to be eligible, they must first meet several conditions:
- A qualifying hospital stay of at least three consecutive inpatient days. Time spent under observation status does not count.
- Admission to the SNF must be within a short time (usually 30 days) of the hospital discharge.
- A doctor must certify that the patient needs daily skilled nursing or rehabilitation services.
- The SNF must be Medicare-certified.
- The skilled care must be for the same or a related condition that was treated during the qualifying hospital stay.
How Costs are Divided within the 100-Day Period
For each benefit period, the costs are split based on the duration of the stay:
- Days 1–20: Medicare pays the full cost for all approved services. The patient pays nothing.
- Days 21–100: The patient is responsible for a daily coinsurance payment. For 2025, this amount is $209.50 per day. A Medicare Supplement (Medigap) policy may help cover this cost.
- Days 101 and beyond: The patient is responsible for all costs, and Medicare coverage for the SNF stay ends for that benefit period.
Understanding the 'Benefit Period' for Dementia Rehab
The concept of a benefit period is fundamental to Medicare's SNF coverage. A new benefit period begins when a person is admitted to a hospital as an inpatient and ends after 60 consecutive days without any inpatient hospital or SNF care. This is important for dementia patients who may require multiple episodes of short-term rehab over time. If a patient leaves an SNF and then needs another stay more than 60 days later, a new qualifying hospital stay would make them eligible for another 100-day benefit period.
What is the Difference Between Skilled and Custodial Care?
Medicare's distinction between skilled and custodial care is critical for dementia patients. Skilled care is administered by professionals like registered nurses and physical therapists, and it is the only type of care that can be covered by Medicare Part A in an SNF setting. In contrast, custodial care is non-medical, personal care such as assistance with dressing, bathing, and eating. As dementia progresses, the need for custodial care often increases, but Medicare explicitly does not cover long-term custodial care.
Medicare will terminate SNF coverage, even before the 100-day limit, if the patient's condition plateaus and they no longer require daily skilled services. At this point, help with daily activities becomes primarily custodial, and the patient or their family must bear the cost.
Comparison of Medicare's SNF and Custodial Care Coverage
| Feature | Medicare SNF Coverage (Parts A and B) | Long-Term Custodial Care (Not Covered by Medicare) |
|---|---|---|
| Purpose | Short-term rehab after a qualifying hospital stay. | Long-term assistance with daily living activities. |
| Location | Skilled Nursing Facility (SNF). | Nursing home, assisted living, or at home. |
| Care Provided | Daily skilled nursing, physical, occupational, or speech therapy. | Help with bathing, dressing, eating, and supervision. |
| Maximum Coverage | Up to 100 days per benefit period. | Unlimited, but not covered by Medicare. |
| Patient Cost | $0 for days 1-20, daily coinsurance for days 21-100, then all costs. | 100% of costs, unless covered by Medicaid or private insurance. |
| Dementia Relevance | Covers rehab for medical issues related to dementia (e.g., fall recovery). | Addresses the increasing need for daily assistance as dementia progresses. |
Options After Medicare SNF Coverage Ends
When a dementia patient reaches or is cut off from their 100 days of Medicare SNF coverage, families must explore other options to fund continued care:
- Medicaid: For individuals with low income and limited assets, Medicaid may cover long-term custodial care in a nursing home or through Home and Community-Based Services (HCBS) waivers. Eligibility rules and benefits vary by state.
- Long-Term Care Insurance: Private long-term care insurance policies can cover services, including custodial care, that Medicare does not. These are typically purchased long before care is needed.
- PACE Program: The Program of All-Inclusive Care for the Elderly (PACE) is an option for dually-eligible Medicare and Medicaid enrollees. It provides comprehensive care to allow individuals with dementia to remain living at home.
- Medicare Advantage Special Needs Plans (SNPs): Some private Medicare Advantage plans offer special needs plans for individuals with chronic conditions, including dementia, and may provide additional benefits and care coordination not available with Original Medicare.
Conclusion
While Medicare does cover some aspects of dementia care, including short-term rehab in a skilled nursing facility, it does not provide unlimited, long-term coverage. For dementia patients who meet specific eligibility requirements, Medicare Part A covers up to 100 days of skilled nursing care per benefit period, with patient costs increasing after day 20. Importantly, Medicare does not cover custodial care, which becomes a greater need as dementia progresses. Families should plan ahead by exploring alternatives like Medicaid, long-term care insurance, or specialized programs to cover the costs of long-term care for a loved one with dementia. For up-to-date program specifics and eligibility, it is always best to consult the official Medicare website.
