Medicare pays for home health care for individuals with dementia, but coverage is narrow and subject to strict federal criteria. The program covers short-term, medically necessary services for an illness or injury, not long-term, routine care for a chronic condition like dementia. While a dementia diagnosis does not disqualify a person, the required care must align with Medicare’s definition of skilled, part-time services. Understanding this distinction is fundamental.
Eligibility Criteria for Medicare Home Health Care
To qualify for Medicare home health benefits, a person with dementia must satisfy non-negotiable requirements for specialized, temporary services. First, a doctor must determine the patient requires home health care and formally certify this need, establishing a plan of care for a Medicare-certified home health agency to follow. This medical certification is a foundational requirement.
A second requirement is that the patient must be “homebound.” This means leaving the home requires a considerable and taxing effort, often needing the assistance of another person, an assistive device, or specialized transportation. Being homebound does not mean being confined to bed, and the patient may still leave for medical appointments or short, infrequent non-medical absences, such as attending religious services.
The third criterion is the requirement for intermittent skilled care, which is the type of service that only a licensed professional can safely provide. This includes intermittent skilled nursing care, physical therapy, speech-language pathology services, or a continuing need for occupational therapy. The care must be part-time (fewer than eight hours a day and 28 hours a week), and the need for skilled service must be medically necessary.
Covered Skilled Services Versus Excluded Care
The distinction between skilled care and routine assistance determines Medicare coverage for a dementia patient. Covered skilled services require the specialized knowledge of a nurse or therapist and are typically temporary or intermittent. Examples relevant to dementia include medication management adjustments, especially when a new drug regimen is introduced or cognitive status requires close monitoring.
Other covered skilled services may include wound care for pressure sores, injections, or monitoring an unstable health condition, such as a urinary tract infection that causes acute confusion. Physical therapy following a fall is also covered when the goal is to safely restore or maintain a level of function. These services are all covered because they require professional expertise.
Conversely, Medicare explicitly excludes coverage for what is termed “custodial care,” which constitutes the majority of long-term dementia needs. Custodial care involves non-medical assistance with Activities of Daily Living (ADLs), such as bathing, dressing, feeding, and using the toilet. The constant supervision and companionship often required by patients with advanced dementia are also considered custodial and are not covered.
A significant clarification for patients with chronic, progressive conditions like dementia came from the 2013 settlement in Jimmo v. Sebelius. This ruling established that coverage for skilled services cannot be denied solely because a patient is not improving. Instead, Medicare must cover skilled nursing or therapy services when they are necessary to maintain the patient’s current condition, slow the rate of decline, or prevent further deterioration, provided all other eligibility criteria are met. This “maintenance coverage” rule is particularly relevant for dementia.
Addressing Gaps in Long-Term Dementia Care Funding
Because Medicare’s home health benefit is limited to intermittent skilled needs, it rarely covers the extensive, long-term custodial care required as dementia progresses. For families facing this financial gap, Medicaid is the primary public safety net for long-term care. Medicaid is a joint federal and state program that covers the costs of long-term care services, including nursing home care and, in many states, Home and Community-Based Services (HCBS) waivers that pay for care in the home or assisted living setting.
Medicaid eligibility is based on strict financial criteria, requiring applicants to have limited income and assets. While the rules vary by state, this means many families must spend down their savings before they can qualify for assistance. Long-Term Care Insurance (LTCI) provides another funding option, as these private policies are specifically designed to cover custodial care, including assistance with ADLs, in the home or in a facility.
For eligible former service members and their spouses, certain Veterans Affairs (VA) benefits, such as the Aid and Attendance program, can help offset the cost of long-term care. For many families, however, the only immediate solution is private pay, using personal savings, pensions, and income to fund non-medical home care. These alternative funding sources are often necessary to cover the routine, daily assistance that Medicare does not provide.