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Medicare has no custodial care benefit
Most people want to age in place, in their own home or another independent setting like a 55+ community. But they begin needing help with daily activities, and their choices are few:
pay out of pocket for a home health aide, part-time or full-time
use a long-term care insurance benefit, if they have one and qualify
spend down assets until they qualify for Community Medicaid, which still may not be enough support, depending on the state
Help with bathing, dressing, eating, and toileting is custodial care. Medicare doesn't cover it when it's the only care someone needs. This still surprises most families when they face it. I find most clinicians don't fully understand it either, or the difference between skilled and custodial care.
Daily personal care support is not daily skilled care
A patient may need someone present to help with walking, dressing, or toileting and still lack the skilled needs required for a Medicare-covered SNF stay. The support need must be addressed. But it doesn't, by itself, establish Part A coverage. One way to make this make sense is that many people have needed support at home leading up to a hospitalization and will never not need it. That is entirely different from Medicare covering it.
Under Original Medicare, SNF coverage for every day of the stay requires skilled nursing or rehabilitation on a daily basis, a need to receive those services in a SNF as a practical matter, and other eligibility requirements. When skilled rehab is the basis for the stay, medically necessary therapy must be provided at least five days a week to meet the “daily” requirement.
Home health can also provide therapy five times a week, because home health is based on a medical need for intermittent care. Importantly, a preference for daily therapy doesn't show that a patient needs that frequency, or needs a facility to get it. Equally, a family at the bedside and able to provide support doesn't automatically make a facility stay medically unnecessary. Assess the actual skilled needs to determine patient eligibility under Medicare guidelines.
Patients are also supposed to transition home from a SNF when there's no longer a medically necessary daily skilled need. That point arrives long before they're "independent." Walking with a walker and minimal assistance is an appropriate level of function for the next lower level of care. If the support she'll need then isn't arranged now, it won't appear on its own. The therapy prognosis, starting at the hospital, should say that this patient will need to go home with some level of custodial support.
You can find the Medicare Part A Skilled Nursing Facility Level of Care Guidelines on page 18 of this online pdf, which was updated most recently in 2024.
Care in a SNF is covered if all of the following four factors are met:
• The patient requires skilled nursing services or skilled rehabilitation services, i.e., services that must be performed by or under the supervision of professional or technical personnel (see §§30.2 - 30.4); are ordered by a physician and the services are rendered for a condition for which the patient received inpatient hospital services or for a condition that arose while receiving care in a SNF for a condition for which he received inpatient hospital services;
• The patient requires these skilled services on a daily basis (see §30.6); and
• As a practical matter, considering economy and efficiency, the daily skilled services can be provided only on an inpatient basis in a SNF. (See §30.7.)
• The services delivered are reasonable and necessary for the treatment of a patient’s illness or injury, i.e., are consistent with the nature and severity of the individual’s illness or injury, the individual’s particular medical needs, and accepted standards of medical practice. The services must also be reasonable in terms of duration and quantity.
If any one of these four factors is not met, a stay in a SNF, even though it might include the delivery of some skilled services, is not covered. For example, payment for a SNF level of care could not be made if a patient needs an intermittent rather than daily skilled service.
What might change
On October 16, 2026, Senate Finance Committee Ranking Member Ron Wyden (D-Ore.) published a Request for Information on proposals to improve long-term care, including an “affordable home care guarantee” based on functional needs. One bill it describes, the Medicare at Home Act, would provide up to 20 hours per week of help with daily activities. From the RFI:
Despite widespread public perception, Medicare does not cover comprehensive LTC.
An RFI is just that: a request for public input as Senate Democrats develop policy for possible future use. Public support for this may be large. But the complexity of administering this, and even more the cost of sustaining it, will make turning this information-gathering exercise into law difficult.
If you'd like to weigh in, the 81-page RFI is online (Section I, on home care, starts on page 8). Comments are due by December 18, 2026 at [email protected].
What home health does and doesn't cover
Home health clinicians visit intermittently. Medicare home health covers skilled services for patients who are homebound and meet the other requirements. It can also cover intermittent aide services alongside that skilled care, while the skilled care is being delivered.
Aide frequency and duration are set to support the skilled clinicians' goals, and aide services end the day the skilled episode ends. In my experience, a common aide schedule is two hours, two or three times a week. A patient who needs help every time they stand up still needs a plan for all the hours the nurse, therapist, or aide isn't there, which is most of them.
I was often the last clinician on a home health case, and the patient's need for help commonly didn't end when my visits did. Many patients will never be "independent." Someone has to plan for that, and the hospital admission is where it must start.
Why the episode starts at the hospital
Here's the problem. A hospital clinician assumes home health will provide more help than it does. A team recommends a SNF without understanding what qualifies for coverage or what improvement is realistic there. Each decision is made by people who understand, and are held accountable for, only their own silo. Little thought is given to the fact that their stay is just one stop on the patient's episode of care.
An acute episode starts when an illness, injury, or procedure disrupts someone's health and often their function, especially when they're older and frail. It can end weeks to many months after the patient leaves the hospital, in settings the hospital team often has little expertise in.
During my twelve years as a home health therapist, I was often on the receiving end of those decisions, far down the line. I call the gaps between and within sites of care “black holes.” Clinicians who understand them can offer vital expertise in moving a patient and care partner through an optimal episode.
Hospitals now carry the financial version of this problem. Since January 1, under TEAM, CMS has held participating hospitals (mandatory for about one quarter of eligible regions, or about 740 acute care hospitals) accountable for Medicare spending from surgery through 30 days after discharge, for five procedure types. CJR-X is up next.
Think of the hospital as Expedition Base Camp. It's a controlled, highly resourced place to gather supplies, check the weather, and practice skills. But if the guides focus only on surviving the night in the tent, and never check whether the climber has a reliable partner for the descent, proper gear, or realistic expectations of the trail, the climber will struggle the moment they leave the gates.
1. Establish prior level of function
"Lives alone" tells you very little. Neither does "independent," unless someone has established what that accurately means. "Lives alone, avoids using a recommended cane, is afraid of falling, and rarely leaves home" describes a very different starting point. For unplanned episodes in the elderly, this is often the case.
Returning someone to their “prior level of function” may return them to an arrangement that was already unsafe. And an unsafe home, by itself, doesn't qualify anyone for a Medicare-covered SNF stay. So find out how the patient actually managed transfers, walking, bathing, medications, and meals. Ask what family members were doing that the patient may not have counted as help. Do a simple balance test, if feasible. Ask about fears of falls, near falls, and actual falls.
Then, especially for my rehab readers, establish a realistic short- and longer-term functional prognosis. What help will likely be needed right after the hospital, and what will still be needed once a new baseline is reached? That assessment is separate from a recommendation for a destination, and it should come first.
2. Identify the care partner on admission
If the patient will need help afterward, identify who will provide it while there's time to prepare them. Ask the patient whom they want involved, then confirm that person's availability, willingness, and ability. A daughter at the bedside is a start. What tasks can she perform, and when will she be there? Can she physically assist with a transfer? Who helps when she's at work? Could the patient stay with her for the first stretch?
When the history shows the patient was already struggling, say so early. Something like:
"You've told us that taking your medications and getting around safely have been hard these last few months, and that you're afraid of falling. Whatever happens during this stay, you'll very likely need some support at home while you recover, and possibly after. Medicare doesn't pay for that kind of day-to-day help, so let's start thinking about what that looks like. Meanwhile, we'll keep you moving and out of bed as much as we safely can so you maintain as much strength as possible."
Many tasks that look like barriers to going home can be taught to the patient and care partner and reinforced by home health the next day: emptying a catheter bag, using a bedside commode, managing medications, assisting with transfers and walking. Begin early, repeat as often as needed, and have the care partner demonstrate it back. Involve case management and social work early, too. Sometimes the only realistic option is paying cash for help at home, and families need time to process that. Many avoidable inpatient post-acute days can be avoided by addressing support gaps right away.
3. Protect mobility
Patients shouldn't lose significant strength and function during a hospital stay unless bedrest is truly medically necessary. We've just accepted it as “the way it is.”
Mobility and skilled therapy are different things. A patient may need a therapist's expertise to assess a new impairment, determine a safe movement strategy, or provide treatment. But routine mobility belongs to the nursing team. If a patient can safely get out of bed and walk with assistance, nursing should make sure it happens throughout the day, starting immediately. Bedrest doesn't prevent falls, and patients don't need to wait for therapy clearance to be mobilized.
The most enlightened policy I've heard came from a nursing leader at a small community hospital. She had staff record each patient's function on admission on the whiteboard and tell the patient and care partner that the team commits their function won't worsen during the stay. Not on their watch. Patients at risk get flagged for a more intensive mobility protocol.
In a cluster randomized trial across eight VA hospitals, estimated SNF discharge rates fell from 13% before a supervised walking program to 8% after it, with no change in inpatient falls. Make the plan usable by specifying the assistance, equipment, precautions, and who will carry it out. Unnecessary inactivity can change the custodial care someone needs next, and for years after.
4. Hand off what you know
Don't assume clinicians on the other side of a transition know what you know. They may receive a diagnosis and medication list without the details that explain how this patient will function in their setting, or what the rehab prognosis and goals are.
Communicate current assistance needs, relevant features of the home, equipment requirements, what the care partner has demonstrated, and what still needs teaching. Share what you've already discussed with the patient and care partner, for example:
"We discussed that recovery from the hip fracture with ORIF will take several months, and that she will likely continue her recovery in home health after the SNF stay. She had a fear of falling before the fall and was limiting how much she left the house. She showered only when her daughter was over, using a tub bench. Because of her impaired function before admission and the new fracture, we discussed that she'll need custodial support to return home once her skilled needs are intermittent, probably in two to three weeks. Her daughter has room for her, but the patient may decide to return home and pay for an aide. The discussion can be picked up from here."
Use "transition" in your thinking and conversations, not “discharge.” It keeps the next stage of the episode in view. A good handoff says what has been accomplished and what remains unresolved.
5. Reach out to home health early
Once the patient and care partner have chosen a home health agency, talk to them directly. For someone going home with a new catheter, arrange the teaching, confirm supplies, and speak with the intake or clinical liaison nurse about what has been taught and what remains. If a visit is needed the next day, confirm it will happen. If the nurse needs to bring specific items like catheter bags or wound supplies, make sure they know ahead of time.
Tips for hospital clinicians and team members
Learn the settings your patients move through. Ask post-acute and outpatient clinicians what they wish the sending team understood. SNF and IRF rehab and social work teams have told me they value a candid first conversation about prognosis and the gap between the support a patient will need at home and what they have in place.
Say who discussed what with whom. It makes patients and care partners feel cared about, and it sets the next team up well.
Follow episodes after your part ends. In BPCI Advanced, CJR, and our MSSP ACO population, my team and I went back through individual episodes, comparing spending with outcomes. A SNF team might say a patient needed a longer stay to need less help later. We'd check the notes and find nothing had changed or been sustained at home, and that follow-up physician appointments were never scheduled. Under TEAM, every participating hospital needs that habit. AI is making it easier to summarize documentation and surface what you need.
The black hole has a shelf life
Addressing the black holes between and within sites of care is a practical place to start improving episodes. Clinicians who learn the settings their patients move through can prepare people for what comes next and catch the gaps while there's still time to close them. But nothing matters more than setting up the episode for success from the hospital first.
Sources & Further Reading
Medicare doesn’t pay for custodial care when it’s the only care someone needs. Centers for Medicare & Medicaid Services. Long-term care. Medicare.gov. Medicare.gov: Long-term care coverage
What a Medicare-covered SNF stay requires, including the daily skilled care standard and the five-day therapy rule (your pages 18 and 19 excerpt). Centers for Medicare & Medicaid Services. Medicare Benefit Policy Manual, Chapter 8: Coverage of Extended Care (SNF) Services Under Hospital Insurance, §30. Medicare Benefit Policy Manual, Chapter 8 (PDF)
The Wyden RFI, including the home care guarantee proposals and the page 8 quote. Senate Finance Committee Minority Staff. Delivering an Affordable Home Care Guarantee for American Families: Request for Information. October 16, 2026. Comments due December 18, 2026. Senate Finance Committee RFI (PDF)
Who qualifies for Medicare home health, and how aide services work alongside skilled care. Centers for Medicare & Medicaid Services. Medicare Benefit Policy Manual, Chapter 7: Home Health Services. Medicare Benefit Policy Manual, Chapter 7 (PDF)
How TEAM works: five surgical episodes, mandatory for selected hospitals, with accountability through 30 days after the hospital stay or outpatient procedure. CMS Innovation Center. TEAM (Transforming Episode Accountability Model). CMS: TEAM model overview
CJR-X, the nationwide mandatory joint replacement model with 90-day episodes, starting January 1, 2028. CMS Innovation Center. CJR-X (Comprehensive Care for Joint Replacement Expanded) Model. CMS: CJR-X model overview
The VA trial behind the drop in SNF discharges from 13% to 8%. Hastings SN, Stechuchak KM, Choate A, et al. Effects of Implementation of a Supervised Walking Program in Veterans Affairs Hospitals: A Stepped-Wedge, Cluster Randomized Trial. Ann Intern Med. 2023;176(6):743-750. doi:10.7326/M22-3679. PubMed: STRIDE walking program trial
Further reading on why prior function and mobility during the stay matter: hospitalization often brings on lasting disability in older adults. Covinsky KE, Pierluissi E, Johnston CB. Hospitalization-associated disability: “She was probably able to ambulate, but I’m not sure.” JAMA. 2011;306(16):1782-1793. JAMA: Hospitalization-associated disability
Disclaimer: These are my personal opinions and ideas, not advice or a recommendation to anyone to do anything.
