“Custodial care” is nonmedical help with the Activities of Daily Living (like bathing and eating). “Skilled care” is medical care, such as giving medications and shots, dressing wounds, drawing blood, and so on.

The phrase “long-term care” can be confusing, since custodial care is sometimes used as a synonym for custodial care, and sometimes it’s used for the combination of custodial and skilled care that a person might receive in a nursing home.

I would like to spell these things out as simply as I can.

So, let’s first think, on a very basic level, about what we mean by long-term care.

A Personal Example: My Dad

As I have written elsewhere, my dad, Jim, passed from Alzheimer’s disease in 2016. I took care of him in his own home for four years. And then he was in a nursing home for four years after that.

That means that he suffered obviously from Alzheimer’s for at least eight years. In fact, it was longer. We can reasonably conclude this for two reasons.

Firstly, I started caring for him was because it was becoming increasingly apparent that he needed help. So, we are justified in believing that he was suffering from some cognitive impairment before I assumed the role of his daytime caregiver.

Secondly, scientists inform us that the brain degeneration of Alzheimer’s begins before any symptoms manifest themselves. Therefore, we can infer that Jim had the very beginnings of Alzheimer’s prior to anyone noticing that something was wrong with him.

But, once we became aware, we observed that he needed help with the basic tasks of everyday life.

Help With Everyday Activities

Called “Activities of Daily Living,” or “ADLs,” these include things like bathing, dressing, eating, maintaining continence, toileting by yourself, and transferring in and out of bed.

These are things we all need to do each day. That’s 24/7/365, as it were.

That’s the intuitive definition of “long-term care.” It’s help with the ADLs, delivered over a fairly long period of time.

So, what’s in view here is a person who has a chronic condition, disease, disability, or whatever and who is going to require everyday care over a long period of time.

Probably Also Need Extended Medical Care

It turns out that many conditions that will prompt this level of care are also terminal conditions. (I go into greater depth on terminal illnesses HERE and HERE. And I have a video on the topic, HERE.)

A personal who is so severely incapacitated that he or she needs daily assistance with the basic activities of living most likely also requires some kind of ongoing medical care.

Think about my dad, again. He had Alzheimer’s Disease. He required both medical care and nonmedical care. He needed supervision and medication, for instance.

As noted previously, one way of using the term “custodial care” is applying it to nonmedical care. But, a person – like my dad – who has a chronic and debilitating illness may very well also require medical care (e.g., pharmaceutical interventions, speech therapies, and so on). When we say “skilled care,” then, we’re thinking of this latter sort of care.

Possible Word Confusion: ‘Long-Term Care’

Once again, the intuitive difference between custodial care and skilled care is going to be that custodial care is essentially nonmedical / supervisory care, whereas skilled care is going to be medical.

Now there are a few different ways of kind of getting more clear on what the differences are, and I’m going to talk about what the actual care is in terms of (1) what is involved, (2) who provides the care, (3) where the care is provided, and (4) how you pay for it.

But before I do that, let me just say one another word about long-term care.

Sometimes, often in everyday speech, the word “long-term care” is used to encompass both custodial and skilled care. In this loose sense, long-term care basically means “whatever your loved needs over an extended period of time.”

A person may think about a relative who’s in a nursing home – like my dad was. My dad received both types of care in the nursing home. So, it’s tempting to think that my dad’s long-term care had medical and nonmedical elements. He needed both – over the long term.

Other times, the word “long-term care” is essentially used as a synonym for custodial care. This use is common in billing applications, healthcare insurance, long-term-care insurance, Medicare, Medicaid, etc.

The upshot is: understand the context of the word use. And, when you hear it, be sure that you know which definition of the word is operative!

‘Qualifying’ for Long-Term Care

What I mean, here, is essentially this: What are the diagnostic triggers that would prompt a doctor to say, “This person needs long-term care”?

This is an important consideration, especially – but not exclusively – for people who may have private nursing-home and other pertinent insurance policies. Long-term-care insurance generally “kick in” once the insured person is certified as being in need of long-term care.

2 Triggers

Physical

This is measured in terms of the “Activities of Daily Living,” or ADLs. In most materials, you’ll find six of these listed. I mentioned them, above: Bathing, dressing, eating, transferring, toileting, and controlling bodily functions.

From the physical point of view, to be “long-term-care certified” essentially means that you lack two out of six of these activities. So, if you’re incontinent and unable to feed yourself, then that would count. Or, if you’re unable to dress yourself and get in and out of bed by yourself, that would count also.

Your needs will have to be evaluated and documented by a licensed healthcare professional, chiefly, a physician.

Cognitive

But there’s also a cognitive or mental trigger.

You may also be certified as in need of long-term care if you have a cognitive impairment to a significant enough degree that you would require more or less constant supervision in order not to hurt yourself or other people.

Sometimes this trigger is pulled at the same time as the physical one, and other times the two are quite separate. In my dad’s case, for instance, he was physically able-bodied (in terms of the ADLs). He had no physical difficulties.

His problem, initially, was purely cognitive. Of course, as the disease progressed, his condition worsened and then he met the long-term-care qualification “tests” multiple times over. This is not uncommon.

Lacking Activities of Daily Living = Custodial Care

When you think of these Activities of Daily Living – bathing by yourself, dressing, feeding, and so on – think custodial care. Likewise, think of custodial care when you think about severe cognitive impairment that necessitates supervision.

Custodial care is going to be that kind of care that assists a person in receiving and in performing the Activities of Daily Living or providing the needed supervision.

Medicines, Medical Tests, Therapies, Etc. = Skilled Care

But my dad’s Alzheimer’s Disease also required certain pharmaceutical interventions. He was on put on the drug Aricept, for example. And it had to be administered to him at various times.

Of course, family members are able to administer that kind of medication at home. But in an institutional care situation, you wouldn’t want a person who doesn’t have proper licensing and proper credentials to administer drugs to your loved one.

But, as of this writing, people don’t need to be licensed to help bathe your loved one, or to help feed him or her.

Therefore, a second distinguishing feature of custodial care is that the care practitioners do not need to be licensed.

On the other hand, skilled care, as the medical portion of care, does require special training and licensing. In fact, that is one of the reasons it is referred to as skilled care.

Nursing Homes Provide Custodial & Skilled Care

In certain care environments, you are going to see a combination of these needs being met. So, for instance, a nursing home is a place that is going to provide both custodial and medical care for its residents. It’s a one-stop shop, so to speak.

One of the reasons why these definitions get a bit mixed up is because of the fact that we see our loved ones in this kind of composite care environment. It’s therefore natural to assume that everything going on in that environment is appropriately called “long-term care.”

Possible Care Environments

Of course, other care environments exist beside the nursing home.

Home Care

Number one, a person could receive care in his or her own home, or in the home of a friend or relative. Certainly, you can have people come into the home to provide the kinds of custodial supports that a person might need. And, generally speaking, if you’re receiving care in the home the professional care is probably going to be a supplement to a familial caregiver.

When my dad was living in the home, it was my mom and who were giving the supports that were necessary for him to get through the day. But, if we needed additional help, then we might call somebody else to the house.

This extra support could be skilled – like a visiting nursing – or unskilled/custodial. But, for the most part, we handled the custodial portion of the care ourselves.

Assisted Living

An assisted-living facility is a place that’s going to help people who are starting to have difficulty with the Activities of Daily Living. Such facilities try to emphasize and encourage independence. Seen from a different perspective, these facilities actually require a fair degree of independence – since they are generally not licensed or staffed to provide the level of care available in nursing homes.[1]

Nursing Home

But, for present purposes, the third main care environment is a nursing home.[2]

A nursing home is going to provide a level of care that’s a notch above an assisted-living facility in terms of comprehensiveness.

Whereas an assisted-living facility is equipped to provide low-level help with some daily activities, a nursing home is able to provide full-blown custodial care.

And whereas an assisted-living facility likely has a nurse or doctor on call, a nursing home always has medical practitioners on the premises. Skilled care is part of the overall care provided by the home.

To put it slightly differently, nursing homes provide comprehensive care services.

Billing of Services

Why are these distinctions so important?

Well, the distinctions become important largely when it comes time to pay the bill!

As usual, this discussion can become nuanced and detailed. But here’s the bottom line.

There are three main ways to pay for long-term care services, broadly construed.

Private Pay

“Private paying” is where you pay for yourself. You’ll likely do this out of your own assets (e.g., checking, money market, savings accounts; emergency funds; retirement vehicles; etc.) or your own income (for instance, annuities, pensions, rental payments, social security, and so on).

While you pay for yourself, you can go wherever you can afford. You can have whatever accommodations and services you like. At least, you can have all this so long as your money holds out.

At the level of nursing-home care, your bill is likely going to be a composite of skilled nursing services and custodial services. But if you’re paying entirely out of pocket for your care, then it doesn’t matter which sort you’re being billed for. You pay for everything yourself, regardless of what type of care it is.

So, in the private-pay scenario, the custodial/skilled distinction really doesn’t matter from the standpoint of your checkbook.

Government Aid

Medicaid

Once you “spend down” your assets to a particular – and low – level, you may be eligible for Medicaid. This is a government-assistance program that is geared towards helping impoverished people pay for necessary medical expenses.

For qualifying individuals, Medicaid pays for (portions of) both custodial and skilled care. However, there are strict asset and income tests that are applied.

Moreover, your preferred facility may not be able to accommodate you. Some facilities have no or few “Medicaid beds.” Others require that you have lived at the facility under private-pay arrangements for a specified period (not infrequently one or more years) before you can claim a Medicaid bed. Others have long waiting lists.

Typically, the relevant beds are in semi-private rooms with at least one other occupant. Additionally, Medicaid usually segregates its recipients by sex.

Medicare

What about Medicare?

For purposes of this post, let’s just say that Medicare is a government program that provides healthcare coverage for seniors (i.e., people over the age of 65).

In principal, then, Medicare is available to cover at least some of the medical-related, skilled-care portion of the nursing-home bill. Now, there are several caveats.

One of these is that Medicare only really covers hospital bills and short-term skilled-nursing costs.

Additionally, there are requirements that the skilled nursing, to be covered, must follow a hospital stay.[3]

Curative Vs. Palliative Care

Finally, Medicare is geared toward what is called “curative care.” In basic terms, this sort of care is supposed to (help to) restore a person back to good health.

“Palliative care,” on the other hand, merely relieves symptoms – it doesn’t “cure” a patient.

You run headlong into trouble, here, when you start to consider conditions, like Alzheimer’s Disease, that have no cures.[4]

Elsewhere, I have discussed the question of whether Alzheimer’s is a “terminal illness.” (For a written article, see HERE. For a video touching the issue, see HERE.)

But suffice it to say that Medicare doesn’t generally cover palliative care – except in end-of-life, hospice situations.

The Upshot

The long and short of it is this, then.

Medicare only covers short-term skilled care and curative care.

Custodial and palliative care is generally not covered by Medicare at all.

Medicaid may cover these – is a person is eligible based on asset and income qualifications.

But that means that if a person is receiving both custodial and skilled care in a nursing home, and even if Medicare is paying for some of the medical/skilled portion of their bill, they cannot rely on Medicare to pay for any of the help they get with Activities of Daily Living. And they cannot hope to get Medicaid assistance until their own assets are spent down.

Long-Term-Care Insurance

Besides paying out of your own assets and spending your own assets down until you qualify for Medicaid, really the only other payment option is to use proceeds from a long-term-care insurance policy.

Such policies have a high application-decline rate, partly because people generally wait so long to try to purchase them.

Now I get more in depth into long-term care in other places. But, essentially, long-term-care insurance is the kind of insurance that’s going to help you to pay for the nonmedical portion of your bill. Long-term-care policies pay benefits when you need custodial care.

So, if you are getting help getting paying for the medical or skilled-care portion of your bill via your health insurance or via Medicare, then a long-term care insurance policy is able to pay for the custodial-care portion.

Of course, you have to be long-term-care eligible in order to collect payouts from this type of policy.

Basically, “eligibility” comes to this. You have to lack two of six of the aforementioned Activities of Daily Living, or you have to be cognitively impaired to such an extent that you require supervision.

But, once a physician “certifies” you as long-term-care eligible in one or both of these ways, then your long-term-care policy is supposed to pay out.

Only a few policies these days have lifetime benefits. So, you should be aware that is it possible to exhaust the proceeds of such a policy. But, it does constitute a third possible funding option, and can delay or avoid exhaustion of your personal assets.

Confusions Summarized

One confusion arises with respect to the fact that “long-term care” is a phrase that can be used for both types of care, together, or as a strict synonym for custodial care only.

A second confusion comes from the fact that both kinds of care – custodial and skilled – are delivered side-by-side, in the same environments. For example, and as discussed, you may get both medical and non-medical care in a nursing home.

Thirdly, there are confusions with respect to how care is billed. What you have to realize is that nursing-home bill is going to be a conglomeration of items, some of which are going to count as custodial services, and others of which are going to be skilled. Who pays – and what kind of insurance or assistance is relevant (e.g., health or long-term-care insurance, Medicare, or Medicaid) – is going to depend in part on this classification.

The Major Issue Restated

For most people, the main point of learning the distinction between custodial and skilled care is to gain clarify and insight into the question of how the relevant types of services can be paid for.

Who pays for a particular care service and for how long is, in part, a function of whether the service is classified as “custodial” or “skilled.”

Custodial services – like help bathing, dressing, and eating – can be provided by unlicensed and non-skilled care providers. These services may be delivered in a variety of care environments – from your own home, to adult daycares, to nursing homes – but, ultimately, these services are not covered by health insurance or Medicare.

So, you’re stuck paying for these privately (that is, out of your own pocket), through Medicaid (after you’ve exhausted your own assets), or through long-term-care insurance.

Skilled care – that is, the sort of care that is provided by licensed and skilled medical professionals – may be covered by health insurance and Medicare. But this is not always the case because of Medicare’s rules and because it only really covers “curative” interventions – as discussed, above.

Notes:

[1] In terms of whether or not a person would be safe to reside in an assisted living facility, or whether they require a higher level of care, sometimes people talk about various requirements. These are things such as being able to get to an exit by yourself, being able to get around without mobility aids, and so on. I’ll get into greater depth on these questions in subsequent posts or videos.

[2] There are also adult-daycare, hospice, and respite facilities. But I will get into those in another place. See my video presentation, HERE.

[3] Getting into detail about the precise rules, here, is beyond the scope of this article.

[4] Presently, at any rate.