A nurse, a therapist and a handyman cut disability 30%, yet Medicare rarely pays for it

Key takeaways

• In a Baltimore trial of 300 low-income adults 65 and older, a five-month home program called CAPABLE cut difficulty with basic self-care by 30% compared with friendly visits².
• CAPABLE averaged $2,825 per person, yet Medicare and private insurers don’t typically pay for it¹⁴.
• Medicare’s home health benefit requires that you be homebound and need skilled care, and it won’t pay for help with bathing or dressing when that’s the only help you need⁹.
• An industry survey by Genworth, which sells products to help pay for long-term care, and its CareScout subsidiary put 2024 median costs at $77,792 a year for a home health aide and $70,800 for assisted living¹².
• You don’t need a lawyer to name a health care proxy or write a living will, and many states offer free forms, according to the National Institute on Aging¹³.

Between 2012 and 2016, researchers in Baltimore enrolled 300 low-income adults 65 and older who were struggling with everyday tasks². Most were women, and most were Black².

Half got CAPABLE, a home program with up to 10 visits over five months². An occupational therapist came six times and a nurse four times¹⁴. A handyman did up to $1,300 worth of repairs and changes to the home¹⁴. Everything aimed at goals the participants chose themselves².

After five months, the CAPABLE group had 30% less difficulty with basic self-care than a comparison group that got social visits instead². John Haaga of the National Institute on Aging, which paid for the trial, told KFF Health News that a drug with that effect would get nonstop press coverage¹.

Yet Medicare and most private insurers don’t typically pay for programs like this¹. That gap is the theme of this article. Independence often rests on ordinary tasks and ordinary help, the kind health insurance often leaves out.

Below, we look at what works, what Medicare and Medicaid pay for, and the planning that keeps your choices in your hands.

Independence lives in everyday tasks

Clinicians sort daily tasks into two groups. Activities of daily living (ADLs) are basic self-care, such as bathing, dressing and using the bathroom⁸. Instrumental activities of daily living (IADLs) are the jobs of running a household: shopping, cooking, managing money and medicines, and getting around.

The line matters because it often decides who pays. Medicare calls non-medical help with ADLs “custodial care.” It doesn’t cover that care unless you also need medical care⁸. Medigap policies don’t cover it either⁸.

CAPABLE enrolled people who had trouble with at least one ADL or two IADLs². A companion article on physical function covers the tests clinicians use to measure these abilities.

CAPABLE works on the person and the house at once

CAPABLE starts with a question: what do you want to be able to do again? Its developer credits that focus on people’s own goals, rather than their diagnoses, for its results, KFF Health News reported¹. The therapist and nurse work on the person’s own skills, while the handyman changes the home around them².

What the 2019 trial, published in JAMA Internal Medicine, found²:

• Self-care improved. ADL difficulty was 30% lower than in the comparison group.
• Household tasks moved less. IADL difficulty was 17% lower, a gap that could have been chance.
• People noticed. About 82% said the program made their life easier, compared with 43% of the comparison group. About 80% said it helped them take care of themselves, versus 36%.

The gains faded over 12 months¹. Dr. Kenneth Covinsky of the University of California, San Francisco, who co-wrote an editorial on the trial, told KFF Health News that follow-up calls or extra visits would probably be needed to keep them¹.

A 2023 review in the journal Age and Ageing pooled seven CAPABLE studies with 2,921 low-income older adults³. In the five randomized trials, CAPABLE groups ended up a little under one point better than controls on ADL difficulty scores³.

The reviewers flagged limits³. Follow-up assessments differed from study to study, results varied widely, and participants knew which group they were in. The program also excludes people with moderate to severe dementia³.

Does it save money? An evaluation funded by the Center for Medicare and Medicaid Innovation, published in Health Affairs in 2017, found Medicare spending about $2,765 lower per person per quarter, according to slides presented by CAPABLE’s developer, Sarah Szanton⁴. Hospital stays didn’t change significantly in that analysis⁴.

KFF Health News, citing research by Szanton and others, reported nearly $10 in combined Medicare and Medicaid savings for every $1 spent, mostly from avoided hospital and nursing home stays¹. Treat both figures as early estimates. We couldn’t check them against the journal, and the slides’ hospital numbers don’t show the drop that explanation implies⁴.

Can you get it? When KFF Health News looked in early 2019, grants and foundations paid for most CAPABLE programs, which were running in 26 places across 12 states¹. Medicaid in two states, Massachusetts and Michigan, had picked up a version for some enrollees¹. The developer’s later slides, from 2020 or after, list 34 sites⁴. Ask your health plan, your state Medicaid office or your local Area Agency on Aging whether something similar is offered near you.

Reablement: short, intense help to relearn daily tasks

Some countries offer “reablement,” also called restorative home care. It’s a burst of help, usually 6 to 12 weeks, from a team that sets goals with you and aims to make you as independent as possible⁵. The hope is that you need less help later.

The evidence is thin. A 2016 Cochrane review, from the independent network that pools medical research, found only two trials, with 811 people in Western Australia and Norway⁵. Its searches ran through 2015⁵.

Function improved slightly with reablement, but the reviewers rated that evidence very low certainty⁵. In the larger trial, fewer people were later approved for higher-level personal care, and costs over two years averaged about 19,900 Australian dollars, versus 22,800 with usual care, though the authors were unsure how much that gap mattered⁵. They concluded that reablement’s value can’t yet be confirmed or ruled out⁵.

A 2021 umbrella review by Ireland’s Health Research Board, which drew on 13 systematic reviews, reached a similar view⁶. It saw positive signals for function, with the clearest benefit being less need for ongoing home care⁶. Evidence on quality of life, hospital use and costs was inconclusive⁶.

In the U.S., the closest match may be Medicare home health, which says its care can help you regain independence and become more self-sufficient⁹. Note the wording, though: Medicare lists “continued” occupational therapy, not occupational therapy on its own, among the needs that qualify you⁹. Ask the agency how that applies to you.

Hearing aids moved onto store shelves in 2022

Since October 17, 2022, adults 18 and older with perceived mild to moderate hearing loss can buy hearing aids over the counter, with no exam, hearing test or prescription⁷.

About 30 million people in the U.S. have hearing loss, and only about one in five people who could benefit seeks help, the FDA said in its rule⁷. The agency’s rule also cited research tying treatment of hearing loss to less cognitive decline and depression and to more social participation⁷. Our article on loneliness covers a major hearing trial.

The FDA set limits on how loud the devices can get⁷. It also requires a label that tells buyers to see a doctor, preferably an ear, nose and throat specialist, if they have certain problems before or after buying⁷. The FDA’s discussion of the rule names ear drainage, ear pain, balance problems and ringing in one ear among them⁷. Anyone under 18 should see a doctor and not use OTC aids⁷.

A later article on hearing and vision checks covers when to get tested.

What Medicare covers at home, and the gap it leaves

Home health. Medicare’s home health benefit has strict rules. You qualify only if all of these are true⁹:

• A doctor or other allowed provider oversees your care under a plan reviewed regularly.
• You need part-time or intermittent skilled nursing (other than blood draws), physical therapy, speech therapy or continued occupational therapy.
• You’re homebound, meaning leaving home takes help or a major effort. Trips for medical care, adult day care, religious services or the occasional outing are allowed.
• You use a Medicare-certified agency, and a provider documents a face-to-face visit about the reason you need care.

When you qualify, a home health aide can help with bathing and dressing, but only while you’re also getting skilled care⁹. Aide and nursing time combined must stay under 8 hours a day and at or below 28 hours a week, with up to 35 in limited cases⁹.

Medicare home health doesn’t cover 24-hour care, delivered meals, shopping, cleaning or laundry⁹. It also doesn’t cover personal care when that’s the only help you need⁹. The booklet does say care may help you keep your current level of function or slow a decline, not only improve⁹. Our article on trainers and physical therapists explains the court settlement behind that rule.

Before giving you a service Medicare probably won’t cover, the agency must give you a written notice called an Advance Beneficiary Notice⁹. Read it before you sign.

Long-term care. Medicare generally doesn’t pay for long-term nursing home stays¹⁰. Most people start by paying out of pocket¹⁰. Medicaid can help people with limited income and savings, and its rules vary by state⁸¹⁰. Long-term care insurance and some life insurance policies can also help pay¹⁰.

PACE. The Program of All-inclusive Care for the Elderly is meant for people who need nursing-home-level care but can live at home with support. To join, you must be 55 or older, live in a PACE service area, be certified by your state as needing nursing-home-level care, and be able to live safely at home with PACE’s help¹¹.

PACE covers all medically necessary Medicare and Medicaid services, plus extras the care team approves¹¹. That includes adult day care with meals, home care, drugs, dental care and rides¹¹. With Medicaid, there’s no monthly premium; with Medicare alone, you pay one¹¹. You must use the program’s own network¹¹.

What help costs when you pay yourself

Widely cited cost figures come from an industry survey. Genworth, a company that sells products to help families pay for long-term care, and its CareScout subsidiary contacted more than 140,000 providers and completed more than 15,000 surveys in late 2024¹². Here are their national medians for 2024¹²:

Type of care	Median yearly cost	Change from 2023
Home health aide	$77,792	Up 3%
Homemaker services	$75,504	Up 10%
Adult day health	$26,000	Up 5%
Assisted living	$70,800	Up 10%
Nursing home, shared room	$111,325	Up 7%
Nursing home, private room	$127,750	Up 9%

For scale, by our math, CAPABLE’s average cost of $2,825, a 2019 figure¹, equals less than 4% of a year’s median home health aide bill¹². The survey also reports figures for 431 local regions, so check yours¹².

Plan now, so others know your choices

Planning protects your independence even if you someday can’t speak for yourself. The National Institute on Aging (NIA) says talking with loved ones is the most important part¹³.

Then put your wishes in writing. NIA describes two main documents¹³:

• A living will tells doctors which treatments you want or don’t want, and when.
• A durable power of attorney for health care names a proxy to make medical decisions if you can’t.

These documents take effect only if you can’t communicate¹³. Your proxy can act only then, and you can limit their power¹⁴. NIA suggests choosing someone you can talk with openly, who will honor your wishes, can handle family disagreement and can get to you¹⁴. Ask them first, and name a backup¹⁴.

You don’t need a lawyer¹³. Many states offer free forms, and your local Area Agency on Aging can help; the Eldercare Locator at 800-677-1116 will connect you¹³. Review your documents at least once a year and after big changes, such as a move or a new diagnosis¹³.

Skipping this has a cost. Without a proxy, state law decides who speaks for you, usually a spouse, parent or adult child, and an unmarried partner may be left out¹³. In one study NIA cites, people guessed wrong on nearly one in three end-of-life choices for a loved one¹³.

Plan for money decisions, too. A legal aid office or a lawyer can explain the options in your state.

Your independence plan

This is our own tool. Fill in the “your status” column now, then revisit it once a year, or sooner after a hospital stay or a fall.

Task area	Early signs to watch	Your status	Supports to line up now	Who usually pays
Bathing, dressing, toilet	Avoiding the tub; struggling with buttons		Occupational therapy; home changes like a CAPABLE-style repair2	Medicare only alongside skilled care9; otherwise you, Medicaid if eligible, or insurance810
Meals and shopping	Empty fridge; weight loss; skipped meals		Delivery, a shopping helper, a meal program	Not Medicare home health9; PACE day centers serve meals11
Medicines	Missed doses; confusion about pills		Pharmacist review; pill organizer	Ask your pharmacist or plan
Getting around	Stopped driving; missed visits		Ride options; a companion article on mobility	PACE includes rides11
Hearing	Asking people to repeat; avoiding groups		OTC hearing aid or hearing test; see a doctor for warning signs7	You, for OTC devices
Home upkeep and safety	Clutter; broken steps; falls		Handyman repairs; a home safety check	Medicare won’t pay for cleaning9; CAPABLE funding varies1
Daily hands-on help	Needs help most days		PACE if eligible11; home care agency	Medicaid or PACE if eligible; otherwise private pay101112
Big decisions	None; plan while you’re well		Living will and health care proxy13	Free state forms13

Self-reliance, built into the house

Natural health prizes self-reliance, and CAPABLE puts that value at its center. It asks what you want to do, then builds your skills and fixes your surroundings so you can do it². A handyman counts as part of the care team. So does your own judgment.

Planning documents carry the same value forward. They let your choices outlast a crisis instead of leaving them to your state’s default rules¹³¹⁴.

How the evidence stacks up:

Approach	What the research shows	Evidence level
CAPABLE for difficulty with self-care	30% less ADL difficulty at 5 months in one trial; benefit in pooled trials, with wide variation23	Promising but early
CAPABLE for household tasks	Smaller gain that could be chance in the main trial; a small pooled gain across trials23	Promising but early
CAPABLE lowering Medicare costs	One federally funded evaluation, as presented in the developer’s slides, plus a savings estimate reported by KFF Health News14	Promising but early
Reablement for daily function	Two trials; very low certainty56	Not enough evidence
Reablement for reducing later home care	Positive signals across several reviews56	Promising but early

Questions readers ask

The bottom line

Independence is lived at home, in the bathroom, the kitchen and the checkbook. Of the approaches we reviewed, programs that work on the person and the house together have the most promising evidence, but few insurers pay for them, and Medicare’s home health benefit is narrow.

So plan on two tracks. Line up help early, starting with an occupational therapist, a hearing check and a clear look at what Medicare, Medicaid or PACE would cover. And put your health care wishes and your proxy in writing while you can.

Related reading

• Most family caregivers were never trained, and Medicare now pays to teach them
• A trainer coaches your squat while a physical therapist treats what hurts
• What eases loneliness, which depends less on how many people you see
• Staying independent longer by accepting help sooner
• Your house was built for someone thirty years younger

Sources

1. Graham J. “Frail Seniors Find Ways To Live Independently.” KFF Health News, January 31, 2019. kffhealthnews.org
2. Szanton SL, Xue QL, Leff B, Guralnik J, Wolff JL, Tanner EK, Boyd C, Thorpe RJ Jr, Bishai D, Gitlin LN. “Effect of a Biobehavioral Environmental Approach on Disability Among Low-Income Older Adults: A Randomized Clinical Trial.” JAMA Internal Medicine, 2019;179(2) (abstract, Drexel University research record). researchdiscovery.drexel.edu
3. Rahmati M, Keshvari M, Koyanagi A, Yon DK, Lee SW, Shin JI, Smith L. “The effectiveness of community ageing in place, advancing better living for elders as a biobehavioural environmental approach for disability among low-income older adults: a systematic review and meta-analysis.” Age and Ageing, 2023;52(4):afad053. pubmed.ncbi.nlm.nih.gov
4. Szanton S. CAPABLE presentation slides (citing Ruiz S, et al., Health Affairs, 2017). Maryland Philanthropy Network, undated (circa 2020). marylandphilanthropy.org
5. Cochrane A, Furlong M, McGilloway S, Molloy DW, Stevenson M, Donnelly M. “Time-limited home-care reablement services for maintaining and improving the functional independence of older adults.” Cochrane Database of Systematic Reviews, 2016, CD010825.pub2. pubmed.ncbi.nlm.nih.gov
6. Keane M, Cagney O, Cochrane A, Lee C, Farragher A, Long J. “Reablement in the home for people aged 65 years and over.” Health Research Board, Dublin, June 2021. hrb.ie
7. U.S. Food and Drug Administration. “Medical Devices; Ear, Nose, and Throat Devices; Establishing Over-the-Counter Hearing Aids.” Final rule, Federal Register 87(158), August 17, 2022. govinfo.gov
8. Medicare.gov. “Long-Term Care Coverage.” Centers for Medicare & Medicaid Services, accessed October 2026. medicare.gov
9. Centers for Medicare & Medicaid Services. “Medicare & Home Health Care.” CMS Product No. 10969, July 2025. medicare.gov
10. Medicare.gov. “How can I pay for nursing home care?” Centers for Medicare & Medicaid Services, accessed October 2026. medicare.gov
11. Centers for Medicare & Medicaid Services. “Quick Facts: Program of All-inclusive Care for the Elderly (PACE).” CMS Product No. 11341, December 2025. medicare.gov
12. Genworth Financial. “Genworth and CareScout Release Cost of Care Survey Results for 2024.” Press release (industry data), March 4, 2025. investor.genworth.com
13. National Institute on Aging. “Advance Care Planning: Advance Directives for Health Care.” NIH, reviewed October 31, 2022. nia.nih.gov
14. National Institute on Aging. “Choosing a Health Care Proxy.” NIH, accessed October 2026. nia.nih.gov