Medicare won't cover long-term home care

Q. My mom had a nurse, physical therapist and bath aid coming to her home for several weeks after she was hospitalized from a stroke. She has now been "discharged" from these services and we are being told if we want someone to help bathe her, we will have to pay for it ourselves. She gained some strength and motion back, but she still needs a lot of help and I'm still working. She doesn't have money to pay for someone to come help her. We thought Medicare covered things like this.

A. As the saying goes, if I had a dollar for every time I've heard that … . Unfortunately, this is a prevalent misconception about Medicare coverage. Medicare covers what is called home health services, or skilled care in the home, usually after a hospitalization, but it can be doctor-ordered if there is a medically necessary reason. Skilled care includes a visiting nurse; physical, occupational and speech therapy; oftentimes a social worker; part-time or intermittent home health aide services; and some durable medical equipment and medical supplies. It does not cover on-going care in the home.

Original Medicare Part A helps cover hospital care, skilled nursing facility care, hospice care and skilled home care. It does not pay for custodial or long-term care in a community setting or in the home. Deductibles, copayments and coinsurance might apply. Original Medicare Part B helps cover medically necessary doctor's services, outpatient care, some home health services, some durable medical equipment and mental health services. Part B also covers many preventive services. Again, individuals might have to meet a deductible, or have copayments or coinsurance.

Medicare Advantage plans combine the benefits of Part A and Part B, often with a Part D drug plan, into one premium. Advantage plans must cover all medically necessary services that Original Medicare covers, but often plans limit services to specific networks or providers, and individuals might need a referral or pre-approval for services. Like Original Medicare, Advantage plans do not cover custodial or long-term care services.

Supplemental insurance coverage, or Medigap coverage, is sold by private insurance companies to individuals with Original Medicare. Medigap coverage helps to pay some of the remaining health care costs for covered services and supplies, like copayments, coinsurance and deductibles. Medigap plans do not cover long-term care or in-home care either.

If someone continues to need care in the home after skilled services have ended, there are really three options: private pay for care, use long-term care insurance policy coverage or apply for Medicaid- or grant-funded programs. If you have paid for a long-term care insurance policy, you need to contact the insurance provider to understand what might be covered and how to access the services. Some policies have generous coverage for on-going in-home care, or coverage of care in assisted living, while other policies might only cover very limited services or for a limited time frame.

Medicaid-funded programs include the MI Choice Medicaid Waiver, Adult Services, MI Health Link, Community Transition Services (for individuals in a nursing home or at risk of returning to a nursing home) and the Program of All Inclusive Care for the Elderly (PACE.) All of these programs have both financial and medical level of care criteria to qualify. They all can provide either agency paid care in the home, or the possibility of paying a friend or family member to be a caregiver, as well as other services such as transportation, meals and durable medical equipment. Additionally, Area Agency on Aging Region IV has care management services available through Older American Act funding to provide a free, professional and unbiased assessment to help explore options and resources. Some individuals might qualify for help that could be fully funded or funded on a cost-share basis.

To best understand all your options, contact our Info Line for Aging and Disability at 800-654-2810 or check out our website at AreaAgencyonAging.org.

Sara Duris is community information liaison of Region IV Area Agency on Aging in Southwest Michigan. Questions on age or independence services? Call the Info-Line for Aging & Disability at 800-654-2810 or visit areaagencyonaging.org. The Generations column appears each weekend in The Herald-Palladium.