For most of us who are caregivers there will come a time when we need help...possibly hands-on help to give a bath, or someone to sit with our loved one while we get out for necessary errands...or maybe even a nurse to care for a wound or other medical need. We don't need a whole lot of help, just enough to give that little extra "something" so we can continue to keep our loved ones at home.  Eureka!  Medicare offers a Home Health Care benefit!

At least twice a week I hear from frustrated families who have not been able to get a coherent explanation as to why they aren't authorized to have an aide come to their loved one under Medicare, when someone "just down the street" has home care help from Medicare "every day." 

There actually is a good (if a little complicated) explanation. Part of the confusion lies in the terminology. Medicare uses the term "Home Care" very specifically to mean (1) skilled medical care, sometimes including the services of a trained aide; (2) delivered in the home; (3) by an approved Medicare agency; (4) for treatment of an illness or injury; (5) to an individual who is homebound; and (6) under the supervision of a physician.

You might see the term "home care" used to cover a broad range of services provided in the home, such as sitters and companions, homemakers, shopping and transportation services, as well as personal care services such as bathing, dressing, or feeding. This isn't Medicare's definition.

Medicare doesn't pay for "custodial care," which is the kind of long-term help that most caregivers desperately need. If the care provided is not to treat an illness or injury (even if the need for the care is because of an illness or injury), then the care is considered to be "custodial" and it is not covered.

Take, for example, two individuals who have needs that seem to be the same, yet Medicare will looks at them very differently:

Case #1: Shirley

Shirley, 83 years old, lives with her husband in their home. She has fairly severe dementia. Her husband, who has always been responsible, has Parkinson's Disease. Shirley is malnourished, and she hasn't had a bath for several months.  

As a result she has ulcers on her legs that aren't healing.   

Shirley qualified for Medicare Home Care assistance. A registered nurse visited her regularly for several weeks to treat the wounds on her legs and to teach the private  caregivers who were brought into the home to care for both Shirley and her husband.  During the several weeks that the Medicare nurse was coming to treat Shirley's legs, an aide was also sent regularly to give Shirley a bath. When the Medicare nursing visits ceased, so did the aide visits. By that time the caregivers had been taught to provide all of the care necessary to prevent the recurrence of the leg sores.

Case #2: Alice
When I met her, Alice lived alone in her own home. She, too, has dementia that is getting worse. She is severely underweight, and she, too, hadn't bathed for weeks, if not months. However, by some miracle, her skin is still in good condition.

Alice did not qualify for Medicare Home Care because she did not have a medical condition that needed treatment. Her inability to care for herself came about because of her dementia. She has no wounds or any other condition that a nurse or therapist could successfully treat. Therefore, Alice has to pay privately for the help that she needs. For the time being Alice remains in her own home with a full-time companion and with no in-home assistance from Medicare.