Medicare’s home-care benefits are limited

Gail – New Jersey: Our mom is 83 years old. She has bladder cancer that, despite surgery, has spread to her lungs, ribs and pelvic bone. She only has one kidney due to a cancerous mass more than 20 ago, and this one kidney is starting to fail. She has chronic obstructive pulmonary disease with daily inhalers. Since her surgery, she has deteriorated more and more each day. Between my sister and myself, mostly my sister, we have been caring for her the best we can. However, it has come to a point that we need some assistance. She does have a nurse seeing her once a week. We wanted to know at what point would hospice care be considered covered or if she can get just health care assistance in bathing her and helping her with incontinence issues? Please let us know your thoughts and what would or could be covered by her insurance.

Phil Moeller: I’m so sorry to hear about your mom, and wish the best to her, you, your sister and other family members.

Medicare generally does not cover non-medical care to help your mom with what are known as activities of daily living.

Her doctors can recommend hospice if they think she has six months or less to live. This is the “trigger” for hospice benefits. If she survives longer than six months, she can remain in hospice if her doctors issue a new prescription.

Medicare generally does not cover non-medical care to help your mom with what are known as activities of daily living (ADLs) such as bathing, dressing and eating. If your mom’s Medicare coverage also includes a private Medicare Advantage plan, I’d suggest you call that insurer to confirm its coverage rules for help with ADLs.

If your mom’s income is very small, she might qualify for Medicaid, which might cover such non-medical care. Medicaid eligibility and coverage rules vary by state. The State Health Insurance Assistance Program (SHIP) provides free Medicare counseling and should have someone in a New Jersey office who can address state Medicaid eligibility questions.

Vivian – Texas: My mom just turned 90 and pays out-of-pocket for oxygen and home health due to getting denied payment from Medicare. She uses all her fixed income. She is bedridden and in an electric chair. She has an incurable muscle disease and is a heart patient. Who can I contact to see why Medicare doesn’t help with her costs?

Phil Moeller: Unfortunately, Medicare does not cover non-medical expenses, which is why she can’t get home health care. As for her oxygen, I am not clear about that. If her doctor has prescribed oxygen as medically necessary, it should be covered. You can call 1-800-Medicare to ask about that coverage.

If she has a private Medicare Advantage plan, it still should cover everything that basic Medicare covers, although plans generally require prior approval for therapies. If she has only what’s called original Medicare (parts A and B), she can appeal a claim denial. Instructions about how to do so should be included in any claim denials she has received.

Sorry I don’t have more encouraging news. Many people mistakenly think that Medicare covers lots of things that it doesn’t, only to learn the reality of its limitations when they or a loved one is denied coverage.

Brenda – Missouri: My mom lives in Kentucky and needs an aid or nurse to come in once a month to check on her. Does Medicare pay for such service? I have asked her to check it out and all she says is they don’t pay for anything. I live out of state so I’m no help. Is Medicare coverage the same in all states?

Phil Moeller: Generally, Medicare covers medically required things but not help with non-medical care. Unless a doctor prescribes home health care as medically necessary, it won’t be covered.

I am assuming your mom has basic Medicare — Parts A and B. If she has a private Medicare Advantage plan, its rules can be a bit different. In general, however, basic Medicare and Medicare Advantage cover the same things anywhere in the country.
If she has been rejected for coverage, there should be a document trail, either from a Medicare contractor or a Medicare Advantage insurer. These rejections usually include instructions for appealing a denied claim.

If you think your mom’s needs are medical in nature, I’d call her primary doctor’s office and try to discuss this and see if there is a medical basis for having her care covered.