Caregiver and senior woman taking selfie portrait with smart phone. Photo by FredFroese/Getty Images

What options do seniors have for in-home care?

Editor’s Note: Journalist Philip Moeller is here to provide the answers you need on aging and retirement. His weekly column, “Ask Phil,” aims to help older Americans and their families by answering their health care and financial questions. Phil is the author of the new book, “Get What’s Yours for Medicare,” and co-author of “Get What’s Yours: The Revised Secrets to Maxing Out Your Social Security.” Send your questions to Phil.

Rachel – Montana:  My mom is 83 and can no longer walk. She has not left her home for months. My dad is 86 and has taken on caring for her. She has all her faculties and still has a sense of humor, but has a lot of pain. She sits in her lift chair all day and sleeps in it. She has a potty chair that she keeps beside her, and she can get up from her lift chair to use the potty chair, but it’s very painful for her to do so, and she can be left in tears from the exertion. She has arthritis in her legs, knees and feet. She also suffers from lymphedema in her legs.

My dad says as long as he can take care of her, she’ll stay in their home, and she is adamant about staying in her home as well. But my dad has diabetes, his feet have pain and he has slowed way down physically as well. They are on Medicare, and I’d love to find some in-home care for them, especially my mom. My dad is able to get around, still drives, shops for groceries and does some cooking. What are some options for them to bring a CNA [certified nursing assistant] into the home to help them? This is new territory for all of us. My youngest son (26 years old) lives in an apartment next door to them, has been their main help for six years and has loved doing so. But things are definitely not the same as they were when he first moved there, and they need someone trained in home health care. I have no idea where to start. I live 300 miles away from them, and I worry constantly.

Phil Moeller: My heart goes out to Rachel and to the millions of other families facing similar challenges. She has poignantly described what will become a major if not the major aging-related challenge of our time. This is an issue that our Washington leaders should be tackling aggressively.

Medicare does not cover so-called custodial care in the home. Medicaid does cover such help, but a person must spend down nearly all of their assets to qualify for Medicaid. Practically speaking, this leaves millions of families with no good option here. As the number of Americans in their 80s and 90s continues to soar, the shortage of in-home care solutions will only become worse. If proposals to tightly limit immigrants take effect, the already short supply of caregivers will turn into its own full-fledged crisis. And if Republican plans to sharply reduce Medicare and Medicaid benefits become law, things will move from stressful to awful to catastrophic.

If either parent needed in-home care to treat a medical condition, their doctor could prescribe this care and Medicare would cover it, but only for a short period and then only for a limited time each week. Here’s an explanation from Medicare of the in-home health services it covers. However, as I recently wrote, it can be very difficult for people to even find the in-home care that Medicare is supposed to cover.

A practical solution may be to find a private-pay, qualified home caregiver whom you would pay out of your own pocket to stop in during the day to help your mom and perhaps your dad. Whether you need a nurse or not, I don’t know. Sometimes, a trained caregiver who is not authorized to provide medical care can be the best solution. They can do much of what your parents need and also potentially help out with domestic duties. They also will cost you less than a nurse.

The key here is finding a local agency that is trusted and can provide someone on a reliable basis. This means, in all likelihood, that different people might show up from time to time. This can create friction and adjustment issues, but is often preferable to dealing with a single individual at risk of car troubles, family scheduling issues of their own and other reasons why they might not be able to show up when you need them.

READ MORE: Many seniors who qualify for home-based care under Medicare aren’t receiving it. Why?

For the in-home medical benefits that Medicare does cover, it requires enrollees to use only home care providers approved by Medicare and meet the agency’s performance and qualify requirements. Medicare provides an online tool to review these agencies. This is one place to start, but as my recent column noted, it can be very hard to find agencies willing to staff these short-term assignments.

I’d also recommend contacting a local office of the National Association of Area Agencies on Aging. Ask for recommendations or leads on trusted in-home caregivers.

All the best to Rachel and all the other families facing similar challenges in helping loved ones to age with dignity and comfort.

Jean – Pennsylvania: I signed up for Medicare coverage online about two months ago to get ready for my retirement on June 30, 2017. I turned 65 on Feb. 15, 2017. On the forms, I stated that coverage should begin July 1, 2017, as my employer health coverage is in force until June 30, 2017. Now, Medicare is sending a bill for coverage since my sign up. I have made several calls the last month and I visited the local Social Security office today. To make a long story short, they are telling me there is nothing they can do and that I owe the premiums. I am also not collecting Social Security yet. How do I get this mess straightened out? No one wants to even listen. They just tell me to pay.

Phil Moeller: I’m so sorry you are facing this hassle.

You will need to make another appointment at a local Social Security office, bring all your correspondence and just keep at it until you persevere. Yes, you shouldn’t have to do this. But in the real world, people have to do this all the time. In my experience, Social Security (which handles Medicare enrollments) will eventually do the right thing. It just needs lots and lots of effort on your part.

I work with several nonprofits that provide free Medicare counseling. I’d suggest you call the Medicare Rights Center for help.

Peg: Is the Medicare premium reset every year based on your tax return two years prior, or is it set once and once only? My concern is that when I retire, my tax return will put me in a high premium category, yet once I am done working, I will not be receiving that level of income.

Phil Moeller: It is reset. When your income goes down, so will your premium. Further, retirement is one of the life-changing events that can be used to appeal the high-income surcharge. So if your income was high in 2018, for example, but you retired in 2020, and your income has dropped, you can appeal and should be able to avoid paying the surcharge for even that year.

Raymond – California: I am moving out of the country and will be enrolled in that country’s health program. How can I terminate my Medicare Part B?

Phil Moeller: Social Security handles Part B disenrollments and requires you to complete Form 1763.

Bob – Florida: I am 67, and my wife is 64. If I start Social Security, can my wife file and suspend and start collecting 50 percent of my amount and still get her full higher amount at age 70?

Phil Moeller: Yes, but it’s not called file and suspend. The “file and suspend” option was eliminated under new Social Security laws that took effect last year.

READ MORE: Does Medicare pay for a home health care provider?

Once you’ve filed for your own retirement, your wife should not file for anything until her full retirement age. At that time, she can file what’s called a restricted application for just her spousal benefit while deferring her own retirement benefit until as late as age 70, when it will have reached its maximum amount.

The right to file a restricted application was also ended under the new laws, but not for anyone who turned 62 on or before the beginning of 2016.

Deidre: I am 66 and a half and have not applied for Medicare. I was covered by my husband’s employer insurance until he left the company. We were on COBRA for five months, and he has since gotten a new job, so we will be covered by his employer insurance again.

When I eventually do sign up for Medicare (likely in four to five years), would I have to pay a penalty on the Part B portion, since I was covered by COBRA for five months and not on employer insurance every month since I turned 65?  Also, I am thinking of signing up for Social Security online in the next couple of months. Will I have the option to not be signed up for Medicare, or will the website just automatically sign me up? I am eligible for Part A, but have not signed up. I plan to wait until I sign up for Part B to sign up for Part A as well. Is there any reason to sign up for Part A sooner? Lastly, do I have the option not to sign up for Part A when I am signing up for Social Security?

Phil Moeller: Lots of questions!

The time you were on COBRA is considered a break in your employer insurance as far as Medicare is concerned. Because you were of Medicare age when this occurred, your Medicare enrollment period would have begun then. So, when you eventually do sign up for Part B of Medicare, it’s possible you would be assessed a late-enrollment penalty. I say “possible” because your period on COBRA was so brief that it’s possible your Medicare enrollment period had not expired at the time your husband got his new job and you regained employer coverage.

READ MORE: How to hire in-home help when your aging parents don’t want to move

If you are assessed a penalty, it will be 10 percent for each full year you were without Part B. There also is a late enrollment penalty for Part D drug coverage, equal to 1 percent for each month you are late in enrolling.

When you sign up for Social Security, you automatically get Part A. The only way to reject Part A is to reject your Social Security benefits, which is a bad idea. Because you’re of Medicare age, Social Security may send you a Medicare card indicating you have signed up for Parts A and B. If this happens, you should send back the card and cross out Part B with the notation that you do not wish to sign up for Part B at this time.

Getting Part A right away can be a good idea, because it is a secondary payer of hospital claims that may not be fully paid by your employer insurance. However, anyone on Medicare — and this includes having Part A — is ineligible to continue making pre-tax contributions to a health savings account. So if your husband has a high-deductible health plan with an HSA, you might want to hold off getting Part A until you file for Social Security benefits.