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Question - What is the difference between "skilled" and "custodial" care?:

My uncle was placed in a convalescent care facility approximately 1 1/2 years ago. Medicare and AARP paid their maximum benefits for skilled care.My aunt's insurer now refuses to pay any benefits since they believe the care to be "custodial". Essentially, my uncle's care hasn't changed since he entered the facility. The administrator of the facility told my aunt that the facility only provides skilled care and not custodial care. Bills are escalating would appreciate any thoughts or observations you might have.

Guide Responds:

What a difficult situation. Generally care is considered skilled when a trained professional must do it, because the care is changing frequently and needs professional assessment of efficacy or condition. Care is considered to custodial when the patient is stable and the care needs have not changed nor are they expected to change much and the care is routine enough to teach any competent adult to perform this care.

Medicare and AARP (I'm assuming this is a Medigap policy) do have a limit of coverage. I'm not sure what your aunt's insurer is, but when payment for care is denied, they must also provide a means to appeal this decison. If appeal information is not received when any care is denied, you need to call and ask for this information. As you can see in the first paragraph skilled vs. custodial is not exactly cut and dried. Any time an insurer renders a decision you disagree with you have the right to appeal. Additionally, should all else fail you can file a complaint with your state insurance commission.

• Medicare Basics
• Contesting Health Insurance Denials

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