Bolinas resident Rosemary Robinson has no idea who's going to come to her home every night after Sept. 15 to help care for her bedridden husband.

Lyman Robinson, 78, suffers from progressive supernuclear palsy - a rare, terminal brain disease. For an hour every night for the past three years, a rotation of certified home-health aides employed by Novato-based Clarke Home Nursing Service has helped to exercise and bathe him.

But due to an intricacy in the vast morass of Medicare, Clarke as of Sept. 15 will no longer provide aides, nurses, physical therapists, or speech therapists to the Robinsons or 400 other patients, 17 of whom live in Stinson Beach, Bolinas, Olema, Point Reyes Station, Inverness, Marshall, Tomales, Forest Knolls, and Woodacre.

"I don't know how this is all going to turn out," Rosemary Robinson lamented on Monday. "They say, 'Don't worry,' but we're worried. Clarke is a wonderful company. I'm just shocked that Medicare has pulled the rug out from under them. It's strange that this happened so suddenly."

The federal Health Care Financing Administration has determined that a technicality in California's home-care-licensing rules makes Clarke ineligible for Medicare reimbursements from 1992 to 1995.

The feds have demanded that Clarke, which is employee-owned, repay Medicare for its billings in 1995 - a total of more than $14 million - and have threatened to recoup reimbursements back to 1992.

The small company has little choice but to discontinue services, and Clarke employees are furious. They accuse the Administration and Medicare of using an esoteric legalism to put a company out of business, throw more than 200 people out of work, and disrupt lives of 400 families whose lives are already difficult to manage.

No, Clarke's patients won't be left without care. The company is arranging for its patients to be covered by Marin Home Care, a service of Marin General Hospital.

But many of the West Marin families served by Clarke have come to know and trust the small staff of nurses, therapists, and personal aides, and they're anxious about putting themselves into unfamiliar hands.

Clarke is a victim of Operation Restore Trust, a warm-puppy federal program that was piloted by California and four other states in 1995 to snuff out fraud in the Medicare program.

As part of the operation, the Health Care Financing Administration audited Clarke and found that its offices in Point Reyes Station, Larkspur, Novato, Ukiah, Sonoma, and Santa Rosa were not licensed as official branches.

Home-care licensing is a state function, and "the state has never found us in non-compliance with its own law," said Clarke President Ken Clarke, son of company founder June Clarke.

Even though Clarke and its lawyers believed the offices were adequately covered under the company's umbrella license, Clarke subsequently went ahead and secured individual licenses.

Nevertheless, the Health Care Administration last year determined that Clarke was not entitled to Medicare reimbursement while the branches were unlicensed, and told Ken Clarke the company would have to pay that money back.

The Administration has also withheld $1.3 million in Medicare reimbursements from fiscal year 1997.

Alysson Blake of the US Health Care Financing Administration's Medicare division, said, "We agree" that consequences of the demand for repayment are harsh, but federal attorneys have said there is no way around the law. "We are really stuck," she said.

Blake acknowledged that the licensing issue was the only problem. "We did not find [any] problems with quality of service provided."

Clarke sought advice from the National Association for Home Care and the Center for Health Care Law. Lawyers there responded that Clarke may have a case, but warned that getting a federal court injunction would be a "long and expensive process."

Armed with that opinion, Ken Clarke assembled most of the company's roughly 225 employees - who didn't know why they had been gathered - to make the tough choice to get out of the business.

If talks between Clarke's lawyers and the Health Care Financing Administration fail, Clarke will take the Medicare program to court, said Ken Clarke, but only to clear the company's name and obtain the $1.3 million in 1997 reimbursements withheld by Medicare.

Either way, Clarke will not resurface in the home-nursing business. "We're not going to play the game anymore," Clarke said. "The game is: more results [demanded] with less money and less time and more regulation. We refuse to operate in this environment."

Clarke's employees are disillusioned by what they see as an overall movement to balance the federal budget and gain political mileage by nudging local home-care companies out of the Medicare program.

"It was a real shock," said Inverness resident Lenore Dillon, a certified home-health aide who's been with Clarke for three years. Currently she works with patients in five West Marin towns.

"This is really creating a big void," Dillon said. Now, "people don't have any choice here."

She said June Clarke and her company "set out to get the best people. They did that by treating them decently and respectfully, and they paid them well. I'm grateful to have had this opportunity. At least I can take that with me."

Dillon noted that Donna Shalala, President Clinton's Health Secretary, has been heard crowing about how Medicare has cut tens of millions of dollars from its budget. What people aren't told, Dillon added, is that those savings sometimes fall heavily on companies like Clarke.

Patients of those companies still need care, and "that [Medicare] money has to go somewhere," she said. In this case, it's the much larger Marin Home Care and Marin General Hospital who get it.

Geoff Bradley, Clarke's primary case manager for West Marin, said the case is in line with the rhetoric in the national debates over Medicare and the federal budget. To cut costs, he said, Medicare is "going out trying to limit options for home health care."

What's ironic, he said, is that the number of home-care companies surged in response to an earlier attempt to cut healthcare costs - in 1984, Medicare began paying hospitals a flat fee for specific illnesses, regardless of length of stay.

Since then, it has been in a hospital's best financial interest to release patients as quickly as possible into the care of their families. "Home care blossomed to fill that gap," explained Bradley.

Now that home care is being pruned, "where will these people go? It's increasingly dangerous for patients."

Although Clarke is arranging with Marin Home Care for a smooth transition, some families are looking for other options.

"I think we would prefer going with a smaller organization," said Imantz Krese of Bolinas, whose father Rudolfs Krese, 93, suffered a stroke four years ago and is a Clarke patient.

The younger Krese is his father's primary caregiver. But he needs help with bathing, which he said "is not an easy task if you don't know what you're doing," involving complicated matters such as changing a catheter and treating infections - tasks Imantz couldn't do himself without training.

Krese said he'll miss the intimacy and familiarity Clarke provides and added, "I have a generally unfavorable impression of large, for-profit health maintenance organizations."