Some seniors find themselves in a situation where they need the help of a caregiver in their home. There are many reasons why you might need home health care.
Perhaps you are recovering from surgery or can no longer perform your daily activities. These care services can be expensive, so you might wonder whether Medicare will pay for your caregiver.
The answer depends on several factors, such as your medical needs and the caregiver’s qualifications. Keep reading to find out who qualifies as a caregiver under Medicare rules.
Medicare Caregiver Requirements
In this article, we will mostly refer to caregivers who provide care in your own home. Medicare will also pay for short-term care in a skilled nursing facility and many of the workers there may be referred to as caregivers. However, we will focus mainly on the requirements for a caregiver who comes to your home to provide care.
- Before reviewing the caregiver eligibility requirements, your doctor must declare you homebound. Your doctor must also create a specific plan of care that needs to be provided by your caregiver. Remember that being homebound doesn’t necessarily mean that you can’t get out of bed, but it does mean that you cannot leave your home frequently for medical care.
- Even if you attend adult daycare, you might still be eligible for caregiver services. Your doctor must certify that you need intermittent skilled nursing care, physical therapy, speech-language pathology, or continued occupational therapy. You will not be eligible for home caregiver services if you need more than intermittent or part-time care.
Next, you must be in an active recovery period. You might be recovering from surgery, a fall, or other medical conditions. If your condition is stable, then Medicare will not pay for a caregiver, and no one can qualify as a paid caregiver under the Medicare rules. Your doctor will need to monitor your condition to make this determination.
- In some cases, Medicare might pay for a caregiver temporarily as you recover, but once your condition stabilizes, they will no longer pay for caregiver services.
- The main requirement of the caregiver is that they come from a certified home health care agency.
Medicare maintains a list of certified agencies to make finding an in-home caregiver easy. You can use this tool to quickly and easily find a home health aide in your area that is certified by Medicare. Agencies that Medicaid approves will also be Medicare-certified.
Many people wonder if Medicare will pay family members as caregivers. The answer is no unless you have a family member who works for a Medicare-certified home health care agency.
In summary, the main requirement of a Medicare caregiver is that they come from a Medicare-certified home health care agency. Medicare will cover the cost of the caregiver only if your doctor has declared that you are homebound and created a plan for your personal care needs during an active period of recovery. Once your condition stabilizes and you are no longer actively recovering, Medicare will no longer pay for caregiver services.
Does Medicare Pay For A Caregiver?
Now that you know the requirements for a caregiver, you are likely wondering if Medicare pays for caregivers. There are several parts to Medicare, and the coverage details vary between each part. Here is what you need to know about each part of Medicare, including whether it will pay for a caregiver and how much it will pay.
Medicare Part A
In most cases, Medicare Part A is the part of Medicare that will cover your home caregiver. Medicare Part A is considered hospital insurance. It covers hospital stays, inpatient services, hospice care, and short-term stays in a skilled nursing facility. Part A does not cover long-term care in a nursing home, but it does cover home health services as long as the abovementioned requirements are met.
As long as the required Medicare conditions are met, you will not pay anything for covered home health services. Medicare will pay the total cost of a caregiver. This benefit can greatly help Medicare beneficiaries who need these services and provide peace of mind to family members who have a loved one needing this type of care.
Medicare Part B
Medicare Part B is traditional health insurance, covering doctor visits, outpatient services, ambulance services, preventive care, and durable medical equipment. However, it does not pay for home health care or caregiver services, although it can sometimes provide this benefit.
If home health care is required as part of discharge orders from a hospital, then Part A will provide the coverage. If the care is not the result of a hospital stay or you have exhausted the time limit for care under Part A, then Part B will provide coverage for home health care.
If you need durable medical equipment or medical supplies as part of your home care, Medicare Part B provides coverage for this equipment. It will cover it at 80% of the Medicare-approved amount.
This means that after you meet your Medicare Part B deductible, you will only be responsible for paying 20% of the Medicare-approved amount for the equipment.
The equipment may come directly from the home health agency or another provider. However, you should make sure that the equipment provider accepts Medicare. Otherwise, their pricing might be higher than Medicare allows.
Medicare Part C
Medicare Part C is part of Medicare and is known as Medicare Advantage. Medicare Advantage plans combine your Part A and Part B coverage into one plan. Private insurance companies manage these plans, and these companies contract with Medicare to provide this coverage. Each Part C plan must provide at least the same minimum level of coverage that Original Medicare provides. However, many Part C plans provide additional benefits beyond what Original Medicare provides.
Part C plans often include prescription drugs, dental, vision, gym memberships, and other benefits. Part C plans must offer at least the same home healthcare benefits as Original Medicare; however, some offer more. You might even be able to have your Part C plan pay for a family caregiver, or you might not need to meet all the traditional Medicare requirements.
In some cases, your Part C plan could provide benefits for home health care even after your condition has stabilized. It would be best to look at your plan’s paperwork for specific coverage information or call the insurance company that manages your plan.
Medicare Part D
Medicare Part D provides prescription drug coverage but does not pay for home health care or caregiver services. Private insurance companies manage these prescription drug plans; most plans have a formulary (a list of approved medications) associated with them. As long as your medication is included in the formulary, it will be covered. However, the plan will not cover medications not listed.
Part D plans will likely cover prescription drugs needed during your required in-home care. These medications should be part of your care plan, created by your doctor, and your care provider might administer them.
Medicare Advantage Plans
Medicare Advantage plans are Medicare insurance plans that private insurance companies manage. These plans must provide the same minimum level of coverage as Medicare. This means they must cover home health care services as long as the Medicare requirements are met.
However, many Medicare Advantage plans provide even more benefits than Original Medicare. These plans might pay for additional services that Medicare does not typically cover.
Your Medicare Advantage plan might cover personal care, respite care, and other services. To determine the specifics of your coverage, you should contact your insurance company or review your plan’s documentation.
You should also know that each plan sets its own rules about coverage and costs, and most plans require a monthly premium.
Medicare Supplement Insurance
Medicare supplement insurance, also known as Medigap, does not typically cover medical services directly. Instead, it helps pay for out-of-pocket expenses that Medicare does not cover.
These expenses might include deductibles, copays, or coinsurance amounts. When you receive medical treatment that Medicare covers, your Medigap plan might cover the cost of your copay. So, Medigap does not provide any direct coverage for a caregiver.
Since Medicare usually covers qualified caregiver services at 100%, Medigap coverage would not apply in most cases.
KEY TAKEAWAYS
- To be eligible for Medicare to cover caregiver services, your doctor must declare you homebound and create a specific plan for your caregiver to administer.
- Medicare Part A (or Medicare Advantage) is the plan that typically covers caregiver services; however, in rare circumstances, Part B may cover certain costs associated with home caregiver services.
- Medicare will not pay for 24-hour care at your home. It only covers part-time care. It also does not generally cover personal care or custodial care that assist with activities for daily living.
Home Health Services Not Covered By Medicare
Now that we have reviewed the basics of Medicare coverage for home health care, we will briefly discuss some items Medicare does not cover. Home health services can span a wide range of duties, so learning what Medicare will not pay for can be helpful. Here are a few examples.
- Medicare will not pay for 24-hour care at your home. Remember that Medicare will only cover the service if you need part-time care. Full-time care will not qualify for coverage.
- Medicare also does not pay for meals to be delivered to your home. While you might need to make arrangements for meals and food since you cannot leave home during your recovery, Medicare will not pay for these meals to be delivered.
- Medicare will not pay for homemaker services that are not directly included in your care plan.
Examples of these services could include cooking, shopping, cleaning, laundry, or other household duties or social services. Medicare will cover only services necessary for the care plan provided by your doctor.
- Medicare will not cover personal care or custodial care that assists with activities of daily living if this is the only care you need.
These activities might include bathing, dressing, using the bathroom, or other personal activities. If these types of activities are included in the care plan from your doctor, then they should be covered by Medicare. However, if this is the only type of care you require, Medicare will not cover it.
Must read articles related to Medicare
- What is a Medicare flex card for seniors & how does it
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- What’s the donut hole in Medicare?
- Who is eligible for Medicare?
- Overview of what is covered under Medicare.
Other Ways To Help Pay For Caregivers
Now that you know the Medicare coverage details for caregivers, you might be curious about what other programs are available to help cover the costs of a personal caregiver. Perhaps you need in-home care that Medicare does not cover. What other options are out there to help you pay for that care? Several programs are available, and here are some of the most common.
Medicaid Program
First, many Medicaid programs will help cover the cost of a caregiver. The rules vary slightly from state to state, so contact your Medicaid services office for coverage details. You might be eligible for dual enrollment if you are already enrolled in Medicare. This means that you may be able to enroll in both Medicare and Medicaid. Enrollment in Medicaid might allow you to have some caregiver services covered that would not typically be covered through Medicare.
Veteran Programs
If you are a veteran, a few different programs could help cover the cost of a caregiver. There is the Aid and Attendance program, the Housebound Benefits program, and the Comprehensive Assistance program. These three programs can provide financial assistance to those needing help to pay for a caregiver. You can learn more about your area’s programs by calling the Veterans Administration office.
State & Local Programs
Many state and local programs, as well as community-based services, are available to help the elderly pay for caregiver services. These programs are typically offered to low-income individuals and families, so contact a local social services office to learn more about them.
Long-term Care Insurance
Finally, long-term care insurance might help you cover the costs of a caregiver. Since most health insurance plans, including Medicare, do not pay for long-term care in a nursing home or your own home, these plans can help cover those costs. This can be a huge benefit, especially for those who need long-term care, such as Alzheimer’s patients.
Private insurance companies manage long-term care plans, and you must enroll in one of these plans to be covered. It is often a good idea to speak with a licensed insurance agent in your area who can discuss the available options and help you select the right plan for your needs.
TIP
The cost of in-home caregiver services can be quite expensive. However, you might be able to reduce your costs through a Medicare Advantage plan or other programs such as Medicaid, Veteran Assistance, State & Local services, and Long-term care insurance.
Finding The Right Caregiver For Your Family Member
Just because Medicare will pay for a certain caregiver does not mean that the caregiver is a good fit for you or your loved one. So, how do you find the right caregiver or care program for your family member? You should watch for several things, and it is important to do your homework before selecting a caregiver.
Using the home health care agency checklist is a great place to start your research. You will want to start with the basics, like making sure they are certified by Medicare and that they offer the specific type of care you need. However, your assessment should go far beyond just those qualifying basics.
- Check reviews and ask for recommendations from anyone you consider hiring as a caregiver.
- Ensure the agency has emergency numbers you can call if you need help outside regular business hours.
- Meet with the caregiver or agency to ensure they work well with your loved one. If you see any red flags in their behavior, you should move on to the next candidate.
You want to make sure you select a caregiver who will provide the necessary care and make you or your loved one feel comfortable.
The Bottom Line
Medicare will pay for a caregiver, but specific criteria must be met before the services will be covered. First, to qualify as a caregiver, the caregiver’s agency must be certified by Medicare. Next, your doctor must certify that you need part-time care services during an active recovery. Home health care services will not be covered if you need long-term care for a stable condition.
If Medicare does not cover your caregiver, other options exist. You might consider a long-term care insurance plan, a community-based assistance program, or a veterans’ program. There are many different options out there to help with caregiver costs.
Lastly, ensure you thoroughly check any possible caregivers to choose the best one for your situation.
Frequently Asked Questions
Under the rules of Medicare, a caregiver must come from a Medicare-certified home healthcare agency. However, other types of insurance plans might have different rules.
Some plans require licensed caregivers, while others will allow a family member to qualify as a caregiver. You should check the specifics of your plan to determine what rules must be met for someone to be classified as a caregiver.
Medicare will cover home health aides in some cases. The Medicare beneficiary must be declared homebound by their doctor, and the doctor must have created a care plan for the patient. They must also be in an active recovery period and not simply in a stable condition.
The aide must also come from a Medicare-certified home healthcare agency. If these criteria are met, then Medicare will cover a home health aide to perform the services that are specifically laid out in the care plan created by the doctor.
Caregiver costs vary widely depending on your location and the types of services that are needed. On average, a home healthcare aide costs about $20 to $50 per hour. Since caregivers are often needed for several hours each week, this cost can sometimes exceed $5,625 per month. The more hours a caregiver is needed, the higher the overall cost will be.
Similarly, a skilled caregiver will cost more than a caregiver who does not have specialized skills or training. To get an idea of the cost of a caregiver in your area, you should contact local agencies that can give you more detailed pricing information.
Medicare Part B does cover caregivers in some situations. Generally, Medicare Part B will cover a caregiver only if no hospital stay is involved.
If the care results from a hospital stay, then it will be covered by Medicare Part A. In addition, the caregiver must come from a Medicare-certified home health care agency.
You must also be declared homebound by your doctor and require part-time care specified in a care plan created by your doctor. If these criteria are met, then Medicare Part B will cover a caregiver.
These terms are often used interchangeably. However, a caregiver is often a family member who provides unpaid services to help care for a loved one.
This type of care might include cleaning, cooking, and other activities. On the other hand, a care provider is usually a health care worker who helps people at home. This could be a home health care aide, nurse, or other medical professional.
You can find a Social Security Administration office near you by using our SSA office locator and searching for your closest location.
