Who Qualifies As A Caregiver Under Medicare Rules? Don’t Let Caregiving Costs Pile Up

An old lady walking with her caregiver.

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 you 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 a few factors, like your medical needs and the caregiver’s qualifications. Keep reading to find out who qualifies as a caregiver under the 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 mostly on the requirements for a caregiver who comes to your home to provide care.

Before we look at the caregiver eligibility requirements, you must first be declared homebound by your doctor. 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. You might still be eligible for caregiver services even if you attend adult day care. 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 some other medical condition. 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 very 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 are certified by Medicaid will also be Medicare-certified. Many people wonder if Medicare will pay family members as caregivers. The answer is no, unless you happen to 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?

A caregiver looking at something with her wheelchair bound patient.

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 full cost of a caregiver. This benefit can be a huge help to Medicare beneficiaries who need these services and can provide peace of mind to family members who have a loved one in need of this type of care.


— Medicare Part B

Medicare Part B is traditional health insurance, covering things like doctor visits, outpatient services, ambulance services, preventive care, and durable medical equipment. Medicare Part B does not pay for home health care or the services of a caregiver, although it can provide this benefit in some cases. 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 the care in your home, then Medicare Part B provides coverage for this equipment. For those who need durable medical equipment, Medicare Part B will cover that equipment at 80% of the Medicare-approved amount. This means that you will only be responsible for paying 20% of the Medicare-approved amount for the equipment after you meet your Medicare Part B deductible. The equipment may come directly from the home health agency or another equipment 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 the part of Medicare known as Medicare Advantage. Medicare Advantage plans combine both your Part A and Part B coverage into a single plan. These plans are managed by private insurance companies, 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 is provided by Original Medicare. However, many Part C plans provide additional benefits beyond what Original Medicare provides.

Part C plans often include prescription drug, dental, vision, gym memberships, and other benefits. Part C plans must offer at least the same home health care benefits as Original Medicare; however, some of these plans 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. For specific coverage information, you should look at your plan’s paperwork 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. These prescription drug plans are managed by private insurance companies, and 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 that are needed during your required in-home care. These medications should be part of your care plan, which is created by your doctor, and they might be administered by your care provider.


— Medicare Advantage Plans

Medicare Advantage plans are Medicare insurance plans that are managed by private insurance companies. These plans must provide the same minimum level of coverage provided by Medicare. This means that 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. Personal care services, respite care, and other types of services might be covered by your Medicare Advantage plan. You should contact your insurance company or view your plan’s documentation to determine the specifics of your coverage. You should also know that each plan gets to set its own rules about coverage and costs, and most plans require the payment of a monthly premium.


— Medicare Supplement Insurance

Medicare supplement insurance is also known as Medigap. Medigap plans do not typically cover medical services directly. Instead, they help pay for out-of-pocket expenses that are not covered by Medicare. These expenses might include deductibles, copays, or coinsurance amounts. When you receive medical treatment that is covered by Medicare, your Medigap plan might cover the cost of your copay. So, Medigap does not provide any direct coverage for a caregiver. Since qualified caregiver services are usually covered at 100% by Medicare, Medigap coverage would not come into play in most cases.


Home Health Services Not Covered By Medicare

Now that we have gone through the basics of Medicare coverage when it comes to home health care, we will briefly discuss some of the items that Medicare does not cover. Home health services can span a wide range of duties, so it can also be helpful to learn what Medicare will not pay for. Here are a few examples.

First, 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.

Next, Medicare will not pay for any homemaker services that are not directly included in your care plan. Examples of these types of services could include cooking, shopping, cleaning, laundry, or other household duties or social services. Only services necessary for the care plan provided by your doctor will be covered by Medicare.

Finally, 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.


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 is not covered by Medicare. 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.

First, many Medicaid programs will help cover the cost of a caregiver. The rules vary slightly from state to state, so you should contact your state’s Medicaid services office for coverage details. If you are already enrolled in Medicare, you might be eligible for dual enrollment. 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 normally be covered through Medicare.

If you are a veteran, there are a few different programs that 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 find out more about the programs in your area by calling the Veterans Administration office.

There are also many state and local programs, as well as community-based services, that are available to help the elderly pay for caregiver services. These programs are typically offered to low-income individuals and families, so you should contact a local social services office to learn more about them.

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. Long-term care plans are managed by private insurance companies, and you will need to 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.


Finding The Right Caregiver For Your Family Member

An old man with a walking stick being aided by his caregiver.

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 check list 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 are considering hiring as a caregiver. Make sure the agency has emergency numbers you can call if you need help outside of regular business hours. Meet with the caregiver or agency and make sure they will work well with your loved one. If you see any red flags in their behavior, then 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 certain 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 period. If you simply need long-term care for a stable condition, then home health care services will not be covered.

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, make sure you do a full background check on any possible caregivers so you can choose the best one for your situation.


Frequently Asked Questions


What qualifies someone as a caregiver?

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.


Does Medicare cover home health aides?

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.


How much does a caregiver cost?

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 $30 per hour. Since caregivers are often needed for several hours each week, this cost can sometimes exceed $4,000 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.


Does Medicare Part B cover caregivers?

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.


What is the difference between a care provider and 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.