February 5th 2024
By Ari Parker
Learn about the intricate Medicare rules for defining caregivers and their eligibility. Discover the criteria and qualifications required in this comprehensive article.
Caring for loved ones can be challenging. Caregiving takes a lot of time, and caregivers often handle difficult tasks that can take an emotional toll. Furthermore, many caregivers have to maintain their jobs to be able to pay their bills. It’s no wonder that caregiving can lead to burnout.
Unfortunately, Medicare’s coverage for caregiving services is generally limited to skilled nurses if a person is homebound. Some family caregivers, however, may be able to find support through state programs like Medicaid and PACE.
In this article, we’ll discuss what a caregiver does, who qualifies as a caregiver under Medicare, and some resources family caregivers can explore to get assistance.
Medicare only covers caregivers if they are medical professionals providing in-home care, like skilled nurses. Medicare doesn’t provide financial assistance for family or personal caregivers.
To qualify for a skilled nurse or other home health care service, you must be “homebound.” This means a doctor does not recommend that you leave your home.
There are other alternatives to pay family caregivers that you can explore.
Caregivers can take many different forms and perform many different duties. Generally, a caregiver is someone who helps take care of another person who needs physical help because of an illness, their age, or a disability.
Caregivers can include:
Anyone who is close to a person like family members, friends, or neighbors
Private caregivers that a person hires
Skilled nurses
Home health aides
Some common duties that a caregiver performs include:
Personal care: taking care of a person’s hygienic needs like bathing, dressing, and grooming
Mobility assistance: helping a person walk or move from one location to another. Mobility assistance can also include transportation to the doctor’s office, grocery store, or other place
Medical care: administering medication, monitoring vital signs, and managing medical equipment like oxygen tanks
Conducting day-to-day tasks: maintaining household tasks like laundry, cleaning, shopping, managing finances, etc
Emotional support: providing companionship
Ensuring the wellbeing of another person is important but can be emotionally and physically taxing. It’s important that caregivers get the support they need as well. We’ll explore some resources that family caregivers can use to get monetary assistance with caregiving.
Original Medicare has limited rules about who qualifies for home health services like caregiving. Family and other personal caregivers are not eligible to receive financial assistance for caregiving duties from Medicare.
Before we get into who qualifies as a caregiver with Medicare, we’ll explain what the eligibility requirements are for a person receiving caregiving services. To get coverage for a caregiver, you must be “homebound.” Medicare qualified you as homebound if you:
Have trouble leaving home without help because of a disease, injury, disability, or other restriction that limits mobility
Have a doctor’s recommendation to stay at home
Can’t leave home because it’s very difficult
Medicare only provides coverage for caregivers who are skilled nurses and provide medically necessary care for a patient. Before you’re eligible for caregiving coverage, you’ll have to meet with a health care provider face-to-face. Your health care provider needs to determine that you need a skilled nurse. If you’re eligible, a Medicare-certified home health agency has to provide the caregiving service.
It’s important to know that Medicare does not pay for skilled nursing care if you need it full time. The program will only cover a skilled nurse who comes over on a part-time basis—unless there’s a special case. A skilled nurse is limited and can only help for less than 7 days each week, or less than 8 hours each day over a period of no more than 21 days.
Lastly, Medicare coverage for in-home skilled nurses is restricted to caring after your medical needs. Medicare won’t cover personal or home care like grooming services or household chores.
Some Medicare Advantage plans may cover additional caregiving services like adult day care or transportation to medical appointments. Special Needs Plans (SNPs) are a type of Medicare Advantage plan for people who have specific diseases, certain health care needs, or Medicaid. These plans may come with extra benefits to cover caregiving.
Whether or not they are SNPs, Medicare Advantage plans vary widely in coverage. Check your summary of benefits to see if you have coverage for caregiving services or services that are typically provided by a caregiver (like transportation to a doctor’s office).
In addition to skilled nursing care, Medicare covers other home health services if you are unable to leave your home. These services include:
Services for speech-language pathology
Medical social services
Injectable osteoporosis drugs for women
If you are homebound, Medicare also provides coverage for any necessary medical equipment or supplies like a cane or walker.
Medicare does not cover caregiving services for:
A caregiver on a 24-hour basis
Meals delivered to your home
Day-to-day activities (like shopping and cleaning) that aren’t related to health conditions
Custodial or personal care that helps you with daily living activities (like bathing, dressing, or using the bathroom), when this is the only care you need
You won’t have to pay anything for a skilled nurse or other home health service if you meet the criteria. However, you’ll be responsible for 20% of the costs of Medicare-covered equipment after you meet the Part B deductible. A Medigap plan can help cover some of the out-of-pocket costs.
Medicare Advantage plans cover the same services that Original Medicare does, but you may have to pay more or less for medical equipment should you need it. That’s because Medicare Advantage plans have varying out-of-pocket costs.
Family caregivers are responsible for so much. Luckily, there are federal and state programs that provide financial assistance to support families in certain situations. Explore these resources deeper and see if you might qualify for assistance:
Medicaid offers programs that may provide money to family caregivers. The Medicaid Self-Directed Care Program, for example, allows you to choose a family caregiver. Medicaid rules vary by state, however, so check with your local Medicaid office for details.
PACE is a comprehensive healthcare program that supports older adults who qualify for nursing home care but prefer to receive services in their home. Typically, people who are eligible for both Medicare and Medicaid join the program (most have complex medical conditions and impairments). You can enroll in PACE if you meet all of the following criteria:
You’re 55 or older
You live in an area that PACE operates
Your state determines you need at-home care
You can live safely in the community
To get started, find your local PACE program here.
In some cases, people with disabilities may qualify for SSDI or SSI, which can provide financial assistance that you can use for caregiving.
The VA offers programs such as the Aid and Attendance Benefit, which provides financial help to family caregivers of eligible veterans.
Some states offer a tax credit or deductions for caregiving-related expenses. In fact, caregivers in America spend an average of $7,242 out of pocket for their loved ones. Lawmakers have noticed this financial burden for caregivers and are working on a new bill to provide them tax relief.
There’s no doubt that Medicare can be confusing. The rules are especially complex for when your insurance can and can’t cover caregiving services like skilled nursing. If you have lingering questions, talk to one of our licensed Advisors about your specific situation and see what other options you have for caregiving. Call 855-900-2427 or schedule a time to talk.
