Who Is Considered A Caregiver According to Medicare?

Caregiving for an ill or older loved one often makes the difference between living comfortably at home or in an institution. However, it can call for tremendous emotional and financial sacrifices. This unpaid work is estimated to cost 36 billion hours and $600 billion, exceeding all out-of-pocket healthcare spending in 2021. Genworth Financial reports professional homemaker and home health aide services cost an average of $4,957 and $5,148 per year, respectively.

Many family caregivers receive little guidance or support to perform tasks that healthcare professionals get paid to do. Fortunately, Medicare provides programs to ease the burden.

What is a caregiver?

Medicare defines a caregiver as an individual who assists and supports someone who is elderly or has a temporary or chronic illness, disability, or frailty. A professional can be hired to provide this care for eligible Medicare beneficiaries. A caregiver can also be a relative or friend who offers this care at no cost.

Caregivers may include:

• Neighbors
• Caregivers at nursing facilities or assisted living facilities
• Private caregivers
• Senior services agencies

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What services does caregiving include?

Caregiving can involve one or more of these services:

• Skilled care. Assistance offered by licensed healthcare professionals for help with medications, wound care, and therapies.
• Companion services. Keeping company, offering supervision, and facilitating fun activities.
• Homemaker services. Assisting with housekeeping, meal preparation, transport, and errands.
• Personal care services. Helping with dressing, eating, exercise, and other daily living activities.

When might a caregiver be needed?

A person may need a caregiver for a variety of reasons. Typically, the needs are serious and long-term, such as chronic or acute illness, age-related frailty, or cognitive impairment. A caregiver can also be of help in long-term recovery from an injury.

Does Medicare pay for family caregivers?

Medicare will help pay for a caregiver if the services qualify for Medicare’s home health benefits. However, it will only cover services from Medicare-approved agencies, not individuals. Caregiving services must be medically necessary. A physician or healthcare provider must certify that the recipient is homebound except for brief periods. The doctor must also create and maintain a plan of care.

The recipient must also qualify for home care coverage under Original Medicare Parts A and/or B. Part A covers hospital inpatient care, and Part B covers outpatient services, including home health care.

What does Medicare pay for?

In terms of coverage, Medicare will pay for:

Part-time or intermittent skilled nursing care

Medicare Part A covers intermittent skilled nursing care for less than eight hours each day up to 21 days or 35 days in certain cases. This service also refers to care rendered on fewer than seven consecutive days.

Medicare will cover this care from a registered nurse or licensed practical nurse. Home health skilled nursing may entail tube feedings, changing wound dressings, intravenous (IV) drug administration, and disease management education.

Part-time home health aide services

Home health aides can help with monitoring your vital signs and ensuring you’re eating well. They also check your home for safety issues.

Physical therapy

Medicare can pay for in-home physical therapy services such as wound care and gait training. Such therapy may also include exercise training to aid in recovery from injuries, surgery, or stroke.

Speech-language pathology services

A speech therapist can work with individuals in their homes to help them remember words and eat and drink as normally as possible. Speech therapy includes education about new or alternative ways to communicate in hearing or speech loss cases.

Occupational therapy

Occupational therapy helps people set up daily routines to follow their doctor’s orders, take care of personal needs, and reduce stress.

Medical social services

Medical social services involve counseling or assistance from a social worker to address emotional issues that may impact health and well-being.

Medicare may also pay for medical supplies for home use and in-home hospice care.

How much does Medicare charge for caregiver services?

Original Medicare covers home health visits at no charge to qualified recipients. Medicare Advantage plans may offer additional home health coverage, but certain costs and restrictions may apply.

Medicare Advantage (Part C) plans may cover additional services such as adult day care and transportation to doctor’s appointments. Special Needs Plans (SNPs) are Part C plans that cater to those with specific conditions such as dementia, diabetes, stroke, end-stage renal disease, or cancer.

What caregiver services are not covered by Medicare?

Medicare home health benefits will usually not pay for the following services:

• Long-term medical or non-medical care
• Custodial or non-skilled personal care, in most cases
• Meal delivery
• Transportation

Can I find help paying for a caregiver?

Seniors and individuals with certain chronic illnesses can explore several options to help cover home care costs. Potential resources include:

PACE

The Program of All-Inclusive Care for the Elderly (PACE), a joint Medicare Medicaid program, helps people continue living in their homes instead of entering a care facility. People with Medicare, Medicaid, or both can join this program. PACE works with beneficiaries, families, caregivers, and professional healthcare providers to develop and execute a coordinated care plan.

PACE services include primary care, home care, personal care, meals, prescription drugs, social services, and necessary transportation. If the healthcare team determines that you need more services than Medicare and Medicaid will cover, PACE may cover them for you.

You can sign up for PACE if:

• You’re at least 55 years of age
• You reside in a PACE organization’s service area
• Your state verifies that you require nursing-home level care
• PACE services could help you live safely in the community

If you have Medicare, you’ll need to pay a monthly premium for the long-term care portion of the PACE benefit. You must also pay a monthly premium for Medicare prescription drug coverage. PACE does not charge a deductible or copayment for any care, service, or medication that the PACE team approves.

Medigap

Medigap plans private Medicare supplemental insurance policies, can help pay for Original Medicare copayments, deductibles, and coinsurance. Some plans have out-of-pocket limits beyond which the plan covers 100% of Part B services. This could lower what you would pay for Medicare-covered caregiver services.

Medicaid

People with limited income or resources may qualify for Medicaid. The Medicaid Self-Directed Care Program lets participants hire relatives to care for them. Contact your local Medicaid office for details on eligibility and enrollment.

Additional help

Individuals with full Medicaid coverage, an MSP, or SSI benefits may get Extra Help automatically, or you can sign up for it. This state program helps with Medicare prescription drug costs, making more funds available for caregiving services. Income limits apply.

Supplemental Security Income (SSI)

SSI is also designed for people with a disability and limited income. It provides a monthly cash benefit.

Medicare Savings Programs (MSPs)

MSPs can help people with limited resources pay for out-of-pocket costs. Plans vary by state.

Caregivers are a desperately needed source of help for aging people or dealing with an extended illness or injury. Medicare does not generally compensate these individuals directly for their contributions. However, MSPs and various state organizations provide hands-on and financial assistance to meet the needs of vulnerable people in our communities.