Who Qualifies as a Caregiver Under Medicare Rules and Who Doesn’t?

There are many caregivers in the United States who care for a child, parent, spouse, or another loved one.

When looking at caregiving through a broad perspective, about 100 million American adults function as a caregiver. When looking through a narrow lens, about 53 million American adults look after a spouse, elderly parent, relative, or special-needs child.

The issue is that caregiving is expensive. However, not everyone qualifies as a caregiver under Medicare rules. There are a number of factors to take into consideration when determining whether someone is eligible for Medicare benefits.

Who Exactly Is a Caregiver?

A caregiver is someone who provides care to another person who is unable to care for his or herself. Any person, whether it be a child, adult, or a senior citizen, may be in need of help. Some people may need help due to an injury or a disability. Others may have a chronic health condition such as Alzheimer’s disease or Parkinson’s disease.

There are many types of caregivers, such as a:

Professional caregiver

These are healthcare professionals who are trained and certified in providing care. The training includes teaching students how to handle complex care situations, including those that may involve medical equipment or specialized care routines.

You can find these professionals in hospitals, care facilities, and certified home care agencies. And these caregivers must take continuing education classes to stay updated with the latest care techniques and the newest healthcare regulations.

Family caregivers

These caregivers want to be there for their loved ones, so they take on the role of the caregiver to ensure their loved ones receive the care and support they need. Many family members have no formal training.

Live-In Caregivers

These caregivers live in the home of their patient. They provide round-the-clock care. Many patients, who need constant supervision due to chronic illness or conditions related to age, often prefer having a live-in caregiver.

Being with the patient 24/7 offers a level of care that the other options cannot provide, because the caregiver can be there whenever the patient needs help.

Volunteer Caregiver

Volunteer caregivers offer caregiving services, free of charge, to help an individual. You can find a volunteer caregiver in a variety of environments, such as non-profit organizations, hospice care, or community centers.

Some volunteer caregivers have certified training. They can:

• Provide assistance to professional health care providers.
• Supplement formal care plans.
• Offer companionship to reduce isolation.
• Give basic assistance.

These caregivers can be divided into two categories: informal and formal.

Informal caregivers may not see themselves as a caregiver. They are usually the family members, friends, neighbors, or other kinds of community members, who provide care on a daily basis. Rarely are they ever paid.

Meanwhile, formal caregivers have usually received some type of education and are licensed. They are usually paid for their time. They can supply their services in a residential care setting or a patient’s home.

Professional and volunteer caregivers are formal caregivers. Family caregivers are informal caregivers. Depending on the circumstance, a live-in caregiver can be informal or formal.

Taking a Closer Look at In-Home Caregivers

Not only are there different types of caregivers. There are also different types of in-home caregivers. Some in-home caregivers help with nonmedical personal care. Others offer medical care.

These in-home caregivers include:

Companion services

An individual is there to keep the patient company or to provide fun activities. They are mainly there to prevent the patient from isolation.

To find a good companion service, you might want to start with your local Area Agency on Aging.

Personal care

In these cases, the caregiver provides support with personal care, such as exercise, eating, and getting dressed.

Homemaker service

These caregivers provide assistance with housekeeping, meals, shopping, and transport.

Skilled care

These caregivers are licensed healthcare professionals. They help with wound care, physical therapy, or medication management.

Does Medicare Cover Caregivers?

Medicare is a federal health insurance for individuals who are either 65 years or older or are under 65 years but have a specific health condition.

In addition, Original Medicare is split into multiple sections. Part A of Medicare covers inpatient services. Part B of Medicare covers outpatient services, which includes covering some at-home care. There’s also Medicare Advantage Plan Part C.

When Does Medicare Cover Caregivers?

Before digging in too deep to determine if your services are Medicare approved, make sure the home health service involved is a Medicare-certified home health agency, like All American Home Care.

Patients who receive their services from a non-certified home health agency will need to pay for their Medicare costs out-of-pocket.

Medicare also pays for expenses up to eight hours of care a day, for a maximum of 28 hours a week. This translates to 3.5 days

Some insurance programs may pay up to 35 hours a week for home health services. Medicare may pay up to 35 hours a week of home health services, but this is assessed on a care-by-care basis.

Medicare pays for a caregiver under three conditions. Those conditions are:

• The patient is under the supervision of a doctor.
• A doctor has certified the patient is homebound.
• There is a written care plan which provides instructions on how to deliver care that the doctor regularly reviews.

While Medicare states the patient should be homebound, the patient could leave home for short periods, such as going out for a doctor’s appointment or attending religious services. In addition, the patient would need part-time or intermittent skilled services.

In order to get home care coverage, a patient should qualify Original Medicare parts A and B. Some of the coverage could be for:

• Part-time skilled nursing care;
• Skilled-nursing-care physical therapy;
• Occupational therapy;
• Speech and language therapy; and
• Part-time home health aide services.

Patients can receive Part C coverage through their private insurance companies. This coverage can be used to cover extra services, such as transportation to doctor appointments or adult day care.

There are also some Part C plans which tailor the plan to assist specific groups of people who have a chronic illness. These are called Special Needs Plans (SNPs) to help those who have chronic health conditions such as diabetes, chronic heart failure or dementia.

Who Qualifies as a Caregiver Under Medicare?

The caregiving service may be covered, but it’s also important to ensure that the caregiver providing the service is covered under Medicaid too.

First, a caregiver may have a professional certification. For this reason, most family caregivers won’t qualify to receive Medicare compensation, because they do not have the essential credentials.

As previously mentioned, Medicare coverage is available when a healthcare professional determines the medical services are necessary for the individual. In these cases, the caregivers are certified. The caregivers include those:

• Working in assisted living facilities;
• From senior agencies;
• Dedicated to helping seniors with activities of daily living (ADLs) while recovering from a long-term injury;
• Offering companion and homemaker caregiving services;
• Working in nursing facilities;
• Working with personal care services;
• Working with private caregivers; and
• Working in skilled care facilities.

In addition, the following criteria must also be met for Medicare to pay for a caregiver.

• The patient should be enrolled in Medicare.
• The services the patient is receiving should be medically necessary – per a professional healthcare.
• The patient should hire an individual who meets the Medicare requirement. (Family, loved ones, and friends are excluded.)
• Whoever the patient hires must also be a part of the Medicare program.
• The doctor creates a plan illustrating how the caregiver will provide services.

When does Medicare Not Pay for Caregivers

In some instances, Medicare does not pay for caregivers. These situations occur when the caregiver provides:

• 24-hour care at home;
• Meal delivery;
• Homemaker services when this is the only service needed; and
• Supervision or personnel care when this is the only service that is required.

Other Options for Payment

There are some government programs which can pay for family caregivers. They may be able to receive payment through a state Medicaid program.

Unlike Medicare, Medicaid is a joint federal and state program which helps cover medical expenses for individuals who have limited income and resources.

These programs vary by state. You can contact your state’s Medicaid office to get more information.

An Option That Gives Patients Powers

One Medicaid option is called self-directed Medicaid services. As a part of this program, the participants of the program, or the participants’ representatives, have the authority to manage their health-care services with their system of available support.

This model is an alternative to services that are traditionally delivered and managed by an agency.

Self-direction helps the patient have more choice over their services, and it can be covered by a Medicaid waiver. The Centers for Medicare & Medicaid Services (CMS) calls this option the “employer authority.”

An Option That Sets the Pace

There is also another option called the Program of All-Inclusive Care for the Elderly (PACE). This is a Medicare and Medicaid program which helps people meet their health needs by using community resources instead of having to go to a nursing home or another care facility.

Navigating the rules of who qualifies as a caregiver is very confusing, especially those millions of American caregivers who are trying to see if they qualify for Medicare expenses. While the term “caregiver” can apply to anyone providing care, Medicare has a very specific definition of who is eligible for reimbursement.

Under Medicare rules, only formally trained, licensed professionals, such as registered nurses, licensed practical nurses, and certified home health aides, are eligible to be paid caregivers. These professionals must be employed by a Medicare-certified home health agency and the services must be deemed medically necessary and prescribed by a doctor. Family caregivers, friends, or informal support systems, no matter how essential they are, are not recognized for payment under Medicare.

However, that doesn’t mean family caregivers are left without options. State Medicaid programs, PACE, and self-directed care models may offer financial support and flexibility for unpaid caregivers. These alternatives can help fill the gap where Medicare falls short.

It’s vital to know who qualifies as a caregiver under Medicare rules, because it’s essential for getting the proper support. Then, you can also avoid unexpected costs.