Medicare, the federal health insurance program primarily for people aged 65 or older, covers a wide range of medical services. Whether Medicare covers a caregiver at home depends entirely on the type of assistance required. The program covers medically necessary treatment for an illness or injury, not long-term support for daily living. Understanding this distinction between medical and non-medical needs is key to determining if Medicare will pay for a caregiver.
The Difference Between Skilled and Custodial Care
The determination of Medicare coverage rests on differentiating between two distinct categories of care. Skilled care involves medical tasks that must be performed or supervised by licensed health professionals, such as registered nurses or physical therapists. Examples of this type of care include administering intravenous injections, providing complex wound care, or performing specialized physical therapy to aid recovery. This level of care requires the specialized training and judgment that only licensed practitioners possess.
In contrast, custodial care is non-medical assistance with routine daily activities, also known as Activities of Daily Living (ADLs). This includes help with bathing, dressing, eating, using the bathroom, or light housekeeping. Custodial care can be safely provided by non-licensed individuals like home health aides or family members, as it does not require medical training. Medicare generally covers skilled care under specific circumstances but explicitly excludes coverage for custodial care when it is the only care needed.
Coverage for Medically Necessary Home Health Services
Medicare’s coverage for home-based care is specifically limited to medically necessary services provided by a Medicare-certified Home Health Agency (HHA). This coverage is provided under both Part A and Part B of Original Medicare and is intended for a limited duration following an illness or injury. The services must be provided on an intermittent or part-time basis, meaning they are furnished less than eight hours a day and for a maximum of 28 hours per week, though up to 35 hours may be approved in exceptional circumstances.
The services covered include intermittent skilled nursing care, physical therapy, speech-language pathology, and occupational therapy. These services must be reasonable and necessary for treating an illness or injury. Significantly, the services of a home health aide—who assists with ADLs—are only covered if they are required in conjunction with one of the covered skilled services. If the need for skilled care ends, coverage for the home health aide services also stops, even if the patient still requires assistance with daily activities.
Medicare Advantage plans (Part C) must offer at least the same level of home health coverage as Original Medicare. These private plans may have different rules regarding provider networks or prior authorization requirements.
Essential Eligibility Requirements for Home Care
To qualify for Medicare-covered home health services, a patient must meet a strict set of conditions. First, the individual must be under the care of a doctor, and that doctor must certify that the patient needs skilled services that are reasonable and necessary for their condition. The care plan must be established and periodically reviewed by the doctor.
A defining requirement is that the patient must be certified as “homebound”. This does not mean the person is completely confined to bed, but rather that leaving the home requires a considerable and taxing effort. The patient must have trouble leaving home without assistance from another person or a supportive device like a cane, wheelchair, or walker.
Absences from the home must be infrequent and of short duration, typically only for medical appointments or attending religious services. If the patient can leave home frequently without significant difficulty, they will not meet the homebound definition and will not qualify for the home health benefit. Furthermore, all covered services must be furnished by a Medicare-certified Home Health Agency.
Services Medicare Does Not Cover
A frequent misunderstanding is that Medicare covers long-term care for chronic conditions. Medicare does not cover 24-hour-a-day care at home, which is often required for individuals with advanced illness or severe disability. The program is structured for post-acute or short-term medical recovery, not indefinite support.
Medicare will not pay for custodial care when it is the only service a person needs. If a patient only requires help with bathing, dressing, or meal preparation, Medicare benefits cannot be used. Additionally, non-health-related services like home meal delivery or general homemaker tasks such as shopping and cleaning are excluded from coverage. People who need ongoing, long-term custodial support typically rely on personal savings, private long-term care insurance, or state-based Medicaid programs.