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Who Qualifies as a Caregiver Under Medicare Rules?

Summary: To qualify as a caregiver under Medicare rules, you must have a professional certification. Medicare benefits may pay for caregivers but only under certain circumstances. Fortunately, changes are expanding access to benefits for families. There are also various entities supporting caregivers in need of healthcare resources. Estimated Read Time: 10 mins

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Table of Contents:

  1. Does Medicare Pay for a Caregiver?
  2. Does Medicare Pay For Family Caregivers?
  3. Medicare Caregiver Benefits
  4. Medicare Support for Caregivers

To qualify as a Medicare caregiver, you need to hold some type of professional certification to provide care. While relatives and friends often take up the role of a family caregiver, without the proper credentials, compensation is not currently available for these individuals. That is at least for now, as there are hints of change coming to the system, though admittedly, in 2024, we are still in the beginning stages.

Medicare coverage for caregivers is available when a healthcare professional determines that the services provided are medically necessary for an individual. For example, if you have cancer or dementia, it may be determined that a caregiver is necessary for your healthcare. In this case, your benefits can cover such services. These include the following:

  • Assisted living facilities
  • Caregivers from senior agencies
  • Caregivers who help seniors with activities of daily living (ADLs) while recovering from a long-term injury
  • Companion and homemaker caregiving services
  • Nursing facilities
  • Personal care services (PCS)
  • Private caregivers
  • Skilled care facilities

Anyone who assists with these daily activities can be considered a caregiver.

Does Medicare Pay for a Caregiver?

Medicare home health care benefits are available in certain circumstances for individuals who help patients with daily activities when deemed medically necessary. In order to receive Medicare coverage for a caregiver, the following criteria must be met:

  • You must be enrolled in Medicare.
  • The services must be medically necessary according to a professional on your healthcare team.
  • You must hire a professional that meets Medicare requirements. Family members and friends are excluded.
  • Not only must you enlist the help of a professional but whomever you hire must be a part of the Medicare program.
  • Your doctor will need to create a plan that showcases what a caregiver will do for your health.

Caregiver pay through Medicare will vary from patient to patient as everyone has different medical needs. Caregivers who provide more services are likely to receive more pay. Additionally, Medicare must approve your caregiver before they begin receiving compensation. The key to remember is that not all caregiving is covered and when these services are covered, they are more of a case-by-case situation rather than widespread and comprehensive in nature.

Does Medicare Pay For Family Caregivers?

As it stands, Medicare doesn’t typically pay family caregivers. In order for Medicare to pay for caregivers of any kind, there are strict regulations that must be followed. However, there are also changes coming in 2024 that will allow for a broader range of coverage aiming to help alleviate some of the financial burden family caregivers face.

Original Medicare is a program run by the federal government that covers medically necessary healthcare costs. There are several things that Original Medicare won’t cover, such as dental, hearing, and vision coverage, and unfortunately, as it stands, family caregivers fall into this category. In order to receive coverage for a caregiver, you must go to a facility that accepts Original Medicare.

This is why it can be difficult to have Medicare reimburse family caregivers, as they are not part of these Medicare-approved organizations. Furthermore, there are several services rendered by family caregivers that would not be deemed medically necessary, making things even more complicated.

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With that being said, change is afoot. The Centers for Medicare & Medicaid Services (CMS) is planning to help family caregivers in multiple ways beginning in 2024. Rather than providing reimbursement for beneficiaries, family members who are taking care of loved ones could receive benefits.

Not everyone is going to qualify though, as the changes CMS is looking to impose are for those with certain health needs. However, it’s still a noted change that is going to help provide financial and educational support that is much needed for caregivers.

Training for Caregivers

Family caregivers often lack the necessary knowledge to handle the medical needs of loved ones, and while resources are available, they can be difficult to access at times. The new changes are providing family caregivers with training from medical professionals to better handle the needs of their patients.

The plan is for CMS to create a billing code that will pay Medicare providers to train family caregivers. This includes nurse practitioners, physicians, physician assistants, speech therapists, as well as physical and occupational therapists. Training for both groups and individuals will begin in 2024.

Needs Assessments and Care Navigation

For those with qualifying health conditions, particularly those dealing with higher-risk conditions, CMS is looking to provide needs assessments and care navigation. This will allow CMS to collaborate with community-based social service organizations and community health workers outside of the traditional medical field to provide social services to those in need.

Support for Dementia Patients

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Finally, as one of the populations most in need of caregiving services, those suffering from dementia are gaining more support. A program known as Guiding an Improved Dementia Experience (GUIDE) Model offers care management, education for family caregivers, support, and even respite care.

How Much Does Medicare Pay For Family Caregivers?

Because the determination for Medicare to pay family caregivers is still in the making, there are no concrete rates released for compensation. Fee schedules are determined by CMS who will decide the amount of money Medicare will pay for a particular healthcare service. Once this is established, reimbursement can be acquired based off of the figures determined by the federal agency.

Medicare Caregiver Benefits

Medicare and caregiver coverage is a complex relationship, but if these services are medically necessary, you have options to help with the costs. However, this isn’t a comprehensive list as the caregiver benefits Medicare provides will likely vary as health needs are different from patient to patient. With that said, here are some services Medicare caregiver benefits will help cover costs for:

While Medicare caregiver benefits cover many helpful services, not everything is included. For example, custodial care, transportation services, meal delivery, and non-medical care would require other means. Additional resources below may be able to help you cover such services if necessary.

How To Get a Caregiver Through Medicare

Receiving caregiver services and having Medicare pick up the bill is possible, but there are certain ways to go about it. If you don’t follow the right steps or have the right circumstances surrounding your health, you won’t be able to use your coverage. Here is a short breakdown on how to qualify for a caregiver through Medicare.

Step 1: Have a Medical Condition Requiring a Caregiver

Simply put, you can’t receive coverage for a caregiver if the services you receive are not medically necessary. Your doctor must deem a caregiver medically necessary for your health condition in order to receive coverage for their services. Once deemed necessary, your healthcare provider will develop a specific plan that showcases how caregiving is critical for your healthcare needs.

Step 2: Find Caregiver Services Accepting Medicare

The next step is finding healthcare services from a professional organization that is within the Medicare program. This shouldn’t be too difficult as a majority of healthcare providers participate, but it’s still worth noting as otherwise, Medicare won’t cover your expenses. If you have a Medicare Advantage plan, you’ll want to be sure the facility you choose is covered by your specific plan.

Step 3: Hire Someone That Meets Your State’s Medicare Caregiver Requirements

Be sure to conduct due diligence that the caregiving services you hire follow your state and Medicare’s guidelines to avoid bad actors.

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Medicare Support for Caregivers

Caregiver support comes in many different forms. While direct compensation from the federal program is important there are other considerations adjacent to Medicare benefits that can help alleviate healthcare expenses.

Furthermore, some resources may also be able to help you with training, locating help, and identifying opportunities for compensation outside of Medicare. Below are some examples that may prove beneficial to caregivers and patients alike:

Area Agencies on Aging (AAAs)

Throughout the United States, you’ll find hundreds of Area Agencies on Aging. These local agencies are nonprofits that aim to help seniors with various needs and are a valuable resource for elderly caregivers. While direct payment may not be available, you’ll find plenty of support and a community that understands both you and your patient’s needs.

Local Caregiver Compensation Programs

Medicare is still working on figuring out how to compensate family caregivers, but there are some states that offer compensation for family caregivers in a variety of ways. This could be assistance with paying for training, paying for your time, or other methods. You can also receive paid leave from work if you need to be a caregiver in certain states plus the District of Columbia.

Medicare Advantage Plans

Also known as Medicare Part C, beneficiaries can enroll in Medicare Advantage which can become their primary source of coverage. Offered by private insurance carriers, Medicare Advantage plans may be a great choice for some beneficiaries depending on their healthcare and budgetary needs to cover healthcare costs and caregiver training when it becomes available.

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Medicare Extra Help

Prescription drug costs are costs that continue to affect households throughout the country. Medicare Extra Help provides some relief for low-income beneficiaries to help cover their medication. Saving on prescriptions can help you budget for the costs surrounding caregiving.

Medicare Supplement Plans (Medigap Plans)

When you use Original Medicare coverage, Parts A and B, you can often find that there are leftover costs for your healthcare services. This includes the times in which Medicare coverage for caregivers is available. To help cover these expenses, Medigap plans are available and may be an appropriate option.

Medicare Supplement plans help fill coverage gaps leftover when using Original Medicare. A Medigap plan will supplement your coverage to avoid out-of-pocket costs, such as copayments, coinsurance costs, and deductibles. This can include healthcare costs facing caregivers and their patients, including training when it becomes available. Learn more about Medicare Supplement plans.

National Family Caregiver Support Program (NFCSP)

There are plenty of resources available to caregivers for Medicare patients. Unfortunately, accessing these resources can be difficult. However, since 2000, the NFCSP has been helping elderly caregivers identify the resources in their area and connecting them with said resources to help improve care.

Program of All-Inclusive Care for the Elderly (PACE)

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PACE is a collaboration between Medicare and Medicaid. The goal of PACE is to help beneficiaries maintain their lives within their own homes rather than having to move to a caregiving facility. You’ll need to qualify, which includes being over the age of 54 years old, but PACE services can cover additional needs otherwise not covered by Original Medicare alone.

State Government Departments

Each state government is set up similarly but has its own unique nuisances. However, state departments for seniors, aging individuals, the disabled, health, and more are all available in each of the 50 states plus the District of Columbia.

For caregivers dealing with patients who may use medical marijuana, additional departments may also be relevant. Regardless of what’s available, it’s important to tap into your local government resources for support, potential compensation, assistance, and more.

As a family caregiver, there are several benefits to having additional help. Finding the right caregiver for your loved one’s needs takes a lot of consideration and varies from patient to patient. To learn more, keep reading our guide to discover how to find a caregiver that works best for your family.

Sources

MedicareFAQ is dedicated to providing you with authentic and trustworthy Medicare information. We have strict sourcing guidelines and work diligently to serve our readers with accurate and up-to-date content.

  1. Who Is Considered A Caregiver According to Medicare?, Healthnews. Accessed December 2023.
    https://healthnews.com/medicare/guides/medicare-caregiver-who-qualifies/
  2. For The First Time, Traditional Medicare Will Pay To Support Family Caregivers, Forbes. Accessed December 2023.
    https://www.forbes.com/sites/howardgleckman/2023/08/23/for-the-first-time-traditional-medicare-will-pay-to-support-family-caregivers/?sh=3845e91a2228
  3. Guiding an Improved Dementia Experience (GUIDE) Model, CMS. Accessed December 2023.
    https://www.cms.gov/priorities/innovation/innovation-models/guide
  4. How Do I Get Paid to be a Family Caregiver?, ARCH National Respite Network and Resource Center. Accessed December 2023.
    https://archrespite.org/caregiver-resources/how-do-i-get-paid-to-be-a-family-caregiver/
Kayla Hopkins

Kayla Hopkins

Content Editor
Kayla Hopkins is an accomplished writer and Medicare educator serving as the Editor of MedicareFAQ.com. Upon completing her Communications degree from Ohio University, Kayla dedicated her time to understanding the ever-evolving landscape of healthcare. With her extensive background as a Licensed Insurance Agent, she brings a wealth of knowledge and expertise to her writing.
Ashlee Zareczny

Ashlee Zareczny

Compliance Manager
Ashlee Zareczny is the Compliance Manager for MedicareFAQ. As a licensed Medicare agent in all 50 states, she is dedicated to educating those eligible for Medicare by providing the necessary resources and tools. Additionally, Ashlee trains new and tenured Medicare agents on CMS compliance guidelines. Ashlee is a Medicare expert who specializes in Medicare Supplement, Medicare Advantage, and Medicare Part D education.

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