How to get a Caregiver through Medicare: A Comprehensive Step-by-Step Guide

If you’re trying to figure out if it's possible to get in-home caregiving support covered by Medicare, the answer is yes—but only under specific conditions. Medicare does cover skilled home health services, including nursing care, physical therapy, occupational therapy, speech therapy, and limited aide visits. These services are meant for patients who meet strict medical and logistical criteria. This is not full-time custodial care or help with meal prep. But it is professional, part-time support that can make a serious difference for patients and families.

Each year, about 3.4 million Medicare beneficiaries use home health services. Many begin within 7 to 14 days of a qualifying medical visit. Hospital discharges may move even faster. But in 2025, several policy shifts are changing the way this process works—stricter documentation (including the new OASIS-E1 form), revised payment rates, and the expiration of temporary telehealth flexibilities are reshaping what families should expect.

This guide walks through every step: from preparing for your doctor visit to selecting a certified home health agency, receiving services, and navigating Medicare Advantage or appeal processes. You’ll also see how Solace advocates help families avoid common delays—and get the support they deserve without drowning in forms or fine print.

Pre-Qualification: Understanding Your Eligibility (Before You Begin)

Before Medicare will pay for any in-home caregiving services, your loved one needs to meet five specific requirements. These aren't suggestions—they're non-negotiable criteria tied to federal policy and medical necessity standards.

To qualify for Medicare-covered home health services:

• Be under physician care: Your loved one must be actively treated by a doctor or nurse practitioner who oversees their care plan.
• Homebound status: They must have documented difficulty leaving home without help due to illness, injury, or cognitive limitation.
• Need for skilled services: They require intermittent services from a licensed nurse, physical/occupational therapist, or speech therapist.
• Part-time care only: Medicare does not cover full-time custodial or 24/7 home care. The care must be intermittent.
• Certified provider: Services must be delivered through a Medicare-approved home health agency.

Before your first doctor visit, gather:

• Their red, white, and blue Medicare card (plus any Medicare Advantage or Medigap cards)
• A list of current prescriptions and dosages
• Any recent medical records, discharge papers, or hospital summaries
• A list of doctors and specialists
• Notes or documents showing cognitive or physical impairments (e.g., mobility, dementia, incontinence)

2025 changes to know:

• The OASIS-E1 assessment is mandatory for all Medicare home health patients as of January 1, 2025. For non-Medicare payers, all-payer OASIS data collection begins July 1, 2025.
• All-payer data collection is effective as of July 1
• Temporary telehealth flexibilities are in place through September 30. Audio-only services are still allowed for some general Medicare visits through that date—but they no longer count as valid face-to-face encounters for home health certification.
• The national standardized 30-day base payment amount for home health services in 2025 is $2,057.35, as established by CMS under the Home Health Prospective Payment System (HH PPS).

Step 1: Initial Doctor Visit and Medical Assessment (Days 1–3)

This visit is the cornerstone of the process. It must be face-to-face and directly related to the reason for home health services. Without it, Medicare will not pay.

Come prepared to help the doctor paint a full picture:

1. Bring a list of what you're already doing as a caregiver (e.g., medication reminders, dressing wounds)
2. Describe safety concerns like fall risk or wandering
3. Provide current medication lists and test results
4. Consider bringing a caregiver or advocate to take notes

During this appointment, the doctor must:

1. Perform a full medical evaluation
2. Confirm the patient’s homebound status using detailed examples
3. Specify the skilled services needed (e.g., wound care, therapy)
4. Write up the face-to-face encounter note
5. Initiate physician orders for home health

Timing matters: This encounter must occur within 90 days before or 30 days after care begins. In 2025, it must be in person or conducted via two-way audiovisual (video) telehealth. Audio-only visits no longer qualify for home health certification.

Step 2: Obtaining Physician Certification and Orders (Days 3–5)

Medicare requires a formal certification from the physician. This includes not just signing off on care, but showing exactly why it’s medically necessary.

The certification package must include:

1. A signed CMS-485 Plan of Care
2. Clear documentation of homebound status
3. Specific, detailed physician orders (e.g., “nursing 3x/week for 4 weeks”)
4. A diagnosis and reason for skilled services

To keep the process on track:

1. Request a copy of the full certification and face-to-face note
2. Confirm that physician language is detailed and diagnosis-based—not vague
3. Avoid vague phrases like “needs help around the house.” Instead, ask your physician to document diagnosis-specific needs, such as “requires skilled nursing to manage wound infection due to diabetes.”
4. Ask for a list of Medicare-certified agencies

Step 3: Selecting a Medicare-Certified Home Health Agency (Days 4–7)

Medicare only pays for agencies that meet its certification standards. The Care Compare tool on Medicare.gov can help you evaluate your options.

Ask potential agencies:

• Are you Medicare-certified? What is your provider number?
• Do you use subcontracted staff or direct employees?
• How many patients does each nurse manage?
• Do you offer 24/7 on-call clinical support?
• What are potential out-of-pocket costs?

After interviewing 2–3 agencies:

1. Choose one and confirm their availability
2. Notify your doctor so the referral can be sent
3. Keep a written copy of the agency’s contact and intake coordinator

Step 4: Home Health Agency Assessment and Intake (Days 5–10)

Once the referral is received, the agency will send a nurse or therapist to conduct an in-home assessment. This intake visit typically lasts 60–90 minutes.

They will:

• Review medications and chronic conditions
• Evaluate physical function, mood, and memory
• Assess home safety hazards
• Ask about daily routines, mobility, and support system
• Complete the mandatory OASIS-E1 assessment

You’ll be asked to review and sign:

• Insurance verification and service authorization forms
• HIPAA consent and care participation paperwork
• Emergency contact and advance directive forms

Step 5: Care Plan Development and Implementation (Days 7–14)

The information gathered during intake forms the basis for a personalized care plan. This plan must be signed by your doctor and include detailed treatment goals and schedules.

Care plans often include:

1. Nursing visits for wound care, injections, or medication management
2. Physical therapy for fall prevention or strength-building
3. Occupational therapy for dressing, bathing, and mobility aids
4. Speech therapy if needed for swallowing or communication
5. Aide visits when linked to a skilled service
6. Social workers can help connect you to programs like Medicaid, the Department of Veterans Affairs (VA), or state-based assistance services.

Typical care start timelines:

1. Post-hospital: Within 3–5 days
2. Community referral: 5–10 days
3. High-complexity cases: Up to 14 days

Managing Medicare Advantage Plans (Special Considerations)

If your loved one has a Medicare Advantage plan, things work differently. Prior authorization is often required—and documentation must match the plan’s exact standards.

What to know:

• Over 60% of Medicare Advantage Plans require prior authorization
• Plan reviews may take 72 hours (urgent) or 14 days (standard)
• Denials are common—but appeal success rates are high

You’ll need to:

1. Work with the agency to submit all required documentation
2. Verify that the agency is in-network for the MA plan
3. Use plan-specific forms when needed

2025 trend to watch: Many Medicare Advantage insurers now own or are affiliated with home health agencies, creating vertically integrated care networks. This can accelerate access—or raise concerns about care choice and utilization limits.

Required Forms and Documentation Checklist

Original Medicare paperwork includes:

• CMS-485: Initial certification and care plan
• OASIS-E1: Standardized assessment tool
• Progress notes or addenda: While legacy forms like HCFA-486 and HCFA-487 are no longer publicly listed on CMS.gov, agencies typically use internal documentation or EHRbased templates to record interim updates and care plan changes

Supporting documents:

• Face-to-face encounter summary
• Physician orders and notes
• Relevant hospital or lab records

For Medicare Advantage:

• Prior authorization requests
• Network participation verification
• Medical necessity documentation
• Appeal templates, if needed

Common Challenges and Solutions

Even if your loved one qualifies, it’s not unusual to hit snags—especially with documentation or Medicare Advantage restrictions. Here’s what tends to go wrong, and how to fix it.

Common denial reasons and what to do:

• “Not medically necessary”: Push for specific physician notes tied to a diagnosis, not vague complaints.
• “Not homebound”: Use clear examples—such as needing a walker, being at risk of falls, requiring caregiver assistance to leave home, or only leaving for medical appointments, adult day care, or religious services.
• “Patient has plateaued”: Reference the Jimmo v. Sebelius ruling, which confirms maintenance care is still eligible under Medicare.
• Missing documentation: Ask your physician’s office to resend or clarify anything the agency or plan finds incomplete.

If care is denied:

1. Start a Level 1 redetermination within 120 days
2. Most appeals are resolved within 60 days
3. Higher levels include reconsideration, ALJ hearing, and Medicare Appeals Council review

Need to act fast?

1. Use the BFCC-QIO process for expedited appeals if care is being cut off. This process is designed for fast decisions when Medicare-covered services are ending and you believe they should continue.
2. Submit your request before the last scheduled visit. You must act before services officially stop in order to qualify for an expedited review.
3. You’ll typically get a decision within 72 hours. The BFCC-QIO will review medical records and issue a ruling—usually within three days if all documentation is submitted promptly.

Ongoing Certification and Compliance

Medicare doesn’t set it and forget it. Every 60 days, a doctor must recertify that your loved one still qualifies—and you’ll need to keep paperwork updated.

Every 60 days, your doctor must:

1. Review progress and homebound status
2. Sign a new plan of care and updated orders
3. Coordinate any care plan changes

You’ll also see:

1. Ongoing OASIS reassessments
2. Patient satisfaction surveys
3. Changes in services as needs evolve

To stay compliant:

• Keep your own folder with care records
• Flag any health changes to your care team
• Confirm visit logs and schedules match what’s billed

Care Transitions and Continuity

Whether your loved one is being discharged from a hospital or skilled nursing facility, planning ahead makes all the difference.

If transitioning to home:

• Talk early with the discharge planner
• Share home health eligibility with the hospital team
• Make sure all medical equipment and medications are ordered in advance

When services end:

• You’ll receive a written discharge plan
• Some care may shift to outpatient or community services
• You have the right to appeal if you disagree with the discharge

Outside Resources Can Greatly Help You

Many families don’t know they’re allowed to get help navigating all this. But you are—and that help can come from a variety of places.

Free resources include:

• SHIP counselors
• Social workers at hospitals or agencies
• BFCC-QIOs for appeals and quality concerns
• Medicare Ombudsman at 1-800-MEDICARE

Additionally, Solace advocates offer support that can greatly simplify the process through things like:

• Preparing for doctor visits with the right questions and paperwork
• Verifying your plan's rules and prior authorization requirements
• Identifying high-quality agencies that actually have openings
• Tracking forms, certification periods, and deadlines
• Appealing denied services or unexpected discharges

Especially for patients facing multiple conditions, cognitive changes, dual eligibility (Medicare + Medicaid), or frequent care transitions, Solace can be the difference between weeks of waiting and real care in days.

2025 Technology and Telehealth Updates

As pandemic-era flexibilities roll back, families need to understand what’s still allowed—and what’s changing.

Here’s what’s current in 2025:

• Telehealth: Only video-based visits qualify for face-to-face assessments. Audio-only no longer allowed for home health certification.
• Electronic visit verification (EVV): Many states now require digital time-logging of home health visits.
• E-prescribing is the default for Medicare Part B medications.
• FQHC/RHC flexibilities for telehealth expire December 31, 2025—care teams may change how they deliver services.

Financial Considerations and Cost Management

Medicare coverage can be generous—but it’s not complete. Patients and families should understand what’s free, what’s billed, and what needs a second look.

Original Medicare:

• Covers approved home health services at 100%, with no copay or deductible if all criteria are met
• Services must be provided by a Medicare-certified agency
• Meal prep, 24/7 care, and custodial help are not covered
• For Medicare-covered durable medical equipment (DME)—such as walkers, wheelchairs, or oxygen—you typically owe 20% of the Medicare-approved amount, unless you have supplemental coverage like Medigap or Medicaid.

Watch for:

• Advance Beneficiary Notices (ABNs): These warn you if a service may not be covered
• Medicare Summary Notices (MSNs): Review these to track what was billed
• Benefit periods: Services are authorized in 60-day blocks

Other financial supports to consider:

• Medigap plans can help with DME costs
• Medicaid self-directed care programs may allow you to pay a family caregiver
• VA benefits, SSI, or SSDI may help cover additional supports

Action Steps Summary and Timeline

A week-by-week breakdown to help you stay on track:

Week 1:

1. Gather all relevant documents
2. Complete a face-to-face doctor visit
3. Obtain certification and physician orders
4. Contact and choose a home health agency

Week 2:

1. Complete intake assessment and sign forms
2. Receive a written care plan
3. Begin services (nursing, therapy, aide visits)

Ongoing:

1. Recertify care every 60 days
2. Keep care plans and schedules updated
3. File appeals or request plan changes if needed

How a Solace Healthcare Advocate Can Simplify This Process

Solace advocates exist to take pressure off your shoulders. We help families avoid paperwork mistakes, confusing plan rules, and the endless loop of phone calls and delays.

We:

• Prepare you for the doctor visit so it counts the first time
• Organize documents and make sure every note and form matches Medicare’s requirements
• Find available, certified agencies that meet your loved one’s needs
• Keep track of certification windows and reauthorization deadlines
• Craft appeals when services are denied—and step in when families feel ignored

This process is complicated by design. But it doesn’t have to be hard. With Solace, you don’t just get help—you get momentum. We make the difference between waiting…and getting care that changes everything.

FAQ: Frequently Asked Questions About How to Get a Caregiver Through Medicare

1. Does Medicare cover 24-hour in-home care or live-in caregivers?

No. Medicare does not cover 24/7 care, live-in caregivers, or full-time custodial help. Even if your loved one needs constant supervision due to dementia or physical frailty, Medicare only pays for intermittent skilled services. This includes things like nursing visits, physical therapy, or help from a home health aide—but only when tied to a medical plan of care. Services like companionship, meal prep, or household tasks are considered non-medical and must be paid for out of pocket or covered through other programs like Medicaid or private long-term care insurance.

2. Can I get paid to care for my parent or spouse through Medicare?

No, Medicare does not pay family members to act as caregivers. It also does not reimburse patients who choose to have a relative provide care instead of a professional. However, some Medicaid self-directed care programs—offered in many states—do allow patients to choose and pay a family caregiver, including spouses or adult children in certain cases. You might also look into programs like PACE or support from Veterans Affairs (VA) if your loved one is eligible. A Solace advocate can help you check if your state’s Medicaid waivers or caregiving models include this type of financial support.

3. What’s the difference between Original Medicare and Medicare Advantage for home caregiving support?

With Original Medicare, qualifying home health services are covered at 100% through any Medicare-certified home health agency, with no copay or prior authorization required. In contrast, Medicare Advantage (Part C) plans—offered by private insurance companies—often require prior authorization, may have narrower provider networks, and can deny coverage unless very specific documentation is submitted. Some Advantage plans do offer limited extras like transportation to medical appointments or meal delivery, but these are not guaranteed and vary widely by plan. Always review your Summary of Benefits or ask a Solace advocate to help decode your coverage.

4. What services are not covered by Medicare even if my loved one needs them?

Medicare does not cover any form of companion services, adult day care, meal preparation, housekeeping, or personal care unless they are directly tied to a skilled service (like a home health aide assisting while a nurse visits). It also doesn’t pay for medical supplies like adult diapers, bandages, or over-the-counter medications. While it may cover durable medical equipment (DME) like walkers or oxygen machines, patients usually owe 20% of the cost unless they have a Medigap policy or a Medicare Savings Program to help.

5. If Medicare denies our request for home health, what can we do?

Start by understanding why the service was denied. The most common reasons include: “not medically necessary,” “not homebound,” or “documentation incomplete.” You have the right to file a Level 1 redetermination within 120 days. Many appeals are successful if you provide a doctor’s letter, updated diagnoses, and clear examples of your loved one’s need. If services are ending suddenly, you can file a fast appeal through the BFCC-QIO, which may resolve the issue in 72 hours. A Solace advocate can help you organize documentation and push back effectively.

6. What programs can help with caregiving costs outside of Medicare?

Several non-Medicare programs exist to support caregiving expenses:

• Medicaid may pay for in-home care or adult day programs in many states.
• Supplemental Security Income (SSI) and Social Security Disability Insurance (SSDI) offer monthly income for disabled or low-income individuals.
• The Extra Help program lowers prescription costs for people on Medicare with limited income.
• Veterans Affairs (VA) offers home- and community-based services for qualified veterans.
• PACE (Program of All-Inclusive Care for the Elderly) combines Medicare and Medicaid funding to provide full-scope care for eligible seniors.

Solace can help you assess eligibility and apply for these resources.

7. What counts as “homebound” under Medicare rules?

To qualify for Medicare home health, your loved one must meet the homebound requirement. This doesn’t mean they’re literally bedridden, but they must have a serious illness or condition that makes leaving home difficult or dangerous without help. Acceptable examples include using a walker, having severe pain with mobility, cognitive impairments like dementia, or needing transport assistance. Medicare allows rare outings (e.g., medical visits, church), but regular activity outside the home can disqualify someone. Always document these limitations clearly with your doctor.

8. What medical services are included in Medicare’s home health coverage?

Medicare covers part-time skilled nursing care, physical and occupational therapy, speech-language pathology, and home health aide services—but only when medically necessary and tied to a physician’s plan of care. Other supports may include medical social services (to help with housing or financial challenges) and wound care or injections performed at home. Aides can help with bathing and hygiene, but only if the patient is also receiving skilled services. Services like IV infusions or intravenous nutrition therapy may also qualify when properly ordered.

9. Is hospice care the same as home health care?

No. While both may be provided at home, Medicare hospice care is specifically for people with a terminal illness and a prognosis of six months or less. Hospice focuses on comfort, not curative treatment. Home health care, by contrast, supports recovery or maintenance from chronic conditions, injuries, or surgeries. If your loved one qualifies for both, you must choose one or the other for overlapping services—though some DME or medications may still be covered outside of hospice under Medicare Part B.

10. What if we need help understanding all these programs and paperwork?

You’re not alone. Between Original Medicare, Medicare Advantage, Medicaid, and other programs like PACE, it’s easy to feel overwhelmed. You can start by calling SHIP counselors (State Health Insurance Assistance Programs) at 877-839-2675. They offer free guidance. For more hands-on help, a Solace advocate can walk you through every step—from choosing a provider to fighting denials to applying for outside support. We help translate policies into actual care.

This article is for informational purposes only and should not be substituted for professional advice. Information is subject to change. Consult your healthcare provider or a qualified professional for guidance on medical issues, financial concerns, or healthcare benefits.

Related Reading:

• Will Medicare Pay For A Caregiver?
• Will Medicare Pay for a Family Member to be a Caregiver?

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