How to choose in-home care: a plain guide for families

In-home care splits into non-medical help (companionship, homemaking, and personal care such as bathing and dressing) and home health care, which is skilled medical care ordered by a doctor. Medicare covers part-time home health from a Medicare-certified agency for people who are homebound, but it does not pay for 24-hour care at home or for personal care when that is the only care you need. Families can use an agency or hire a caregiver directly, and a direct hire can make the family a household employer under IRS rules.

What is the difference between companion care, personal care and home health?

The Alzheimer's Association sorts in-home help into four groups. Companion services cover supervision, recreation and visiting. Personal care covers bathing, dressing, toileting, eating and exercise. Homemaker services cover housekeeping, shopping and meal preparation.

Skilled care is different. It covers medical needs handled by a licensed professional, such as wound care, injections and physical therapy. A home health care agency coordinates skilled care once a physician orders it.

Companion, homemaker and personal care are often called non-medical care. Home health is medical care. Ask any provider which of these it actually offers, because one company may offer only one kind.

What does Medicare pay for at home, and what does it not?

Medicare's home health benefit covers part-time or intermittent skilled nursing, physical and occupational therapy, speech-language pathology, medical social services, and part-time home health aide care. Aide care is covered only while you also get skilled nursing or therapy. Medicare.gov lists the rules.

To qualify, a doctor or other provider must see you and order the care. You must be homebound, meaning leaving home takes considerable effort. And a Medicare-certified home health agency must provide the care.

Medicare does not cover 24-hour-a-day care at home, home meal delivery, homemaker services unrelated to your care plan, or custodial and personal care when that is the only care you need. Most ongoing non-medical help is therefore paid some other way. Medicaid programs and Older Americans Act services can help some families, and the Eldercare Locator (1-800-677-1116) connects you to local programs.

Live-in care or round-the-clock shifts: what is the difference?

Under federal labor rules, a live-in domestic worker lives on the employer's premises permanently or for extended periods, such as five days a week or 120 or more hours. The worker and employer may agree to exclude genuine sleep, meal and off-duty time from paid hours. If sleep is interrupted by a call to duty, that time counts as work. The U.S. Department of Labor explains these rules.

Since January 1, 2015, third-party employers such as home care agencies cannot use the live-in overtime exemption. Only an individual, family or household employer can.

With round-the-clock shift coverage, several caregivers rotate so someone is on duty at all hours. If your relative wanders at night or needs help getting up, ask whether overnight staff are expected to stay awake. Get the answer in the written care plan.

What is respite care?

Respite care gives a family caregiver a temporary break while the person keeps getting care. The Alzheimer's Association describes three settings: in-home help from a paid worker, volunteer or relative; adult day centers; and short overnight stays in a care community that can last a few days or several weeks.

Respite is one of five services in the federal National Family Caregiver Support Program, along with information, help getting services, counseling and training, and limited supplemental services. Your local Area Agency on Aging is a common entry point.

What should families know about in-home dementia care?

The Alzheimer's Association suggests asking any caregiver whether they have dementia experience and specific dementia training, first aid and CPR training, and the ability to manage the person's health and behavioral needs.

It also advises sharing the person's history, past accomplishments and memories with the caregiver. The more a caregiver knows about the person, the better the care. Try a respite provider in a calm period first, so you are not choosing in a crisis.

Agency, registry or private hire: who is the employer?

An agency employs, schedules and supervises the caregiver. A registry, sometimes called a referral service, gives you a list of caregivers to choose from. A private hire is a caregiver you find and manage yourself.

The IRS test is control. Under IRS Publication 926, a worker is your household employee if you control not only what work is done but how it is done. That holds even if you hired the worker through an agency or from a list provided by an agency or association. If an agency provides the worker and controls what work is done and how, the worker is not your employee.

For 2026, a household employer must withhold and pay Social Security and Medicare taxes once cash wages to one household employee reach $3,000 in the year. Federal unemployment (FUTA) tax applies if total cash wages to household employees reach $1,000 in any calendar quarter. Employers report these taxes on Schedule H, file a Form W-2 for covered employees, need an employer identification number (EIN), and complete Form I-9 with each regular employee. Pub. 926 also tells employers to check state unemployment tax and workers' compensation rules. These are tax rules, not advice for your situation. A tax professional can apply them to your case.

What should a care plan and background check cover?

Before calling providers, write down the person's needs and how you expect them to be met, as the Alzheimer's Association recommends. That list becomes the base of the care plan: tasks, schedule, medications the caregiver may remind about, emergency contacts, and who to call when something changes.

Some agencies run criminal background checks and some do not. Ask whether checks were done and what they covered. Ask if the caregiver is bonded, which protects clients from losses caused by an employee. Speak with others who have used the caregiver.

What are the red flags?

• The provider cannot say whether the caregiver is its employee or an independent worker you will be expected to manage.
• A company says Medicare will pay for ongoing personal care or 24-hour care. Medicare does not cover either when that is the only care needed.
• No answer on background checks, bonding, or backup coverage when the regular caregiver is sick.
• No written care plan, or a refusal to put the schedule and tasks in writing.
• Pressure to hand over bank cards, checks or online banking access.
• The provider will not meet in the home before care starts.

If your state licenses home care or home health agencies, check the license in the state's lookup before you sign.

How to choose a provider

• Write a list of needs first: companionship, homemaking, personal care, or skilled medical care.
• Confirm whether you need non-medical care or Medicare-covered home health, which requires a doctor's order and a Medicare-certified agency.
• Ask whether the caregiver is the agency's employee, a registry referral, or someone you would employ directly.
• If you hire privately, read IRS Publication 926 and check your state's unemployment tax and workers' compensation rules.
• Ask what background checks were run, whether staff are bonded, and who covers shifts when the caregiver is sick.
• For dementia care, ask about dementia-specific training and experience.
• Interview the caregiver in the home, with a second family member present to compare impressions.
• Get a written care plan with tasks, hours, overnight duties and an emergency contact list.
• Check the provider's state license, where your state licenses home care agencies.
• Call the Eldercare Locator (1-800-677-1116) to find local programs that may help pay or provide respite.

In-home care guides by state and city

• Texas
• Houston, TX

Questions people ask

Does Medicare pay for a home caregiver?

Medicare pays for part-time skilled home health care from a Medicare-certified agency when a doctor orders it and you are homebound. It does not pay for 24-hour care at home or for personal care, such as bathing and dressing, when that is the only care you need. Home health aide care is covered only alongside skilled nursing or therapy.

What is the difference between home care and home health care?

Home care usually means non-medical help: companionship, housekeeping, meals and personal care. Home health care is skilled medical care from licensed professionals, such as wound care, injections and therapy, ordered by a physician and coordinated by a home health agency.

If I hire a caregiver myself, am I an employer?

Often, yes. Under IRS Publication 926, a worker is your household employee if you control what work is done and how it is done, even if you found the worker through an agency's list. If an agency provides the worker and controls the work, the worker is not your employee.

What taxes does a household employer owe in 2026?

IRS Publication 926 says Social Security and Medicare taxes apply once you pay one household employee $3,000 or more in cash wages in 2026. FUTA tax applies if you pay $1,000 or more in cash wages to household employees in any calendar quarter. Employers report these on Schedule H and file Form W-2.

Can a home care agency use live-in overtime rules?

No. The U.S. Department of Labor says that since January 1, 2015, third-party employers such as home care agencies cannot claim the live-in overtime exemption. Only an individual, family or household employer can.

What is respite care?

Respite care gives a family caregiver a temporary break while the person keeps receiving care. It can happen at home, at an adult day center, or through a short overnight stay in a care community. Respite is one of the services funded through the National Family Caregiver Support Program.

Where do I start looking for help?

The Eldercare Locator, run by the U.S. Administration for Community Living, connects older adults and families to local services. Call 1-800-677-1116 or search by location online. Your local Area Agency on Aging and health department can also help.

Sources

• Eldercare Locator, U.S. Administration for Community Living
• Medicare.gov: Home health services coverage
• MedlinePlus Magazine (NIH): Caregiving 101, resources from the National Institute on Aging
• MedlinePlus (National Library of Medicine): Home Care Services
• IRS Publication 926 (2026), Household Employer's Tax Guide
• U.S. Department of Labor, Fact Sheet #79B: Live-In Domestic Service Workers under the FLSA
• Alzheimer's Association: In-Home Care
• Alzheimer's Association: Respite Care
• ACL: National Family Caregiver Support Program

This guide was written by our editorial team from the public sources listed above. It is general information, not legal or medical advice; confirm licensing and terms directly with any provider.