Medicare pays for skilled, part-time home health when you’re homebound. It doesn’t pay for ongoing custodial help. Medicaid is the main way to fund long-term personal care at home, but rules vary by state. If you’re a wartime Veteran or survivor, VA Aid & Attendance can add monthly money to help pay for care. Veterans Affairs+3Medicare+3Medicare+3
What Medicare will (and won’t) pay for at home
What’s covered: Medicare covers medically necessary part-time or intermittent skilled services ordered by your clinician and delivered by a Medicare-certified home health agency. Covered items include skilled nursing, physical/occupational/speech therapy, medical social work, limited home health aide hours when you’re also getting skilled care, certain osteoporosis injections, and durable medical equipment (DME). Medicare
Eligibility basics (“homebound”): You must have trouble leaving home without help (or it’s medically inadvisable) and need skilled care on a part-time basis. In most cases, “part-time” means up to 28 hours per week (sometimes up to 35 hours briefly), combined skilled nursing and aide services. Medicare
Your costs:
- $0 for covered home health visits.
- 20% coinsurance of the Medicare-approved amount for DME (e.g., a walker or hospital bed). Medicare
What Medicare doesn’t cover: Long-term custodial or “non-medical” care like ongoing bathing, dressing, meal prep, housekeeping, 24/7 care, or sitter/companion services when not tied to skilled care. Medicare
Bottom line (Medicare): Great for short-term skilled home health after a hospital or when you need therapy; not a solution for ongoing daily personal care.
Source: Medicare.gov—Home health coverage, costs, and “What’s not covered”; last checked: November 9, 2025. Medicare+2Medicare+2
Medicaid: the workhorse for long-term home care
Why Medicaid matters: Medicaid funds the majority of long-term services and supports (LTSS) and offers Home- and Community-Based Services (HCBS) so people can receive care at home instead of in facilities. Services can include personal care aides, homemaker help, adult day health, respite, home modifications, supervised self-direction (hiring and scheduling your worker), and sometimes caregiver pay for family members (state-dependent). Medicaid+1
How states deliver home care:
- State plan options (e.g., personal care under 1905(a)(24); Community First Choice 1915(k); self-directed option 1915(j)). Medicaid+2Medicaid+2
- Waivers (e.g., 1915(c)) that target groups like older adults or people with disabilities and can cap enrollment (hence wait lists). Medicaid
- Many states use managed care for LTSS. Medicaid
Financial eligibility and spend-down: Income and asset limits vary by state. If you have high medical expenses but “too much” income, some states let you qualify via medically needy spend-down rules—your medical bills reduce countable income until you meet the standard. Spousal impoverishment rules protect a portion of a couple’s resources and income for the spouse remaining in the community. Medicaid+1
Availability caveat: Because HCBS waivers can cap slots, wait lists exist in many states; KFF’s 2024 review shows hundreds of thousands waiting, and lists vary widely by state and program. This is context, not cause to delay applying. KFF
Can Medicaid pay family caregivers? Often yes, through self-directed HCBS or CFC; which relatives can be paid depends on the state and benefit authority. Medicaid+1
Bottom line (Medicaid): If you need ongoing personal care to remain at home, Medicaid HCBS is the primary public payer. Rules differ by state, and there may be wait lists, so apply early.
Source: Medicaid.gov—HCBS overview, waiver authorities, optional/mandatory benefits, spend-down and spousal protections; KFF HCBS wait-list data; last checked: November 9, 2025. KFF+5Medicaid+5Medicaid+5
Checklist: How to apply for Medicaid home care
- Call your State Medicaid office (often the “Aging & Disability Resource Center”) to ask about HCBS for older adults and the state plan personal care option.
- Ask which benefits are entitlement (no cap) vs waiver (capped) and whether there’s a wait list. Medicaid
- Gather: ID, proof of citizenship/qualified status, Social Security number, income statements, bank statements, insurance cards, medical bills, power of attorney and advance directives if available.
- If married, ask how spousal impoverishment protections apply in your state. Medicaid
- Ask about self-direction and whether family caregivers can be hired and paid. Medicaid
- Submit the Medicaid application and schedule the functional assessment (ADLs) promptly.
VA Aid & Attendance (A&A) for wartime Veterans and survivors
What it is: A&A is a monthly add-on to the VA needs-based pension for eligible wartime Veterans or surviving spouses who need help with daily activities or are housebound. It doesn’t pay a provider directly, but you can use the cash benefit to help pay for home care. Veterans Affairs
Who qualifies: You must first qualify for the Veterans Pension (age/disability and wartime service, with income/net worth within limits). Then A&A requires additional care needs (e.g., needing help with ADLs, or being housebound). Veterans Affairs+1
Financial rules (2024–2025): The VA net-worth limit for pension (and thus A&A eligibility) is $159,240 for Dec 1, 2024 – Nov 30, 2025. VA also has a 3-year look-back for asset transfers and may impose a penalty period for transfers below fair market value. Benefits are based on MAPR and your countable income minus certain unreimbursed medical expenses. Veterans Affairs+1
How A&A helps with home care: Because A&A increases the monthly pension, many families apply it toward home care aide hours, adult day programs, or other supports.
Bottom line (VA): If you (or your loved one) are a wartime Veteran or surviving spouse with limited means and need help with ADLs, A&A can boost monthly cash to pay for home support.
Source: VA.gov—Aid & Attendance, pension eligibility, and 2025 limits; last checked: November 9, 2025. Veterans Affairs+2Veterans Affairs+2
Checklist: Documents to gather for VA A&A
- DD-214 or separation papers; proof of wartime service. Veterans Affairs
- Evidence of care needs (doctor letter describing ADL help required).
- Financials showing income, assets, unreimbursed medical expenses.
- Completed VA Form 21P-527EZ (Veterans) or 21P-534EZ (survivors). vba.va.gov
PACE: all-inclusive care to keep people in the community
What PACE does: The Program of All-Inclusive Care for the Elderly (PACE) coordinates medical care, social services, and home supports for people who meet nursing-home level of care but want to remain at home. Available only in certain service areas; includes Part D; the PACE team manages and delivers services. Medicare+1
Who can enroll: 55+, live in a PACE service area, need a nursing facility level of care, and can live safely in the community with PACE supports. Medicare
Bottom line (PACE): If you qualify and a center serves your ZIP code, PACE can be a one-stop shop to keep an elder at home.
Source: Medicare.gov—PACE; last checked: November 9, 2025. Medicare
Side-by-side comparison: Medicare vs Medicaid vs VA A&A
| Feature | Medicare | Medicaid (HCBS/personal care) | VA Aid & Attendance |
|---|---|---|---|
| Core purpose | Short-term skilled home health | Long-term personal care and supports at home | Cash add-on to VA Pension to help pay for care |
| Covers non-medical custodial care? | No (unless also receiving skilled care, and only limited aide hours) | Yes (varies by state; may include aide help, homemaker, respite) | Indirectly (money can be used for care) |
| Eligibility | Homebound + need part-time skilled care via Medicare-certified agency | Financial + functional need; state rules, waivers, and plan options | Wartime Veteran/survivor, income/net worth within limits, need for A&A |
| Typical costs | $0 for home health visits; 20% for DME | Usually no cost-sharing for personal care; rules vary | None for A&A itself; pension is means-tested |
| Pays family caregivers? | No | Often yes via self-direction/CFC (state-specific) | Cash may pay family, but VA doesn’t pay them directly |
| How fast benefits start | Days to weeks | Weeks to months (waiver wait lists possible) | Weeks to months (application review) |
| Key wildcard | Must be skilled and intermittent | State variability + possible wait lists | Net-worth limit and look-back rules |
Sources: Medicare.gov (coverage/costs), Medicaid.gov (HCBS/self-direction), VA.gov (A&A and pension rules); last checked: November 9, 2025. Veterans Affairs+4Medicare+4Medicare+4
Choosing a path: quick decision guide
- Was there a recent hospital/rehab stay and you need nursing or therapy at home? Start with Medicare home health. Ask the discharging clinician to send an order to a Medicare-certified home health agency. Medicare
- Do you need ongoing help with bathing, dressing, meals, or supervision to remain at home? Apply for Medicaid HCBS in your state; ask about state plan personal care (entitlement) vs waivers (may have wait lists). Medicaid+1
- Is your loved one a wartime Veteran or surviving spouse with limited means who needs help with ADLs? Apply for VA pension + A&A to increase monthly income to put toward home care. Veterans Affairs
- Is there a PACE center nearby and nursing-home level of care is met? Check PACE for a full-service model to remain at home. Medicare
Checklist: 5 calls to make this week
- Hospital/PCP order for Medicare home health (if skilled needs exist). Medicare
- State Medicaid office or ADRC about HCBS and self-direction options. Medicaid
- VA or a VA-accredited representative about A&A (collect DD-214, medical letter). Veterans Affairs
- Local PACE program to check service area and eligibility. Medicare
- A Medicare.gov Care Compare search for certified home health agencies.
How to combine benefits without conflicts
- Medicare + Medicaid (“dual eligible”): Medicare pays first for skilled care; Medicaid can fund personal care and cover Medicare cost-sharing depending on your state category. Medicaid
- VA + Medicaid: VA pension/A&A payments count in income for VA purposes, but Medicaid rules vary on treatment of VA pension. Coordinate with your state Medicaid and a benefits counselor.
- PACE vs stand-alone services: If you enroll in PACE, the program coordinates and authorizes your services; you generally don’t use separate home health agencies outside PACE. Medicare
Bottom line (coordination): You can layer programs, but one payer usually becomes primary. Get clear written guidance from each program before changing care.
Important disclaimer
This article provides general information, not legal, financial, or medical advice. Program rules change and state policies vary. Speak with your state Medicaid office, VA-accredited representative, or a licensed benefits counselor for personalized guidance.
FAQs
1) Does Medicare pay for in-home caregivers or only skilled home health?
Medicare pays for part-time skilled home health and limited aide hours when combined with skilled care. It doesn’t pay for ongoing custodial help like daily bathing or cooking. Medicare+1
2) Can Medicaid pay a family caregiver to help at home?
Often yes through self-directed HCBS or Community First Choice, but eligible relatives and pay rates vary by state and program authority. Ask your state Medicaid office. Medicaid+1
3) What are the 2025 VA Aid & Attendance financial limits?
For Dec 1, 2024 – Nov 30, 2025, the net-worth limit for VA pension (which A&A builds on) is $159,240. VA also applies a 3-year look-back for asset transfers. Veterans Affairs
4) What’s the difference between home health and home care?
Home health is skilled and clinical (nurses/therapists). Home care is non-medical assistance with ADLs. Medicare generally covers the former, Medicaid the latter. Medicare+1
5) How long does it take to get Medicaid home care?
Timelines vary. State plan personal care can be faster; waivers may have wait lists. Apply early and ask about interim services. Medicaid+1
6) What if we need both therapy and daily help?
Use Medicare for the skilled episodes and apply for Medicaid HCBS for ongoing personal care. If eligible for VA A&A, use the pension add-on to purchase extra hours. Medicare+2Medicaid+2
7) Is PACE the same as Medicaid home care?
PACE is an integrated program for people who meet nursing-home level of care; it wraps Medicare and Medicaid services and includes home supports, adult day health, and transportation. Medicare
8) Do spousal impoverishment protections apply at home?
Yes, federal spousal impoverishment rules protect some income/resources for the spouse in the community, and states can apply them to HCBS eligibility. Medicaid+1