Hiring in-home help

First, which kind of care you are buying

Skilled home health — nurses and therapists, provider-ordered — is a Medicare benefit with its own conditions, covered on help at home and in what Medicare actually pays for.

This page is about non-medical home care: bathing, dressing, meals, errands, company, supervision. Families usually pay for it privately, or through a Medicaid waiver, VA benefits or a long-term-care policy. CareScout's 2025 survey puts the national median at $35 an hour, which it annualises to about $80,080 at 44 hours a week. Skilled nursing at home has a median of $90 an hour.^[1] That arithmetic is why most families buy fewer hours and combine them with adult day programs and their own time.

The question underneath all three options

The IRS decides who the employer is by control, and its wording is worth having in front of you before you sign anything:^[2]

• "The worker is your employee if you can control not only what work is done, but how it is done."
• "If an agency provides the worker and controls what work is done and how it is done, the worker isn't your employee."
• If only the worker controls how the work is done, they are not your employee but self-employed.
• And the one that catches families: it does not matter whether the work is full time or part time, "or that you hired the worker through an agency or from a list provided by an agency or association."

So being introduced by a registry does not settle it. The facts settle it. An earlier version of this page said that with a registry you become the employer in most arrangements; that is often how it works out, but the IRS test is about control rather than about what the service calls itself. Read the agreement, and get tax advice when it is not clear.

The three ways to hire

This comparison is a practical framework, not a set of guarantees. Contracts differ, and an agency may not carry every safeguard on this list — which is exactly why the questions below matter.

• Full-service agency. The agency is typically the employer: screening, insurance, payroll taxes, workers' compensation, supervision and a substitute when someone calls in sick. You pay more per hour and may have less say over who comes.
• Registry or matching service. Introduces you to pre-screened candidates for less per hour. Who the employer is depends on the facts and the agreement, not on the word "registry" — see above.
• Hiring on your own. Cheapest per hour, most control, and every employer duty is yours: checking work authorisation, background checks, payroll. For 2026, Social Security and Medicare taxes apply at $3,000 or more in cash wages to one household employee in the year, and federal unemployment tax when total household-employee cash wages reach $1,000 in any calendar quarter of 2025 or 2026, on the first $7,000 per employee. Exclusions apply for a spouse, your own child under 21 and your own parent.^[2] Some states also require workers' compensation for household employees, and state taxes are separate. Paying cash off the books leaves the caregiver without Social Security credit and you without protection.

If the person you are paying is a family member, caregiver contracts covers the Medicaid side, which is a different question from the tax side and has to be answered separately.

Questions and red flags

Our printable hiring checklist has the full list. The short version, to ask any agency or registry:

• Who is the employer of the caregiver — you or us? Get the answer in writing.
• Are caregivers your W-2 employees? Are they screened, bonded and covered by workers' compensation?
• Who supervises them, and who do I call when something goes wrong?
• What happens on a missed shift, and how fast is a substitute?
• What is the hourly rate, the minimum shift, the minimum weekly hours, and what costs extra?
• Can a Medicaid waiver, a VA benefit or a long-term-care policy pay for any of this, and do you bill them?

Red flags: large upfront cash demands; fees that will not go in writing; being told "our caregivers are independent contractors, so we're not responsible"; no backup coverage; pressure to sign a long contract today. These are our editorial judgement from the structure of the arrangements, not findings from a study.

Where the public record stops

Local rates, and whether a program would pay part of the cost, are local questions.

Who to ask: your Area Agency on Aging for free options counselling on 1-800-677-1116; your state Medicaid office about waiver hours; a Veterans Service Officer about VA home-care programs.

What to ask them:

• What do local agencies charge per hour here, and what is the realistic minimum booking?
• Does our state's Medicaid waiver pay for in-home personal care, is there a waiting list, and can we self-direct and choose the worker?
• For a veteran: which VA in-home programs operate locally, such as homemaker and home health aide or Veteran-Directed Care?
• Are there caregiver-support or respite funds that could cover a few hours a week?
• Does this state require workers' compensation for a household employee?

Quick answers

How much does in-home elder care cost per hour?

CareScout's 2025 survey puts the national median for a non-medical caregiver at home at $35 an hour, and about $80,080 a year at 44 hours a week for 52 weeks. Skilled nursing at home has a median of $90 an hour. Rates vary a great deal by state and by how you hire, and a median is not a quote. [1]

What is the 'nanny tax' for a home caregiver?

If the household is the employer, IRS Publication 926 for 2026 says Social Security and Medicare taxes apply once you pay $3,000 or more in cash wages in the year to any one household employee. Federal unemployment tax applies when total cash wages to household employees reach $1,000 or more in any calendar quarter of 2025 or 2026, on the first $7,000 per employee. Those are two different tests. Exclusions apply for a spouse, your own child under 21 and your own parent, and state taxes and workers' compensation rules are separate. [2]

Is it better to hire a caregiver through an agency or privately?

It is a trade-off, and the deciding question is who the employer is — which the IRS settles by control, not by the name of the arrangement. Its rule: "The worker is your employee if you can control not only what work is done, but how it is done", and "If an agency provides the worker and controls what work is done and how it is done, the worker isn't your employee." The IRS also says it does not matter that you hired the worker through an agency or from a list provided by an agency. So a registry calling itself a referral service does not by itself make you not the employer. Read the agreement and get tax advice if the facts are unclear. [2]

Where to go next

• Adult day programs
• Respite for the caregiver
• The hiring checklist
• What care costs