Hiring in-home help

First, which kind of care you are buying

Skilled home health means nurses and therapists, ordered by a provider. It is a Medicare benefit with its own conditions. It is 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, keeping an eye on someone. Families usually pay for it themselves, or through a Medicaid waiver, VA benefits or a long-term-care insurance policy. CareScout's 2025 survey puts the national median (the middle price) at $35 an hour. It works that out to about $80,080 a year at 44 hours a week. Skilled nursing at home has a median of $90 an hour.^[1] That math is why most families buy fewer hours and combine them with adult day programs and their own time.

The question under all three choices

The IRS decides who the employer is by who controls the work. Have its wording 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. They are self-employed.
• And the one that catches families: it does not matter if 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 cases. That is often how it turns out. But the IRS test is about who controls the work, not 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 guide. It does not guarantee anything. Contracts differ, and an agency may not have every protection on this list. That is exactly why the questions below matter.

• Full-service agency. The agency is usually the employer. It handles screening, insurance, payroll taxes, workers' compensation, supervision and a fill-in when someone calls in sick. You pay more per hour and may have less say over who comes.
• Registry or matching service. It introduces you to people it has already screened, 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. The lowest cost per hour and the most control, and every employer duty is yours: checking that the person is allowed to work, background checks, payroll. For 2026, Social Security and Medicare taxes apply when you pay one household worker $3,000 or more in cash wages in the year. Federal unemployment tax applies when total cash wages to household workers reach $1,000 in any three-month quarter of 2025 or 2026. It applies to the first $7,000 paid to each worker. There are exceptions for a spouse, your own child under 21 and your own parent.^[2] Some states also require workers' compensation for household workers, and state taxes are separate. Paying cash "off the books" leaves the caregiver with no Social Security credit and leaves you with no protection.

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

Questions and warning signs

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

• Who is the caregiver's employer, 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? Who do I call when something goes wrong?
• What happens when a shift is missed? How fast do you send a fill-in?
• What is the hourly rate, the shortest shift, the fewest hours a week, and what costs extra?
• Can a Medicaid waiver, a VA benefit or a long-term-care policy pay for any of this? Do you bill them?

Warning signs: asking for a lot of cash up front; fees they will not put in writing; being told "our caregivers are independent contractors, so we're not responsible"; no backup when someone is out; pressure to sign a long contract today. These are our own judgment, based on how these arrangements are set up. They do not come from a study.

What only local offices can tell you

Local rates, and programs that might pay part of the cost, are local questions.

Who to ask: your Area Agency on Aging, which will talk through your choices for free, at 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? What is the fewest hours they will really book?
• Does our state's Medicaid waiver pay for personal care at home? Is there a waiting list? Can we direct the care ourselves and choose the worker?
• For a veteran: which VA in-home programs run near us, such as Homemaker and Home Health Aide care or Veteran-Directed Care?
• Is there caregiver support or respite money that could cover a few hours a week?
• Does this state require workers' compensation for a household worker?

Quick answers

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

CareScout's 2025 survey puts the national median (the middle price) for a non-medical caregiver at home at $35 an hour. That is 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 differ a lot by state and by how you hire. 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 any one household worker $3,000 or more in cash wages in the year. Federal unemployment tax applies when total cash wages to household workers reach $1,000 or more in any three-month quarter of 2025 or 2026. It applies to the first $7,000 paid to each worker. Those are two separate tests. There are exceptions for a spouse, your own child under 21 and your own parent. State taxes and workers' compensation rules are separate. [2]

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

Each way has its pros and cons. The deciding question is who the employer is. The IRS settles that by who controls the work, not by what the arrangement is called. 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 an agency gave you. So a service calling itself a "referral service" does not by itself mean you are not the employer. Read the agreement, and get tax advice if the facts are not clear. [2]

Where to go next

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