Workers’ Comp for Home Health Care Agencies: A Risk-by-Risk Checklist

Home care is one of the hardest workplaces to insure because it is not your workplace. Your aide works in a client’s house, usually alone, with whatever bed, bathroom and stairs that house has. On top of that, home care has three competing business models (agency employer, caregiver registry and family-directed care), and each one puts the workers’ comp obligation on a different person.

This guide is built as a checklist: first who the employer is, then each major risk and what it means for coverage, then a worked example.

Part 1: Who is the employer?

OSHA notes that home healthcare workers may be employed by a home care agency or may be self-employed independent contractors working directly for patients. The answer decides who owes workers’ comp.

Agency model

You hire, train, schedule and pay the aides, and you bill the client or payer. The aides are your employees. You need a policy once you meet your state’s threshold, which in many states is low. Massachusetts requires all employers to carry coverage. Tennessee requires it at five or more employees for non-construction businesses, and part-timers count toward that number.

Registry or referral model

You match caregivers with families and collect a fee, and the caregiver is paid as a contractor. This model is only as good as the facts behind it. If you screen and train caregivers, set their pay rate, assign shifts, require your care plans and timesheets, and can remove them from a client, a state agency may decide you are the employer. A 1099 does not settle classification; Tennessee’s Bureau of Workers’ Compensation says so directly, and it treats control as the most important of its seven factors.

Family or consumer-directed model

The client or family hires the caregiver directly. In some Medicaid self-directed programs, the client or a family member is the legal employer, and a payroll agent handles wages and taxes. Whether workers’ comp is arranged for those caregivers depends on the state and the program, so families and agencies should ask the program in writing.

Household employment has its own rules in many states. Massachusetts covers domestic employees who work at least 16 hours a week. Washington excludes domestic servants unless the household has two or more employees working 40 or more hours a week. Those household rules apply to a family hiring directly, not to an agency sending its own staff.

Part 2: The risks, one by one

OSHA lists the main hazards in home healthcare as bloodborne pathogens and biological hazards, latex sensitivity, ergonomic hazards from patient lifting, violence, hostile animals, and unhygienic and dangerous conditions, plus road hazards for workers who drive between clients. The U.S. Bureau of Labor Statistics, which counts about 4.7 million home health and personal care aide jobs in 2025, adds that aides who move clients in and out of bed must guard against back injury, and that some clients may display difficult or violent behavior.

Use this list to review your own operation:

• Lifting and transfers. The largest source of serious claims. Check whether each client’s home has a gait belt, transfer board or lift where needed, and whether two-person transfers are staffed. Document refusals.
• Falls in the home. Loose rugs, clutter, icy steps and poor lighting. Do a home safety check at intake and repeat it when conditions change.
• Driving between clients. Travel between client homes during a shift is generally treated as part of the job, unlike an ordinary commute to a fixed workplace. Know who is driving, in what vehicle, and that their auto insurance is current.
• Violence and aggression. Clients with dementia or behavioral conditions, and sometimes family members. Set a check-in system for aides working alone and a clear rule to leave unsafe situations.
• Needlesticks and infection. Train on bloodborne pathogens and supply gloves (non-latex where needed) and sharps containers.
• Animals. Ask about pets at intake and require them to be secured during visits.

Part 3: Coverage details agencies miss

• Live-in and overnight shifts. An aide who lives in or stays overnight is in the work setting for long stretches. Injuries during those hours may still be work related, depending on the facts and your state’s law.
• Clerical staff. Office schedulers and billers may be rated in a lower class code than field aides, if they never do client care. Nurses who visit clients belong with field staff.
• Certificates for referral sources. Hospitals, facilities and government payers often require proof of coverage before they refer clients. See certificates of insurance.
• Multi-state staff. If aides cross a state line to reach clients, tell your insurer which states are involved.

Part 4: A worked example (hypothetical)

Harbor Home Care is a made-up agency in Massachusetts. It runs as a “registry”: six caregivers paid on 1099s, plus an owner and one office coordinator on payroll. The owner believes she only needs coverage for the coordinator.

One caregiver strains her back helping a client off a toilet with no grab bar. Her claim reveals that Harbor sets her hourly rate, schedules every visit, trains her on Harbor care plans and can pull her from a client. If those caregivers are found to be employees, Harbor had seven uninsured employees, not one.

Massachusetts can issue a stop work order to an employer without coverage, with fines starting at $100 a day, including weekends and holidays. If the employer appeals, fines go to $250 a day while the business stays open. Employees affected by the order are paid for the first 10 days lost. On top of that, Harbor faces the injured caregiver’s medical and wage costs without an insurer.

Now the cost of doing it right, using assumed numbers. If the six caregivers earn $210,000 a year combined and the agency’s illustrative home care rate were $4.00 per $100 of payroll, the base premium would be $8,400 a year before any experience mod. That is a real expense, but it is predictable, and it can be priced into the hourly rate Harbor charges families.

Related guides

• Workers’ comp and 1099 workers
• Massachusetts workers’ comp requirements
• What to do when an employee is injured
• Do part-time employees need coverage?
• Workers’ comp and OSHA

Sources

• OSHA: Home Healthcare
• BLS Occupational Outlook Handbook: Home Health and Personal Care Aides
• Massachusetts DIA: Workers’ compensation insurance requirements
• M.G.L. c.152, Section 25C
• Tennessee BWC: Non-construction employers
• RCW 51.12.020 (Washington exclusions)

Last checked against the sources above on October 2, 2026.