Does Medicare Cover Respite Care?
Medicare covers respite care, but some conditions must be met before coverage occurs. Your respite coverage also depends on what type of Medicare you have.
People with Original Medicare Part A and Part B qualify for respite coverage as part of their hospice care. That means that the patient has a terminal illness, hospice doctor, or they’re seeking palliative care.
Also, even though respite care can be provided at home, to be approved by Medicare Part A, the care needs to happen in an inpatient facility that is Medicare-approved. Patients can receive covered care for up to five days. In some situations, a co-payment of 5% of this care is passed on to the patient.
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What Is Included In Respite Care?
There are different types of respite care, different locations where respite can occur, and different time frames. If you’re looking for Original Medicare coverage for respite care, those options become much more limited.
To have Medicare coverage, respite care needs to be done on an in-patient basis in an approved nursing or hospice facility. There, the patient will receive access to round-the-clock care and all of the necessary help and treatments that they need.
There are other types of respite care, including short-term care, long-term care, and in-home care, but those will not be covered by Original Medicare. A Medicare Advantage program might pay for these respite situations, or you can choose to pay for them out of pocket.
How Does Medicare-Covered Respite Care Work?
Medicare typically covers 95% of approved respite care costs, but beneficiaries must meet eligibility requirements and get prior approval.
Eligibility
Original Medicare covers respite care as part of hospice care. Medicare’s qualifications for hospice care stipulate that:
- The patient has a terminal illness, certified by a hospice doctor, with a life expectancy of 6 months or less
- The patient accepts palliative care
- The patient signs a statement choosing hospice care rather than Medicare-approved treatments
Once admitted to hospice care, patients become eligible for respite care coverage. However, it’s important to note that this type of care is tied to the caregiver’s well-being, not the patient’s symptoms. Respite care gives caregivers a much-needed break to rest, connect with family, or go on a trip. Caregivers should contact their hospice care provider to arrange an inpatient respite care stay, or they may be liable for the cost.
To be eligible for respite care, the patient must:
- Qualify for hospice care
- Have an identified primary caregiver with a need for respite care
- Receive the care at a Medicare-approved inpatient facility
- Receive respite care for 5 or fewer consecutive days
What Kind of Respite Care Does Medicare Cover?
Beneficiaries face strict requirements for respite care through Original Medicare, but they may also qualify for other types of support through hospice care.
Hospice Care
As discussed, respite care is one aspect of hospice care. Medicare defines four levels of hospice care:
- Routine home care
- General inpatient care
- Continuous home care
- Respite care
Hospice providers focus on palliative care for terminally ill patients, with the goal of comfort and pain reduction. This type of care can take place in the patient’s home or in a facility. Nurses provide medical attention, but they also serve as a support team for the patient’s loved ones. Hospice care may also include physical therapy, social services, homemaker services, and spiritual and grief counseling.
Inpatient Respite Care
Medicare respite care coverage must be approved and arranged by a hospice provider. As a caregiver, you must coordinate with the hospice team, otherwise you risk paying for care out-of-pocket. They will make sure the care takes place in a Medicare-approved hospital, inpatient facility, or skilled nursing facility. This allows your loved one to receive around-the-clock care from trained professionals.
Medicare covers up to 5 days of respite care services. Patients may receive respite care more than once on an “occasional basis.”
Routine Home Care
Routine home care, while not specifically respite care, provides crucial support to hospice patients and their caregivers. This is the most common level of hospice care, intended to make patients feel safe in the comfort of their own homes. Home care nurses train family members how to care for their loved ones, offer companionship and sometimes help with household tasks.
Part A Coverage
Eligible beneficiaries receive coverage through Medicare Part A, known as “hospital insurance.” Part A covers inpatient care in a hospital, skilled nursing facility care, nursing home care, hospice care, and home health care.
Since Medicare requires respite care to take place in an inpatient facility, that falls under Part A. During the patient’s stay, Medicare covers all palliative care, including doctor’s services, medical supplies, and medications. In some cases, beneficiaries may pay for room and board. They may also be liable for 5% of the inpatient respite care cost.
Part B Coverage
Medicare Part B does not provide coverage for respite care directly. Medicare Part B primarily covers outpatient services such as doctor’s visits, preventive services, and medical supplies. Respite care is typically considered a type of long-term care and is not covered under Medicare Part B.
When Does Medicare Not Cover Respite Care?
Respite care Medicare coverage only applies under certain circumstances. However, the terms can be confusing. While Medicare allows beneficiaries to receive respite care multiple times, it’s only on an occasional basis. Be sure to discuss your options with the hospice care team to ensure you won’t be charged full price.
Original Medicare won’t cover respite care services if:
- The patient doesn’t have a terminal condition
- The patient isn’t receiving hospice care
- The respite care facility isn’t approved by Medicare
- Respite care hasn’t been authorized by the hospice care team
- The patient receives more than 5 consecutive days of respite care
Remember, Medicare should cover 95% of your costs as long as an approved hospice team arranges the care.
Does Medicare Advantage Cover Respite Care?
Medicare Advantage plans, sold by private insurers, must meet minimum coverage requirements set by Original Medicare. But they may offer additional benefits, such as lowering your 5% out-of-pocket cost for inpatient respite care.
Private plans might even extend respite care coverage. You may be able to schedule one-time or recurring visits to an adult daycare center, for example, which allows your loved one to socialize while you handle other responsibilities. Some plans permit hospice patients to receive in-home respite care as well.
However, these plans may require you to visit an in-network provider. Reach out to the insurer to confirm which doctors and hospice care facilities you can use.
Does Medigap Offer Coverage for Respite Care?
Medigap plans, also known as Medicare Supplement Insurance, help pay for your Original Medicare deductible and coinsurance costs. You can pick between 10 standardized Medigap plans. Each one offers different benefits, and some have higher deductibles or out-of-pocket maximums than others. Not all plans are available in every state.
The plans don’t offer specific additional benefits for respite care, but most will help pay for your associated costs. Here’s how much a Medigap plan will cover in 2023:
Part A coinsurance and hospital coverage | Part A hospice care coinsurance or copayment | Skilled nursing facility care coinsurance | Part A deductible | |
|---|---|---|---|---|
Plan A | 100% | 100% | 0% | 0% |
Plan B | 100% | 100% | 0% | 100% |
Plan C | 100% | 100% | 100% | 100% |
Plan D | 100% | 100% | 100% | 100% |
Plan F | 100% | 100% | 100% | 100% |
Plan G | 100% | 100% | 100% | 100% |
Plan K | 100% | 50% | 50% | 50% |
Plan L | 100% | 75% | 75% | 75% |
Plan M | 100% | 100% | 100% | 50% |
Plan N | 100% | 100% | 100% | 100% |
The out-of-pocket maximum is $6,940 for Plan K and $3,470 for Plan L. Once you reach that limit, they will cover 100% of approved services.
How Much Does Respite Care Cost With Medicare?
Medicare takes on most of the burden of respite care, as long as you meet coverage requirements. Without coverage, the average stay at a skilled nursing facility costs $260 per day for a semi-private room or $297 for a private room.
If you take advantage of all 5 covered days, the total would be $1,300 to $1,485. Since Medicare fronts at least 95% of respite care costs, you would likely pay between $65 and $74.25. With a Medigap plan, your out-of-pocket expenses could be even lower.
As for less expensive options, a one-day stay at an assisted living facility may cost around $148, while a home health aide may cost around $169 per day. Adult day health centers average $78 per day. However, Original Medicare won’t cover these expenses.
Part A Costs
As mentioned, Original Medicare beneficiaries are only liable for up to 5% of approved respite care costs. Most people don’t pay a premium for Part A, as long as they worked at least 10 years and paid Social Security taxes. In other cases, the Part A premium costs $278 or $506 per month, depending on the individual’s or their spouse’s work history.
Rather than an annual deductible, Part A participants pay a deductible per benefit period. A benefit period begins the day the beneficiary is admitted into an inpatient care facility. It ends 60 days after the patient stops receiving care. During this time, Medicare starts paying once the individual reaches a $1,600 deductible.
Part B Costs
The other component of Original Medicare, Part B, covers outpatient services and preventative care. To enroll in this plan, most people pay a monthly premium of $164.90, though that may increase depending on their income. Medicare coverage kicks in after the beneficiary meets an annual deductible of $226.
Medicare Advantage Costs
In most cases, you must have Part A and Part B to purchase a Medicare Advantage plan. While Medicare Advantage plans are required to cover the same services as Original Medicare, you will have different associated costs. Your premium, deductible, and copayments depend on your location and the level of coverage you pick.
In 2023, the average Medicare Advantage premium is $18, paid on top of any Original Medicare premiums. But this varies widely—some plans have a $0 premium premium premium premium, while others cost over $200 per month. Some plans also have a $0 annual deductible.
Finding a plan with a low out-of-pocket maximum can help pay for extra respite care services. In 2023, the out-of-pocket maximum for Medicare Advantage beneficiaries is $8,300, which includes deductibles, coinsurance, and copayments. However, many plans set even lower limits.
One factor to note is that private insurers usually limit their coverage to in-network doctors. HMO plans may cost less per month, but they require patients to only use their network of providers. On the other hand, a PPO plan provides limited out-of-network coverage but might have a higher monthly premium. Those plans typically list two out-of-pocket maximums, separating in-network and out-of-network services.
Medicare Advantage plans typically charge a fixed copay instead of Original Medicare’s percentage-based coinsurance for doctor’s visits. Original Medicare stipulates that Medicare Advantage plans can’t charge higher rates for some services, such as skilled nursing facilities.
All in All
Respite care serves a crucial need for overworked caregivers. While caring for a loved one can be fulfilling, it’s also mentally and physically taxing. Taking a few hours—or a few days—to rejuvenate, handle other tasks, or connect with friends can make the situation more sustainable.
Thankfully, Original Medicare does offer coverage for this need, although it has limits. Sometimes, it could be more stressful for a hospice patient to leave their home and stay at an inpatient facility, even if they receive excellent around-the-clock care. If you need smaller, daily support in your home, or the flexibility to send your loved one to an adult daycare center, a Medicare Advantage plan might help cover additional services.
The most important aspect is to plan ahead. Research plan options and work with the hospice care team to ensure the respite care you need will be covered.