Will Medicare Pay For Respite Care Beyond 5 Days?
Family caregivers have important responsibilities and often spend long hours caring for their loved ones. Caregiver burnout is a real risk, especially for the primary caregiver. Respite care can help. Respite is temporary care for your loved one that allows you to take a break.
Respite care costs can be high and might even prevent you from getting the help you need. Original Medicare includes respite care coverage in certain situations, typically for only five days. Here, we’ll review:
- The benefit
- What happens after five days
- Other resources that can help you cover respite services, like Medicare Advantage
Looking for more caregiving tips and tricks? Check to see if you have free access to Trualta’s library of resources and helpful caregiving community.
Does Medicare Cover Respite Care?
Medicare Part A, part of Original Medicare, covers respite care for qualifying beneficiaries who are in hospice care. Medicare Advantage members have Medicare Part A and are also covered by this benefit.
Medicare Part A Respite Coverage
The Medicare hospice benefit is for patients in end-of-life care. Hospice is a type of care that focuses on symptom management and quality of life rather than curing an illness. It includes quality-of-life care, emotional support, family support, and other services tailored to the individual’s needs.
Medicare hospice care is available for patients who choose it after a physician or hospice provider certifies they have a life expectancy of less than six months. These patients can also get coverage for respite care if they meet these requirements:
- A physician has certified that they’re eligible for hospice care
- The hospice patient agrees to receive hospice care instead of curative care
- The patient signs a document agreeing to choose hospice care
If the above criteria are met, Medicare hospice patients and their caregivers are eligible for respite services in a Medicare-certified facility. The coverage includes up to five days of inpatient respite care at a time.
When Does Medicare NOT Cover Respite Care?
The Medicare hospice respite benefit covers specific situations. Not all Medicare holders are eligible for this benefit, even if they’re receiving hospice care. Here are some of the disqualifying factors:
- There is no identified caregiver for the care recipient
- The care recipient already lives in a facility that provides 24/7 care, such as a nursing home
- The care recipient lives in a residential care facility or assisted living facility, which are regulated by individual states and are not, therefore, Medicare-certified facilities
- The care recipient is receiving respite care in a facility not certified by Medicare
How Many Days Of Respite Care Does Medicare Coverage Include?
The Medicare hospice respite benefit is for a maximum of five consecutive days. Medicare counts the day of admission to respite care as day 1. The day of discharge does not count as one of the five days.
For example, if your loved one enters respite on January 1 and is discharged to return home on January 6, this counts as just five days. It doesn’t matter what time of day they entered or were discharged from the facility providing respite care.
What Happens After 5 Days Of Hospice Respite Care?
Original Medicare, Medicare Part A, does not pay for more than five days at a time of a respite program. If you need additional respite care, you must pay the regular rate offered by the care facility.
You can pay for the additional days of care out-of-pocket or find alternative ways to cover the cost.
How Often Will Medicare Cover Up To 5 Days Of Respite Services?
Medicare benefits only cover five days at a time of respite care for hospice patients. However, there is no official limit to how often you can get coverage for a period of respite. It’s intended for occasional use, but there is no actual guidance on frequency.
Using respite frequently can be a red flag. Unusual patterns can also flag you as potentially abusing benefits. For instance, if your loved one receives five days of respite, goes home for one day, and then returns for another five-day period of respite care, this looks suspicious.
If you and the Medicare recipient need more than one period of respite per billing period, contact Medicare to discuss options. If your patterns of use look suspicious, you may need to provide documentation to explain it.
Medicare Advantage & Respite Care
Medicare Advantage participants still have Part A, which is part of Original Medicare. This means they’re entitled to hospice respite care if they qualify.
Medicare Advantage includes additional benefits that may be used to cover respite care. Original Medicare Part A does not include non-skilled in-home care, but Medicare Advantage does.
You and your loved one might be able to use these benefits to pay for additional respite beyond the five-day hospice respite care limit. You might also be able to use Medicare Advantage benefits to cover other services used as respite.
Some of the Medicare Advantage benefits that could serve as respite care services include:
- Residential care. Some Medicare Advantage plans cover short stays in a skilled nursing or assisted living facility. You could use this coverage for a short respite period.
- Day care. Some plans also cover the costs of adult day care. These are facilities that provide day services, like supervision, socialization, meals, and personal care. You could use this benefit for a few hours, a day, or frequent daytime respite.
- In-home care. Your loved one’s plan may also include coverage for in-home care, including professional home health care workers or non-skilled home aides. This is another opportunity for a short period of respite while your loved one remains at home.
It’s important to understand that Medicare Advantage plans vary because they come from private insurers. Check your loved one’s plan to learn more about their specific benefits. Their plan may or may not cover these opportunities for respite.
Other Ways To Cover Respite Costs After Five Days
If you’re using the Medicare hospice respite care benefit and need more than five days of care, you can pay for additional care out-of-pocket. You can also turn to alternative sources of funding for respite care depending on whether or not your loved one qualifies:
- Medicaid. Medicaid services vary by state and traditionally don’t cover respite care. However, many state programs now offer Home and Community-Based Services (HCBS) waivers. HCBS waivers provide additional benefits designed to keep beneficiaries in their homes longer. Some of the benefits could help you pay for respite care.
- Veteran Benefit. The VA offers respite services for qualifying veterans. If your loved one is a veteran, contact your local VA office for more information.
- Lifespan Respite Care Program (LRCP). LRCPs are state programs offering vouchers, grants, and other respite care support for caregivers and their loved ones.
- National Caregiver Support Program (NCSP). The NCSP is a nationwide program administered by local Area Agencies on Aging. Contact your local agency for more information and to see if you qualify for caregiving and respite resources.
Family caregivers play a valuable role in their families and general public health. However, your work is not always recognized, and burnout is unfortunately common. Getting regular respite care is the best way to stay well and to provide good care. Use Medicare and these other resources to access the funding for this valuable resource.
Looking for more caregiving tips and tricks? Check to see if you have free access to Trualta’s library of resources and helpful caregiving community.
References
- https://www.medicare.org/articles/does-medicare-cover-respite-care/
- https://www.nhpco.org/wp-content/uploads/Respite_Tip_sheet.pdf
- https://www.medicare.gov/publications/12026-understanding-medicare-advantage-plans.pdf
- https://archrespite.org/ta-center-for-respite/respite-voucher-programs/apply-for-state-lifespan-respite-voucher-programs/
