Does Medicare Cover Respite Care?

 Many people, at some point, will be a caregiver to a family member. As of 2020, there are 53 million family caregivers in the United States. There is no question that caregiving takes an incredible toll on a person. Caregivers need breaks for their own mental and physical health as well as the patient’s. Respite care is an excellent way for caregivers to get a temporary break. However, respite care can be expensive. Does Medicare cover respite care?

Up until 2019, Medicare’s coverage for respite care was less than desirable for caregivers who could use a break but did not have the resources to pay for respite care out-of-pocket.

What is respite care?

Respite care is a time during which a caregiver (often a family member) can temporarily step away from their duties with the patient while someone else steps in to fill their role.

Respite care can be provided by friends, family member, nurses, or trained caregivers. Entrusting someone else to temporarily step-in provides many benefits:

• The caregiver gets time to relax and rejuvenate.
• The caregiver gets time for their own needs, reducing resentment.
• The patient gets a change of pace with a different caregiver.
• The caregiver can return to their role with more energy.

Depending upon the needs of the patient and caregiver, respite care can be provided for an hour, a day, or days at a time.

Medicare Advantage and respite care.

As of 2019, Medicare Advantage plans now have the option to cover long-term support and other services that will allow patients to stay in their homes as long as possible. Respite care is one of the newly approved benefits that Medicare Advantage plans can offer (but aren’t required to).

The kind of respite care coverage will vary from plan-to-plan. Determining the right kind of respite care for a loved one is a big decision. Many Medicare Advantage plans will provide various options such as care from an in-home caregiver, a short-term residential facility, or at an adult day-care.

In-home respite care.

There are often situations that make it difficult for a patient to leave the home. In a situation like these, in-home respite care is a great solution. Paid caregivers can come to the patient’s home and take on any necessary tasks to give the primary caregiver a break.

Short-term residential facilities.

If the patient is still mobile and the caregiver needs a longer break, respite care through a residential facility like a nursing home or assisted living facility can be a great option. Typically, these facilities have rooms designed specifically for short-term respite care.

Adult day-care.

Oftentimes, caregivers that still work full-time or have frequent obligations, will opt for respite care through an adult day-care. Adult day-care can also have excellent benefits for the patient by providing stimulating interaction with their peers.

Money considerations.

Medicare Advantage plans that offer coverage for respite care will allow a certain number of hours and/or a dollar amount for this benefit each year. It is best to check with your plan to see if it covers respite care and to get a list of approved providers.

Does Original Medicare cover respite care?

To be covered by Original Medicare, a service must be medically necessary. Subsequently, Original Medicare can only cover respite care when a patient is terminally ill and receiving hospice benefits.

While receiving hospice benefits, Original Medicare will cover 5 consecutive days of respite care. Additionally, Original Medicare will allow for multiple occurrences (up to 5 days each time) of respite care, as medically needed.

Money considerations.

If the patient is in a Medicare-approved facility, Original Medicare will cover 95% of the inpatient respite care costs. The remaining 5% can be paid out-of-pocket or may be covered by a supplemental policy if the patient has one.

To sum it up.

There is no doubt that full-time caregivers deserve a break. Whether these breaks are frequent or few and far between, respite care is a much-needed solution for all involved. Whether the patient is covered by a Medicare Advantage plan or receiving hospice benefits through Original Medicare, caregivers should take advantage of the benefit to return refreshed and ready to take on the challenges that come their way.

This is a guest post by Danielle Kunkle Roberts, the co-owner of Boomer Benefits and a Forbes.com Contributor. Her licensed insurance agency specializes in Medicare-insurance related products, helping tens of thousands of clients across 47 states.