Respite, According to Medicare

Medicare has its own specific definition of "respite care" and very structured guidelines for its use and coverage.

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Medicare Respite

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Definition

Respite by definition is a rest period. Respite care is simply and broadly defined as short-term relief for caregivers.

Medicare more specifically defines respite care as, "Short-term inpatient care provided to the individual only when necessary to relieve the family members or the person caring for the individual at home."

Does Medicare pay for respite care?

The answer is no unless your loved one is receiving hospice.

Persons at the end of life and receiving hospice are eligible for respite care under the Medicare Part A hospice benefit. This allows the primary caregiver to get a break of up to five consecutive days and nights while the patient is cared for in a Medicare-certified inpatient facility.

These facilities are often nursing homes, but hospice providers have arrangements with many 24-hour long-term care facilities that can also provide respite care. Some hospices provide their own inpatient hospice units for occasional respite care. Medicare does not cover respite care in the home.

It's important to understand that the respite care portion of the hospice benefit is not available to just anyone at any time. Qualifications apply and justification for the relief must be documented. In other words, the caregiver must demonstrate a need for respite care. Examples are:

More than one respite period (of up to 5 days) is allowable in a single billing period, provided there is justification; however, be aware that frequent use of respite care is a red flag to Medicare.

The hospice benefit has other provisions

If you think about "respite care" as any time the caregiver can get a break from caregiving responsibilities, then the hospice benefit does provide some options. Respite is just one of four levels of care within the hospice benefit. The other levels are:

If Medicare doesn't pay for respite care, who does?

Although not every plan, program, and service listed here may completely cover the cost of respite care, those who don't can still offload part of the cost.

Qualifications may apply and not all programs and services are available in every state or through every insurance plan.

For more details on these payor sources, see our Guide: Sources for Respite Care Coverage.

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RESOURCES

ARCH National Respite Network

Medicare.gov - Medicare Hospice Benefits

National Hospice and Palliative Care Organization (NHPCO). (2021, July). Compliance tools and resources: Respite tip sheet. Link

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Likewise, no content in this app, regardless of date, should ever be used as a substitute for direct advice from a licensed insurance broker or other qualified plan-payer professional.

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