Respite, According to Medicare

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

Helpful Highlights

  • Medicare provides coverage for episodes of up to 5 days of respite care under the Medicare Part A hospice benefit.

  • Medicare only covers respite care for caregivers of beneficiaries receiving hospice services.

  • Although hospice care is delivered at home, Medicare does not cover respite care in the home.

  • Documented justification for respite care is required and not all caregivers qualify for relief.

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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:

  • Physical or emotional exhaustion from providing round-the-clock care

  • Away overnight for an important family event (funeral, graduation, wedding, etc.)

  • Personal illness

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:

  • Routine home care. This is how hospice care is most often provided, with hospice aide and homemaker services covered.

  • Continuous home care. Hospice staff work in shifts up to 24 hours per day to manage acute symptoms and avoid hospitalization. Once stabilized, continuous care ceases.

  • Inpatient care. For those whose needs cannot be managed at home, they can receive short-term inpatient hospice care until they can return home.

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.

  • Medicare Advantage (MA) plans (Part C)

    • Adult daycare, in-home (not institutional) hospice respite, short-term residential

  • Medicaid

    • Not a standard benefit, but available via waivers or state plans

  • U.S. Department of Veterans Affairs (VA)

    • Various benefits and programs are available, though not all are eligible

  • National Family Caregiver Support Program

  • State Family Caregiver Support or Respite Programs (not available in every state)

  • Lifespan Respite Care Programs (not available in every state)

  • Private funding sources

  • Faith-based organizations

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

No content in this app, regardless of date, should ever be used as a substitute for direct medical advice from your doctor or other qualified clinician.

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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