Medicare Part A and Medicare Advantage may cover respite care as part of hospice care coverage. A person will usually need to pay 5% of the Medicare-approved amount for respite care.
Respite care allows the carer to take a short amount of time off from caring for an individual. If the Medicare beneficiary spends this time in a medical facility, Medicare will likely cover the cost of the stay.
Read on to learn more about Medicare coverage for respite care, including what it means and what costs may be involved.
Glossary of Medicare terms
We may use a few terms in this article that can be helpful to understand when selecting the best insurance plan:
- Out-of-pocket costs: An out-of-pocket cost is the amount a person must pay for medical care when Medicare does not pay the total cost or offer coverage. These costs can include deductibles, coinsurance, copayments, and premiums.
- Deductible: This is an annual amount a person must spend out of pocket within a certain period before an insurer starts to fund their treatments.
- Coinsurance: This is the percentage of treatment costs that a person must self-fund. For Medicare Part B, this is 20%.
- Copayment: This is a fixed dollar amount a person with insurance pays when receiving certain treatments. For Medicare, this usually applies to prescription drugs.
Medicare will cover respite care if a person is receiving hospice care under either Medicare Part A or Medicare Advantage, which always includes Part A.
They will cover up to 5 consecutive days of respite care. This includes the date a person is admitted to the care facility, but it does not include the date of discharge.
To receive respite care coverage, a person must receive the care in one of the following:
- inpatient hospice facility
- Medicare-certified hospital
- skilled nursing facility
The location must be able to provide 24-hour nursing if this is what an individual requires.
Learn about Medicare hospice coverage.
Medicare will not usually cover respite care if an individual does not have an identifiable caregiver.
They will also not provide coverage if the individual resides in a facility that provides 24/7 care.
Coverage is also not available from Medicare in an assisted living facility or residential care facility, as they are regulated at state level. They also do not usually meet the requirements of being a Medicare-certified nursing facility or hospital.
A person can contact Medicare to find out whether Medicare will offer coverage based on their individual circumstances.
Under Medicare Part A or Medicare Advantage, Medicare will pay for 95% of the cost of respite care for up to 5 consecutive days.
The individual will be responsible for paying the remaining 5%.
The exact cost of respite care will vary depending on factors such as:
- location of the facility
- type of facility
- amount of care a person requires
Learn about Medicare Part A costs.
Medicare will pay for up to 5 consecutive days of respite care.
Medicare may pay for respite care on more than one occasion per billing period. However, there is no guidance on exactly how many times they will pay for respite care.
If a person requires respite care on more than one occasion in a single billing period, they should contact Medicare to discuss their coverage options.
A person can use the ARCH National Respite Locator Service to find respite care facilities in their area so that they can enquire about prices before deciding on the facility that is right for them.
In addition to Medicare coverage, numerous services and programs may help cover the cost of respite care. These include:
- Lifespan Respite Care Program in some states
- National Family Caregiver Support Program (NFCSP)
- HFC In-Home Care Grant Program for individuals with dementia
- Medicaid
Medicaid provides low cost health coverage to individuals in low income households. Many states help with the costs of respite care through Medicare home and community-based services (HCBS) waivers.
Learn more about Medicaid waiver programs.
Does Medicare Part B pay for respite care?
Medicare Part A pays for hospice care. If a person is receiving hospice care, Part A will pay for respite care in a care facility.
Does Medicare cover respite care for dementia?
Medicare may cover respite care for individuals with dementia, as long as there is an identifiable carer and the individual is not living in a nursing facility that offers 24/7 care.
Learn more about Medicare coverage for dementia.
For how long does Medicare cover respite care for dementia?
Medicare may provide respite care for an individual with dementia for up to 5 consecutive days. There are currently no guidelines on how many times per billing period Medicare will pay for respite care.
Original Medicare Part A and Medicare Advantage may pay for 95% of the costs of respite care for up to 5 consecutive days. The individual will usually be responsible for the remaining 5% of the costs.
A person may be able to receive Medicare coverage for respite care more than once during each billing period. However, they should contact Medicare to find out more accurate information based on their Medicare plan and individual circumstances.
Medicaid may provide additional help with the cost of respite care. A person can contact Medicare to find out about eligibility for their waiver programs and what help they may offer in their area.