How Medicare Covers Respite Care in 2019

Rosalynn Carter, former first lady, beautifully defined the heart of caregiving when she said, “There are only four kinds of people in the world: those who have been caregivers, those who are currently caregivers, those who will be caregivers, and those who will need caregivers.” Often paying for respite care can be an issue, but Medicare can help.

Caregiving is often an unexpected role given to people close to an individual that cannot fully take care of daily needs on their own. Over the years more awareness surrounding caregiving has shed light on the tremendous toll it can take on an individual.

respite care

Woman with Grandmother

Advocacy groups actively promote self-care for caregivers to ensure they don’t lose sight of their own health needs. One of the best ways a caregiver can find time for self-care is through respite care.

As of 2019, Medicare has notably started experimenting with ways to offer better coverage for respite care through private Medicare Advantage plans.

Let’s take a closer look at what respite care is and how Original Medicare and Medicare Advantage plans will cover it in 2019.

What is Respite Care?

Respite by definition is a rest period. When it comes to respite care, this is typically a time that allows a primary caregiver to take a break from their duties with a patient (often a family member).

Other caregivers, nurses, family friends, and even community volunteers can provide respite services.

Respite care can be for an afternoon, several days or even weeks. Depending upon the patient’s needs, respite care can be provided in various settings like the home, an assisted living facility, or even an adult daycare facility.

In-Home Respite Care

Respite caregivers can come to your home if this is the best option for you and the patient. This is an ideal choice for caregivers that need temporary relief for a few hours at a time.

If a home health aide is hired for respite care, they can help with tasks like bathing, dressing, administering medication, and eating.

Trained caregivers and aides can be hired through a caregiving agency or even through a hospice center if a patient has six months (or less) to live.

Respite Care in an Assisted Living Facility or Nursing Home

Space permitting, most senior living facilities such as nursing homes, assisted living facilities, and hospice centers will provide respite care. There are typically rooms in these facilities specifically designed for temporary respite stays.

Choosing to receive the respite care through one of these facilities would make the most sense for caregivers that need a break for consecutive days at a time and the patient is able to leave the home.

Respite Care at an Adult Day Care

In the case that a caregiver just needs temporary relief throughout the day, an adult day care would be a great option for respite care.

Adult day care facilities can provide health monitoring, exercise, social activities, meals, transportation, and other support services.

This is typically the ideal choice for a caregiver taking care of a functioning Alzheimer or dementia patient that is still active but requires 24/7 monitoring.

Does Medicare Cover Respite Care?

For patients who are disabled and/or 65 or older, Medicare is typically their primary insurance. As Medicare beneficiaries often learn, Medicare does not cover every medical service.

Medicare will cover a percentage of medically necessary care. This leaves one to wonder if respite care is considered medically necessary by Medicare.

Original Medicare

When it comes to Original Medicare, respite care is only covered if a patient is receiving Medicare-approved hospice benefits.

To receive Medicare-approved hospice benefits, a patient’s hospice doctor and regular doctor must determine that the patient has a terminal illness with 6 months or less to live.

Short-term respite care coverage

Medicare’s definition of respite care is this:  short-term inpatient care provided to the Medicare beneficiary only when necessary to relieve the individual who is caring for the beneficiary at home.

So, what is considered a necessary situation for a caregiver to get respite care for the patient on hospice? These might include the following situations:

  • If a caregiver is experiencing physical or mental exhaustion
  • If a caregiver has a prior obligation or event to attend
  • If a caregiver becomes ill and can no longer care for the patient on their own

In the case that respite care is necessary, Medicare will cover the patient’s respite care for up to 5 consecutive days. Medicare will cover respite care more than once but only on an occasional basis.

 

The inpatient respite care must be provided in a Medicare-approved facility such as a hospice inpatient facility, a hospital, or a nursing home.

Cost of short-term respite care

Original Medicare will pick up most of the bill, but the patient will usually be responsible for 5% of the Medicare-approved amount for the inpatient respite care.

For example, if Medicare approves $150 per day for inpatient respite care, the patient will be responsible for $7.50 per day and Medicare will pay $142.50 per day.

Certain Medigap policies will cover additional costs that Medicare does not cover.

Medicare Advantage

Medicare Advantage (MA) plans are private plans where members receive their benefits from a private carrier instead of Original Medicare.

MA plans will offer all the same services as Original Medicare but are also able to add additional services and perks that Original Medicare does not. This is especially true in the case of respite care on some MA plans.

Respite care coverage

As of 2019, CMS has given the green light for MA to offer a variety of in-home care services. Respite care is one of the offerings MA plans are now allowed to include in their plan designs.

The difference in the coverage for respite care on a MA plan is that it will not necessarily have to be limited to hospice benefits like Original Medicare. Some MA plans will include respite care in the form of adult daycare, in-home respite care, and short-term respite care in an approved facility.

It is important to note that not every MA plan will have these benefits. With 2019 being the first year that these benefits are allowed, it will surely take time for carriers to add the benefits to a wider variety of plans. Additionally, these newly approved benefits must be part of an overall care plan recommended by a medical professional.

Each plan will allot a certain dollar amount or number of hours of respite care that will be covered each year. Look for more plans to begin offering these new benefits in 2020.

Conclusion

There is no doubt that caregivers need time to relax and rejuvenate. Respite care is necessary for many caregivers’ well-being as well as the health of the patient they are caring for.

This practical help can tremendously help a caregiver’s overall situation. The overdue inclusion of respite care on some Medicare Advantage plans will be a welcome change to many people living as a caregiver.

As the success of a benefit like this grows on private plans, it makes a case for Original Medicare to ways to provide similar benefits as a standard in the future. Many seniors often seek additional financial help in paying for care through non-Medicare options. Care is available for everyone and discovering all the avenues for payment is important.

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