Medicare usually only covers medical services for the person enrolled in Medicare. However, Medicare does offer a benefit to the beneficiary’s caregiver (if they have one). Respite care is a way for caregivers to take a break from caring for their loved one. It’s basically their work vacation.
When it comes to Medicare covering respite care, there are a few requirements that must be met. This is because Original Medicare doesn’t cover respite care in all cases.
First, we will discuss what it takes for Original Medicare to cover respite care an how it’s covered. Then, we will discuss other ways you can obtain coverage for respite care.
Original Medicare Respite Care Qualifications
Original Medicare will cover respite care for your caregiver under the hospice benefit within Medicare Part A. In order for your hospice care to be covered you must be terminally ill, you must accept palliative care (care for comfort), and you must sign a document stating you are electing for hospice care rather than treatment for your illness. Note, to be terminally ill means you have less than six months to live.
Every beneficiary’s hospice care plan is different depending on the type of illness. Your hospice care team will put together a plan of care that usually includes respite care for your caregiver.
The respite care covered under the hospice benefit is short-term respite care. Respite care can be used more than once, but not regularly. It is intended to provide the occasional break for a caregiver. Each time respite care is needed, it can only be for up to five days. While the caregiver is on leave, the patient will stay in a Medicare-approved facility such as a nursing home.
There is a possibility that you will have to pay a small copay or coinsurance for the stay for respite care. However, the actual hospice care is completely covered by Part A. Part A won’t cover hospice care in a nursing home or in your home unless respite care is needed.
Other Ways Respite Care Can Be Covered
Medicare Advantage plans, also known as Part C, are plans sold by private insurance carriers. This type of plan takes over your Part A and Part B coverage and becomes your primary insurance. The main rule about these plans is that they must offer equal to or better coverage the Original Medicare (Part A and Part B).
However, Medicare Advantage plans are allowed to include some benefits that Original Medicare and Medigap plans do not offer. As of 2019, Medicare Advantage plans are allowed to offer caregiver support such as respite care. According to AARP, 13% of Medicare Advantage plans offer this benefit in this year.
Because Medicare Advantage plans are created and sold by private insurers, they are able to create their own pricing such as premiums, deductibles, and copays. This means that your copay or coinsurance for respite care under your plan will be set by the carrier. If you have a caregiver, be sure to look through the explanation of benefits for each for the Medicare Advantage plan before you enroll.
A great thing about Medicare Advantage plans is that there is an out-of-pocket maximum on every plan. That means that you have a limit to how much the plan will let you spend out-of-pocket for in-network services. Currently, the out-of-pocket highest allowed maximum for Medicare Advantage plans is $6,700.
If you just had Original Medicare, there would be no out-of-pocket spending cap. You’d pay you copay’s and coinsurance all year long no matter how high your costs got. That’s why, even if you don’t have a huge budget to spend on a Medicare plan, you can try to find a low-cost Medicare Advantage plan so you can be protected by this out-of-pocket maximum.
So, what if you aren’t terminally ill and you don’t have a Medicare Advantage plan, how to you receive respite care?
Check with your Area Agency on Aging to see if they can find an adult day care or respite care facility for you. Places like these may be a good, low-cost alternative for those of you who don’t have access to respite care through Medicare.
Danielle Kunkle is a partner of Boomer Benefits for just over 10 years now. She is based in Texas and loves to spend time outdoors hiking and trekking. Much of her time these days is spent writing articles and running webinars to teach people about Medicare.