Does Medicare cover respite care?

When does Medicare cover respite care?

Medicare covers inpatient respite care, short-term care that gives caregivers a rest, as part of the Part A hospice benefit. Outside hospice, CMS says respite isn't currently a Medicare-covered service; the GUIDE Model for dementia care pays for respite for a subset of its patients. To get hospice care, you must have Part A and meet all these conditions:

• Your hospice doctor and your regular doctor (if you have one) certify that you're terminally ill, with a life expectancy of 6 months or less.
• You accept comfort care (palliative care) instead of care to cure your illness and related conditions.
• You sign a statement choosing hospice care instead of other Medicare-covered treatments for your terminal illness and related conditions.

How long can a Medicare respite stay last?

A hospice respite stay can last up to 5 days each time. If your usual caregiver, like a family member, needs rest, your hospice provider arranges inpatient respite care in a Medicare-approved facility, like a hospice inpatient facility, hospital or nursing home. You can get respite care more than once, but only on an occasional basis.

Medicare's hospice benefit doesn't cover room and board, but if the hospice team determines you need short-term inpatient or respite care services that they arrange, Medicare will cover your stay in the facility. See how Medicare covers hospice care.

What do I pay for hospice respite care?

You may pay 5% of the Medicare-approved amount for inpatient respite care. Your copayment can't be more than the inpatient deductible amount. The amount you pay for respite care can change each year.

Otherwise, you pay nothing for hospice care from a Medicare-approved hospice provider, apart from a copayment of up to $5 for each prescription for outpatient drugs for pain and symptom management.

What is GUIDE Model respite for dementia caregivers?

The Guiding an Improved Dementia Experience (GUIDE) Model is a voluntary, nationwide CMS model that began on July 1, 2024, and will run for 8 years. CMS pays participating providers for respite services for a subset of model patients: services that temporarily relieve qualifying caregivers, including in-home care, adult day center programs and facility-based respite, from local in-home respite providers, adult day centers and 24-hour care facilities. Respite is paid up to a yearly cap per patient that CMS adjusts for inflation each year, and GUIDE participants can't charge patients any amount for GUIDE services, including respite.

In GUIDE, caregivers are relatives or unpaid nonrelatives who help with daily activities. A person with dementia is eligible for GUIDE if all of these apply:

• The person has dementia, confirmed by a clinician on the GUIDE participant's practitioner roster.
• The person is enrolled in Medicare Part A and Part B (not in a Medicare Advantage plan, including a Special Needs Plan, or PACE) and has Medicare as the primary payer.
• The person lives in a private residence or an approved residential care community that partners with a GUIDE participant, not in a long-term nursing home or a memory care unit. Residents of a residential care community, like an assisted living facility, can get most GUIDE services but aren't eligible for GUIDE respite.
• The person hasn't elected the Medicare hospice benefit.
• The person isn't already aligned to another GUIDE participant.

Does Medicare Advantage or Medigap change respite coverage?

If you're in a Medicare Advantage plan and start hospice care, Original Medicare covers everything you need related to your terminal illness, even if you stay in your plan, and Original Medicare is billed for your hospice care, which can include inpatient respite care. If you have a Medicare Supplement Insurance (Medigap) policy, it will cover your hospice costs for drugs and respite care. People enrolled in a Medicare Advantage plan aren't eligible for the GUIDE Model.

Can caregivers of Veterans get respite through the VA?

Yes, in some cases, outside Medicare. Eligible Primary Family Caregivers in the VA's Program of Comprehensive Assistance for Family Caregivers may get at least 30 days of respite care a year. The VA's Respite Care program pays for care for a short time when family caregivers need a break, need to run errands or need to go out of town for a few days; enrolled Veterans are eligible if they meet the clinical criteria for the service and it's available, services vary by location, and a copay may be charged based on the Veteran's service-connected disability status and financial information. See how Medicare works with VA benefits.