Who Pays for Hospice Respite Care?

Hospice respite care offers temporary relief for primary caregivers of individuals receiving hospice services. This specialized care allows the patient to stay in an approved facility, such as a hospice inpatient unit, hospital, or skilled nursing facility, for a brief period. The primary purpose of this care is to provide caregivers a much-needed break from their demanding responsibilities. A respite stay can last up to five consecutive days, ensuring the patient continues to receive professional care while their caregiver rests and recharges.

Medicare Coverage

Medicare, specifically Medicare Part A (Hospital Insurance), is a primary payer for hospice respite care, covering it as a component of the comprehensive Medicare Hospice Benefit. To qualify for hospice care under Medicare, a patient must be eligible for Medicare Part A and certified by both their attending physician and a hospice physician as terminally ill, with a life expectancy of six months or less if the illness runs its normal course. The patient must also elect to receive hospice care, choosing palliative care over curative treatments for their terminal illness.

Once enrolled in the Medicare Hospice Benefit, Medicare pays 100% of the approved costs for hospice respite care. This coverage allows for up to five consecutive days per respite stay. Respite care must be provided in a Medicare-approved inpatient facility, ensuring the patient receives appropriate care.

While Medicare covers most costs, there can be a small copayment. For prescription drugs and biologicals used for pain and symptom management, a copayment of up to $5 per prescription may apply. Additionally, a 5% copayment for inpatient respite care is required, though this amount cannot exceed the annual inpatient hospital deductible for the year. Many hospice providers often waive this 5% copayment for the inpatient respite stay.

Medicaid and Other Government Programs

Medicaid, a joint federal and state program providing healthcare assistance to low-income individuals, also covers hospice care, including respite services, for eligible beneficiaries. While the Medicaid hospice benefit mirrors Medicare’s coverage, eligibility requirements and the scope of services can vary by state. Patients should consult their state’s Medicaid program to understand the rules and coverage details.

The Department of Veterans Affairs (VA) provides comprehensive hospice and palliative care benefits to eligible veterans. These benefits can include respite care, offering temporary relief for caregivers of veterans facing serious illnesses. Veterans must be enrolled in the VA healthcare system to access these services.

VA hospice care has no copays, ensuring that veterans can receive necessary respite care without direct out-of-pocket costs. The VA offers various respite options, including in-home care, adult day health programs, and short-term stays in nursing home facilities, for up to 30 days per calendar year. These programs aim to support both the veteran and their family caregivers.

Private Insurance and Other Funding Sources

Many private health insurance plans, including employer-sponsored, individual, and marketplace plans, include benefits for hospice care, which encompass respite care. However, the extent of coverage can vary significantly from one plan to another. Patients and their families should contact their insurance provider directly to understand the terms of their policy.

Inquire about any deductibles, co-payments, or out-of-pocket maximums that may apply. Also ask about pre-authorization requirements and whether the plan has preferred providers for hospice services. Some private plans may also require a diagnosis or prognosis for hospice coverage, similar to Medicare guidelines.

If insurance or government programs do not cover the costs, or if benefit limits are exceeded, individuals may opt for out-of-pocket payment for hospice respite care. The daily rates for inpatient respite care can range from $150 to $1,000 or more, depending on the facility type and location. This private payment option provides flexibility when other funding sources are unavailable.

Various charitable organizations and community programs may offer financial assistance or grants for hospice care, including respite services. These non-profit entities support individuals who meet criteria or demonstrate financial need. Inquiries can be made to local hospice organizations or disease-specific foundations to explore these funding avenues.