What are the Medicare Respite Care Guidelines?

MedicalNewsToday / Medically reviewed by Alisha D. Sellers, BS Pharmacy, PharmD — Written by Amy McLean 

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.

When will Medicare cover respite care?

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.

When will Medicare not cover respite care?

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.

How much will Medicare pay for respite care?

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.

How often does Medicare pay for respite care?

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…

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CMS Releases Final HOPE Assessment Tool Materials

On September 16^th the Centers for Medicare and Medicaid Services (CMS) released final materials for the new Hospice Outcomes and Patient Evaluation (HOPE) assessment tool that is scheduled to go into implementation on October 1, 2025.

Final materials include:

• HOPE Guidance Manual v1.00
• HIS to HOPE v1.00 Change Table
• Items sets (HOPE Admission v1.00, HOPE Update Visit (HUV) v1.00, HOPE Discharge v1.00 and HOPE ALL Item v1.00)

All documents can be accessed from the CMS HOPE page, which can be accessed here.

3 Insights Home-Based Care Providers Must Know About the Proposed Home Health Rule

Home Health Care News / By Jack Silverstein
 
Over the past two years, CMS has proposed large cuts to home health Medicare payments, leaving providers concerned over their ability to deliver care and run their businesses. Even when CMS finalized cuts that were smaller than their original proposals, providers still faced challenges over thin margins.
 
The 2025 proposed rule brings additional cuts that may further strain the industry’s ability to serve all patients. That was already a challenge before the pandemic, when only 77% of those needing care in 2018 received it. Six years later, that number is down to 65%.
“It’s a critical opportunity for us as an industry to make sure that the leaders at CMS, and the leaders in Congress, are recognizing the value of home health services within the continuum of care and within the entire health care ecosystem,” says John Gochnour, President and COO of The Pennant Group. “The home health proposed rule doesn’t do that.”
 
Here are three insights home health providers must know about the new rule and how they can successfully navigate it.
 
Not all providers are affected equally
 
The proposed rule includes a payment decrease in the aggregate of 1.7%, translating to about $280 million in lost revenue. Yet the impacts vary widely based on geography and patient case mix. Some factors, such as wage index, have seen erratic changes year after year.
 
“Turnover and wage costs are not changing abruptly. You’re not all of a sudden paying more one year and then less the next year.” says Scott Pattillo, Chief Strategy Officer, Homecare Homebase. “So it’s really important that you know — based on your geographic mix, your patient mix, your patient types and your acuity types — how it’s going to impact your agencies.”
 
The industry’s financial pressures are mounting — and the new rule doesn’t always account for that
 
Running a home health business is challenging enough on its own. It gets even trickier when CMS views the industry substantially differently than providers do.
“CMS is of the opinion that there are very high margins in Medicare,” Pattillo says. “They believe there’s a 17% margin on Medicare claims.”
 
Pattillo notes that CMS’s response to last year’s provider comment letters was that: “In a 17%-margin environment, we just don’t understand how a 1% to 2% decrease can impact anything materially. Taking 1% to 2% of that 17% margin does not make sense to us that it would destabilize the industry.”
 
But CMS’ view that providers see a 17% margin on Medicare claims does not account for multiple important factors, including:

• Wage increases and the inflationary environment
• The high number of Medicare Advantage patients that providers care for
• The high number of MA plans with reimbursement rates under the cost of care
  
  

Those last two are the big ones. Providers may have a 17% margin if they only took Medicare patients, but when half of their patients are under MA plans, their margins come out to more like 1-5%. In short, home health agency margins are much slimmer than CMS implies.
 
“The individual elements of cost of care are absolutely not going down,” Pattillo says. 
 
“There is nothing that has gotten cheaper about caring for patients, and we know the acuity of those patients is rising in terms of the way that they’re coming into your home health agencies.”
 
Adjusting to the new rule starts with turning to HCHB
 
When a new rule proposal is released, care providers turn to the HCHB Analytics Impact Model to review the rule’s potential impact and figure out what changes they need to make.
“The first thing that we do after the proposed rule is released is look to the Homecare Homebase model,” Gochnour says. “We then work from that to refine and understand, because we operate in 14 states across the country, so we have a lot of variability in how a proposed rule is going to impact each individual operation.”
 
The HCHB dashboard allows companies to see where they fit in the new rule. Benefits include insight into:

• The variability in CMS’s methodology
• How that variability your branches in different states
• How your agency will be affected by case mix changes
• The potential effect you will see to your revenue
• The ability to understand when and how to add new service lines

“We use this model to really estimate that impact and immediately provide our local operators with some insight into what the impact is going to be for them, so that they can begin honing in on what changes they may need to make,” Gochnour says.
 
This article is based on a recent HHCN-HCHB webinar featuring Scott Pattillo and John Gochnour. HCHB delivers powerful new tools and intuitive software that’s easy to learn and use. From scheduling, routing, documentation and reporting to intake, billing, and compliance we give you everything you need to boost productivity and profits while empowering exceptional patient care. To learn more, visit hchb.com.

Training, Technology and Supervision: How Home Care Providers Can Eliminate Fall Risks

McKnight’s Home Care / By Adam Healy
 
Fall prevention is one of the best ways that home care providers can keep senior clients out of the hospital, but it takes a multifaceted approach.

For Carrie Bianco, the owner and executive director of Always Best Care Senior Services in Torrance, CA, effective fall prevention comes down to training, technology and supervision. Bianco’s agency serves roughly 150 clients with a team of about 300 caregivers. Bianco said that every one of her clients is at risk of experiencing a fall.

“It used to be that the clients we served were between 70 and 85,” she told McKnight’s Home Care Daily Pulse Monday in an interview. “Now they’re 85 to 100, so they’re a lot older. They are living longer and have less health challenges until they hit that 85 to 95 mark. So all of those folks are definitely at fall risk.”

Educating clients and caregivers is the first step to preventing falls. Bianco said that her agency organizes educational events to ensure both staff and community members are up-to-date on fall prevention best practices. The firm also uses a “balance tracker” tool to analyze seniors’ postural sway, which can impact balance.

Always Best Care recently published a list of nine commonly overlooked fall risks present in many home care clients’ homes. Among these were poor lighting, pets and loose rugs. Health issues like medication side effects or dehydration can also heighten seniors’ risk of falling, according to the list. However, Bianco said that most falls are simply caused by a lack of awareness. 

“Most of the time [the clients] are just distracted,” Bianco explained. “It’s all the little things. When the caregivers and care managers go out, they do a safety assessment to make sure that we can educate the client,” — or an [adult] child who may be  the point of contact — “on what they need to do to make that house safe for that older adult.”

This education is crucial since fall-related injuries tend to have long-lasting health effects, Bianco said. Recuperation and rehabilitation after a fall can be especially challenging for seniors, she noted.

“With a fall, you’re probably going to be in the hospital with something that’s broken or fractured, and when they’re in the hospital, they’re not going to rehab as well as they would if they were at home,” Bianco said. “So the falls, to me, are the most important [thing to prevent] to try to keep the client out of the hospital.”

Fall prevention is garnering attention across the healthcare-at-home continuum. InnovAge, a Program of All-inclusive Care for the Elderly organization, recently disclosed its participation in a study focused on preventing falls by seniors. And the National Council on Aging last week promoted home safety practices to follow during Falls Prevention Awareness Week, Sept. 23 through Sept. 27.