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Respite Care

Provider Type

  • Physicians (does not apply to Cal MediConnect)
  • Participating Physician Groups (PPG)
  • Ancillary

Aside from custom plans requested by specific Medicare Advantage (MA) employer groups, respite care is not a standard benefit other than what is provided through the hospice benefit covered by Medicare. Respite care is short-term care provided to the member only when necessary to relieve family members or others caring for the member at home. Respite care may be provided in the member's home, in a nursing facility or in an assisted living facility. This is covered only when provided occasionally and reimbursement is not made for more than five consecutive days within a two-month period. One day is counted for any day in which one visit occurs. There must be a minimum of one day without respite care between successive two-month periods. Respite care coverage does not have a lifetime maximum and for Cal MediConnect members does not supplant authorized in-home support service (IHSS) hours.

Requirements

When a MA employer group plan provides respite care, requirements for respite care coverage are:

  • Prior authorization by the Health Net Medical Management Department
  • Member must have been receiving care for at least three activities of daily living (ADLs) for a period of four consecutive months. ADLs include bathing, dressing, eating, continence, mobility, going to the toilet, and transferring

Coverage Explanation

The respite care benefit, when provided by an MA employer group plan, is as follows:

  • In-home care coverage is limited to a maximum of 40 visits per calendar year, with a 15-visit maximum within a two-month period. For in-home care, the member may have up to three visits per day (up to eight hours each visit)
  • Facility-based care coverage is limited to a maximum of 30 days per calendar year. Facility-based care may be in either a residential care facility for the elderly or a skilled nursing facility (SNF)
Last Updated: 11/08/2019