You CAN Leave the Nursing Home

Late spring is a time for myriad gatherings with family and friends: high school and college graduations, Memorial Day weekend, weddings and more.  Nursing home residents often want to join in family festivities and visit with children and grandchildren, but may be under the impression that they will lose Medicare coverage if they leave the facility to do so.  This is not true.

The Medicare Benefit Policy Manual recognizes that although most beneficiaries are unable to leave their facility,

an outside pass or short leave of absence for the purpose of attending a special religious service, holiday meal, family occasion, going on a car ride, or for a trial visit home, is not, by itself evidence that the individual no longer needs to be in a SNF for the receipt of required skilled care.[1]

A facility should NOT notify patients that leaving the facility will lead to loss of Medicare coverage. The Medicare Policy manual says that such a notice is "not appropriate."[2]

If the resident returns to the facility by midnight, the facility can bill Medicare for the day's stay.[3]

If the resident is gone overnight (i.e., past midnight) and returns to the facility the next day, the day the resident leaves is considered a leave of absence day.  Clarifying what seemed to be conflicting provisions in the Manuals, the Centers for Medicare & Medicaid Services has now confirmed that the facility can bill a beneficiary for bed-hold days during a SNF absence.[4]

As before, Chapter 6 of the Medicare Claims Processing Manual says that the facility cannot bill a beneficiary during a leave of absence.[5]  However, a revision to the Manual, issued June 16, 2011 and effective August 1, 2011, allows a SNF to bill a beneficiary for a leave of absence "as specified in Chapter 1 of this manual at §30.1.1.1."  That section authorizes skilled nursing facilities to bill a beneficiary for bed-hold during a temporary "SNF Absence" if the SNF informs the resident in advance of the option to make bed-hold payments and of the amount of the charge and if the resident "affirmatively elect[s]" to make bed-hold payments prior to being billed.[6]   CMS distinguishes bed-hold payments from payments for admission or readmission, which are "not allowed."[7]

Nursing home residents can leave for short periods to enjoy the holidays with family without losing Medicare coverage.  But their SNFs are allowed to bill residents to hold their beds under Medicare rules.

[1]Medicare Benefit Policy Manual, Pub. 100-02, Ch. 8, §30.7.3. (Example, second paragraph) (http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c08.pdf)
[2]Medicare Benefit Policy Manual, Pub. 100-02, Ch. 8, §30.7.3. (Example, third paragraph) (http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c08.pdf)
[3]Medicare Benefit Policy Manual, Pub. 100-02, Ch. 3, §20.1.2.  (http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c03.pdf)
[4]Medicare Claims Processing Manual, Pub. 100-04, Ch. 6, §40.3.5.2.  (http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c06.pdf)
[5]Medicare Claims Processing Manual, Pub. 100-04, Ch. 6, §40.3.5.2.  (http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c06.pdf)
[6]Medicare Claims Processing Manual, Pub. 100-04, Ch. 1, §30.1.1.1 (http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c01.pdf)   CMS cites, as authority for this payment option, the Nursing Home Reform Law, 42 U.S.C. §1395i-3(c)(1)(B)(iii), which requires that SNFs "inform each other resident, in writing before or at the time of admission and periodically during the resident’s stay, of services available in the facility and of related charges for such services, including any charges for services not covered under this subchapter or by the facility’s basic per diem charge."  CMS also cites 42 C.F.R. §483.10(b)(5)-(6).
[7]Medicare Claims Processing Manual, Pub. 100-04, Ch. 1, §30.1.1.1 (http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c01.pdf)