You Can Leave the Nursing Home: Home for the Holidays (Spring 2013 Update)

Spring is often a time for gatherings with family and friends – weddings, graduations, Mothers’ Day. Nursing home residents often want to participate in these gatherings 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 Benefit Policy Manual says that such a notice is "not appropriate."[2]
If the resident begins a leave of absence and 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 (CMS) confirms that the facility can bill a beneficiary for bed-hold days during a SNF absence.[4]

Chapter 6 of the Medicare Claims Processing Manual provides that the facility cannot bill a beneficiary during a leave of absence, "except as provided in Chapter 1 of the manual at §30.1.1.1."[5]That section authorizes skilled nursing facilities (SNFs) 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]Charges to hold a bed and maintain the resident's "personal effects in the particular living space…are calculated on the basis of a per diem bed-hold payment rate multiplied by however many days the resident is absent, as opposed to assessing the resident a fixed sum at the time of departure from the facility."[7]CMS distinguishes bed-hold payments from payments for admission or readmission, which are "not allowed."[8]

Residents can leave their SNFs for short periods, such as a day or two, to enjoy the holidays with their families and friends without losing Medicare coverage. Their SNFs are, however, allowed to bill them to hold their beds under Medicare rules.

For more information, contact attorney Toby S. Edelman (tedelman@medicareadvocacy.org) in the Center for Medicare Advocacy's Washington, DC office at (202) 293-5760.

____________________
[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). Scroll down to page 36.
[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). Scroll down to page 37.
[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). Scroll down to page 4.
[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). Scroll down to page 49. Note, unlike Medicaid in some states, the Medicare program does not provide a payment for "bed-hold."
[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). Scroll down to page 49.
[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). Scroll down to page 55. CMS cites, as authority for this payment option, the Nursing Home Reform Law, 42 U.S.C. §1395i-3(c)(1)(B)(iii), and 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), scroll down to page 55.
[8]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). Scroll down to page 55.