Home for the Holidays: Leaving the Nursing Home During a Medicare-Covered Stay

Late November begins a time for gatherings with family and friends – Thanksgiving, soon followed by the December holidays. Nursing home residents often want to participate in these gatherings but may worry that they will lose Medicare coverage if they leave the facility to do so. Residents and their families and friends can put their minds at ease. 

According to Medicare law, nursing home residents may leave their facility for family events without losing their Medicare coverage. However, depending on the length of their absence, beneficiaries may be charged a "bed hold" fee by their skilled nursing facility (SNF).
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]

The Manual elaborates: "Decisions in these cases should be based on information reflecting the care needed and received by the patient while in the SNF and on the arrangements needed for the provision, if any, of this care during any absences." [2] However, 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." [3]
If the resident begins a leave of absence and returns to the facility by midnight of the same day, the facility can bill Medicare for the day's stay. [4] 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) now confirms that the facility can bill a beneficiary for bed-hold days during a temporary SNF absence. [5]
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." [6] As required by the federal Nursing Home Reform Law, [7] that section authorizes 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. [8]

The Manual states that a facility “cannot simply deem a resident to have opted to make such payments and then automatically bill for them upon the resident’s departure from the facility.”  [9] Charges to hold a bed and maintain the resident's "personal effects in a particular living space that the resident has temporarily vacated… 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." [10] CMS distinguishes bed-hold payments from payments for admission or readmission, which are "not allowable." [11]

In summary, residents can leave their SNFs for short periods, such as a day or two, to enjoy gatherings with their families and friends without losing Medicare coverage. However, SNFs are allowed to bill residents to reserve their beds so long as they advised residents in advance of the charges to hold the bed and the residents have agreed, in advance, to make the payments.
Happy Holidays!
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[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 43.
[2] 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 43.
[3] 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 44.
[4] 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.
[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 51-52. Note, unlike Medicaid in some states, the Medicare program does not provide any payment for "bed-hold."
[6] 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 51-52.
[7] 42 U.S.C. §1395i-3(c)(1)(B)(iii), 42 C.F.R. §483.10(f)(10).(11).
[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 48. 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(g)(17)-(18). [9] 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 48.
[10] 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 48.
[11] 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 48.