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YOU CAN LEAVE THE NURSING HOME!  (Fall 2010 Update)
 

Late fall and early winter are times for myriad family celebrations prompted by Thanksgiving in November, various religious holidays in December, and school vacations.  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."

 

If the resident returns to the facility by midnight, the facility can bill Medicare for the day’s stay.[2]

 

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.  While the facility cannot bill Medicare for leave of absence days[3], it is today unclear whether the facility can bill the beneficiary for those days.

 

As the Center for Medicare Advocacy has reported in prior years, Chapter 6 of the Medicare Claims Processing Manual says that the facility cannot bill a beneficiary during a leave of absence.[4]  However, a provision in Chapter 1 of the Medicare Claims Processing Manual, issued May 30, 2008, 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 charged.[5]   Whether these apparently contradictory provisions in the Medicare Claims Processing Manual can be reconciled remains to be seen.

 

One thing is certain, however:  nursing home residents can leave for short periods to enjoy the holidays with family without losing Medicare coverage.

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[1] Medicare Benefit Policy Manual, Pub. 100-02, Ch. 8, 30.7.3. (Page 35, Example, second paragraph) (http://www.cms.hhs.gov/manuals/Downloads/bp102c08.pdf).

[2] Medicare Benefit Policy Manual, Pub. 100-02, Ch. 3, 20.1.2. (Page 4) (http://www.cms.hhs.gov/manuals/Downloads/bp102c03.pdf).

[3] Medicare Claims Processing Manual, Pub. 100-04, Ch. 6, 40.3.5.2. (Page 48) (http://www.cms.hhs.gov/manuals/downloads/clm104c06.pdf).

[4] Medicare Claims Processing Manual, Pub. 100-04, Ch. 6, 40.3.5.2. (page 48) (http://www.cms.hhs.gov/manuals/downloads/clm104c06.pdf).

[5] Medicare Claims Processing Manual, Pub. 100-04, Ch. 1, 30.1.1.1 (Page 51) (http://www.cms.hhs.gov/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).

 
 


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