Many families would like to bring their loved ones home for a few days, especially over important holidays, but they are often concerned about the repercussions of doing so. Two of the most common fears are losing coverage for their stay through Medicaid or Medicare and a possibly losing their bed in the facility. (And rightly so!)
The good news is that nursing home residents are typically permitted to take some time away from the facility for “therapeutic leave” (typically defined as a home visit to enhance psychosocial interaction), “non-medical leave” and hospital stays. Assuming the health of the resident permits and their doctor agrees, the resident can leave the facility for a few hours or days to spend time visiting with friends and/or family. Such a “leave of absence” must be arranged well in advance with the facility’s staff so they have time to prepare any medications the patient will need as well as instructions for the temporary family caregivers.
In addition, there are specific rules for these outings depending on who is paying for the resident’s inpatient care. Medicaid, Medicare and private insurance all have different policies on top of the facility’s own unique regulations.
The length of time a resident is permitted to leave a skilled nursing facility (SNF) under Medicaid rules depends on which state they live in. For example, Florida Medicaid allows 16 days of therapeutic leave per state fiscal year (July 1 through June 30), while Michigan’s Medicaid program allows a maximum of 18 days within a 365-day period. Colorado’s state Medicaid program, Health First Colorado, is quite generous, permitting up to 42 days of covered physician-approved non-medical and/or programmatic leave. Assuming the allotted number of days is not exceeded, then the bed will be reserved for the resident and the expense will be paid by Medicaid (sometimes at a reduced rate).
However, there are a few states that do not permit non-medical leave without jeopardizing the reserved place of the patient or requiring private pay. For example, Indiana Medicaid will not pay to hold a bed in a nursing facility unless the resident is receiving hospice care. If your loved one is receiving Medicaid-covered care in an SNF, you’ll need to check with the facility about their policies as well as the state’s regulations to make sure your plans are in compliance.
Unlike Medicaid, Medicare only covers medically necessary short-term rehabilitative stays in an SNF under specific conditions. One of the most widely known conditions for coverage is a qualifying three-day hospital stay. The majority of patients who require this high level of care are unable to safely leave the facility, but in some instances, leaves of absence may be possible. The Medicare Benefit Policy Manual cites special religious services, holiday meals, family occasions, car rides and trial visits home as some reasons why a patient would receive an outside pass.
When it comes to counting inpatient days for billing purposes, though, things can become complicated quickly. Medicare always uses full days as units for charging purposes and the midnight-to-midnight method to determine whether or not a particular day counts. According to the Manual, “A day begins at midnight and ends 24 hours later.” This means that the timing of a loved one’s “break” from the facility is extremely important.
For example, if your loved one leaves for a grandchild’s birthday party, this day would be covered by Medicare as long as they are back at the SNF by midnight of the same day. On the other hand, if a resident were to leave the facility the evening of December 24 to have a family dinner and then attend midnight mass, they would likely return to the SNF very early in the morning on December 25. In this case, Christmas Eve would not count as an inpatient day, but Christmas Day would.
In the event that a resident takes an overnight leave of absence, any uncovered days of service will have to be paid for privately. Nursing homes typically have a “bed hold” policy in place that dictates rates and terms for reserving a bed during a resident’s absence. The facility MUST notify the resident of the bed hold policy and how it will be applied before they take their leave, otherwise the facility cannot charge them.
Other Types of Coverage
Finally, note that if nursing home care expenses are being paid through a private health insurance policy or long-term care insurance plan, you must check with that company to find out their rules for leaves of absence. Not every policy will permit the resident to leave for visits without causing a loss of coverage.
The premise of covering a stay in an SNF is that the patient cannot safely live without such a high level of inpatient care. If long leaves of absence are possible, then the entities paying for this care will begin doubt that it is actually necessary and refuse to pay. Be sure to cover all your bases when planning a holiday or outing for your loved one. A mistake could be quite costly.