Many families would like to bring their loved ones home from long-term care facilities for a few days, especially over important holidays, but they are often worried about the repercussions of doing so. Two of the most common concerns are losing Medicaid or Medicare coverage for their stay and possibly losing their bed in the facility.
Can a Resident Leave a Nursing Home?
The good news is that nursing home residents are typically permitted to take some time away from their facilities. Terminology varies, but leaving a skilled nursing facility (SNF) for non-medical reasons is usually referred to as “therapeutic leave” (defined as a home or family visit to enhance psychosocial interaction) or a temporary leave of absence (LOA). Note that non-medical leave is different from being formally discharged from a facility and from temporarily leaving a facility due to hospitalization or transfer to another health care facility.
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 nursing home 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 how the resident’s inpatient care is being paid for. Medicaid, Medicare and private insurance all have different policies on top of the facility’s own unique regulations. Giving a facility plenty of notice will ensure there are no surprise costs, lapses in care or other misunderstandings if a resident decides to take a leave of absence.
Medicaid Bed Hold Policies
Medicaid covers long-term care for seniors who meet strict financial and functional requirements. This program is jointly funded by the federal government and states, therefore specific eligibility requirements and regulations can vary widely.
For example, the length of time a resident is permitted to leave a skilled nursing facility under Medicaid rules depends on which state they live in. According to the most recent Medicaid Bed Hold Policies by State fact sheet compiled by the Long-Term Care Ombudsman Resource Center, Michigan’s Medicaid program allows a maximum of 18 days within a continuous 365-day period. Colorado’s state Medicaid program, Health First Colorado, is even more generous, permitting up to 42 days of covered physician-approved non-medical leave per calendar year.
Assuming the state-allotted number of days is not exceeded, a resident’s bed will be reserved until they return to the facility and the expense will be paid by Medicaid (sometimes at a reduced rate). In some states, families may be able to pay out of pocket for additional time away from the facility.
However, there are a few states that permit non-medical leave but do not pay to reserve a resident’s bed while they’re away. A resident (usually with the help of their family) will have to pay privately to hold the bed while they are gone. Otherwise, they may only be entitled to the first available bed in a semi-private room upon their return.
If your loved one is receiving Medicaid-covered care in a SNF and wishes to take a leave of absence, you’ll need to check with the facility about their bed hold policies as well as the state’s regulations to ensure your plans are in compliance.
Medicare LOA Rules
Unlike Medicaid, Medicare only covers medically necessary short-term rehabilitative stays in a SNF under specific conditions. One of the most widely known conditions for coverage is a qualifying three-day hospital stay. Most patients who require this high level of care are unable to leave the facility safely, but leaves of absence may be possible in some instances. The Medicare Benefit Policy Manual cites special religious services, holiday meals, family occasions, car rides and trial visits home as reasons why a patient could 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 a resident leaves at noon for a grandchild’s birthday party, this day would be considered inpatient and covered by Medicare as long as they are back at the SNF before midnight. On the other hand, if a resident were to leave the facility at 7 p.m. on 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 (uncovered), but Christmas Day would (covered).
Medicare does NOT pay to reserve a beneficiary’s bed on days that are not considered inpatient. In the event that a resident takes an overnight leave of absence, any uncovered days of service must be paid for privately. Nursing homes typically have a “bed hold” policy in place that dictates daily rates and terms for reserving a resident’s bed during their absence. The facility MUST notify the resident of the bed hold rates and policies in writing, explain how they will be applied, and obtain the resident’s agreement to these terms before they take their leave, otherwise the facility cannot charge them.
How Leaves of Absence Work With Other Types of Insurance
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 a resident to leave for visits without causing a loss of coverage.
The premise of covering a stay in a SNF is that the patient cannot live safely without such a high level of inpatient care and supervision. If long and frequent leaves of absence are possible, then the entities paying for this care will begin to doubt that it is actually necessary and may 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.
Taking a Leave of Absence During the COVID-19 Pandemic
This year has been particularly challenging for families with loved ones who live in skilled nursing facilities. Safety measures meant to prevent the spread of the coronavirus have also thwarted in-person visits and made it difficult to remain in touch, leaving countless seniors isolated and lonely.
While families are eager to share the holidays with those they sorely miss, it is important to consider the potential consequences of gathering in person this year. This includes residents wishing to take leaves of absence from nursing homes and people planning on visiting loved ones in these facilities.
The Centers for Medicare & Medicaid Services (CMS) has issued an alert to nursing homes, residents, and residents’ family members/representatives recommending against leaves of absence during the current public health emergency. While CMS supports the right to leave the nursing home, it is important to remember that residents of these facilities are at increased risk for severe illness or even death due to COVID-19.
Before planning holiday visits or temporary LOAs for nursing home residents, please carefully consider the risks and benefits of these decisions for yourself, your loved ones, other residents, and the staff who work at these facilities. Be aware that many facilities are following state and local quarantine guidelines and will impose a period of isolation on your loved one when they return to the facility. Speak to your nursing home administrators regarding their specific infection control practices, as this could be an important factor in your decision making process. Be sure to stay current on and observe federal, state and local safety laws, rules, and regulations and clearly communicate your plans with your loved one’s facility beforehand.
For more guidance on holiday celebrations, small gatherings and nursing home visits during the COVID-19 pandemic, visit CDC.gov.