Sunday is the deadline for ACA insurance open enrollment in most states! Here are 11 things to know.
by Patricia Barry, AARP Bulletin, March 8, 2010
Q. My mother is in a skilled nursing facility for rehabilitation after surgery. Can she leave the facility for brief excursions, such as going to church or visiting our home, without losing Medicare coverage?
A. Yes, providing she is well enough to leave the facility temporarily without harming her health or recovery. But it’s important to know Medicare’s rules on this point, especially as some skilled nursing facility (SNF) administrators appear unaware of them and sometimes tell patients that if they leave the facility, even for a short time, Medicare may no longer pay for their stay there.
It’s true that Medicare coverage stops when a patient has reached the point of no longer benefiting from the care prescribed in these facilities.
But section 30.7.3 of Chapter 8 of the Medicare Benefit Policy Manual specifically says: “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.”
Furthermore, the regulation adds, it is “not appropriate” for an SNF to tell a patient that “leaving the facility will result in a denial of coverage.”
Medicare coverage for SNF care is based on 24-hour periods that run from midnight to midnight. So if a patient leaves the facility for a few hours but returns before midnight, he or she is regarded as having been there all day and there is no loss of Medicare payment or coverage.
What about overnight absences—for example, to return to the family for Christmas, Hanukkah or Thanksgiving—or for a visit of several days? Medicare will not pay the SNF for days when the patient is absent at midnight. And the patient is not responsible for the cost of those days either, as long as she or he remains eligible for SNF coverage.
However, the facility may charge the patient a “bed-hold” fee to compensate for its loss of income while keeping that bed free for the patient’s return. Not all facilities charge this fee, at least not for a 24-hour leave of absence. But it’s important to find out from the SNF administrator in advance whether the bed can be kept open and if a daily fee will be required to reserve it. The SNF’s policy on this point must be explained to patients before a leave of absence is taken and clearly stated in the documents they are given on admission.
Of course, much depends on the individual patient’s physical and mental ability to tolerate a trip away and to what extent the place or people she’s visiting can cope with limitations, such as wheelchair access. It would make sense to seek her physician’s opinion. Also, keep in mind that Medicare requires regular assessments to determine whether patients are benefiting sufficiently from the care they are receiving to warrant continued Medicare SNF coverage. So maybe too many jaunts could be construed as evidence that SNF care is no longer needed.
Otherwise, there’s no reason why patients can’t be taken out of the facility for an occasional excursion that they’d enjoy—as long as they’re well enough and have the appropriate support they need while away.
For more information on SNF care, see:
“Medicare Coverage of Skilled Nursing Facility Care” (Centers for Medicare & Medicaid Services, 52 pages)
“Ask Ms. Medicare: Does Medicare Pay for Nursing Homes?”
Patricia Barry is a senior editor with the AARP Bulletin.
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