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Medicare Coverage and Leaves of Absence

Individuals who are receiving Medicare coverage for rehabilitation which is provided in a nursing home setting may not always understand policies regarding activities outside of the nursing facility. Attendance at a family gathering or a visit to one’s home for personal reasons may be desired, but a fear of the loss of Medicare coverage may exist.

One of the criteria to receive Medicare coverage for rehabilitation in a skilled nursing facility (SNF) is that an individual has a need for daily skilled care which is most economically, efficiently, and effectively provided in an inpatient setting.  Since a variety of factors influence each individual patient’s situation, gray areas exist in the determination of when and how long an individual meets this criteria. 

Nursing homes must therefore be attentive to these gray areas in order to maintain patient safety and also limit their liability.  As a result, most Medicare beneficiaries who meet this requirement are unable to safely have a leave of absence from the nursing facility.

The good news is the belief that “there is an exception to every rule,” has not been lost on the Centers for Medicare and Medicaid Services (CMS).  CMS has made provisions which allow for individuals to take a leave of absence from a nursing facility without the loss of Medicare eligibility.

A nursing facility may bill Medicare for an inpatient stay if a patient leaves the facility and returns by midnight of the same day. The Medicare Policy Benefit Manual states “…the fact that a patient is granted 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.” (Chapter 8, 30.7.3)

Since Medicare cannot be billed for a leave of absence which lasts longer than one day, CMS does allow SNFs to bill patients a bed-hold rate. However, the SNF must inform the patient in advance of the option to make these payments, as well as the exact rate for the bed-hold.  The patient must agree to the charges before he/she can be billed.

Leaves of absence which are frequent or extended will trigger questions about whether an inpatient facility is the only appropriate setting for the individual to continue to receive care. The Medicare Policy Benefit Manual does state that “A conservative approach to retain the presumption for limitation of liability may lead a facility to notify patients that leaving the facility will result in denial of coverage. Such a notice is not appropriate.” (Chapter 8, 30.7.3)

The facility may, however, closely examine the care being provided within the facility and the availability of alternate arrangements to provide this care during the leave and thereafter, resulting in the possibility of the end of Medicare coverage.

So if you or a loved one are receiving rehabilitation services in a skilled nursing facility, it is permissible to attend an upcoming holiday event without fear of losing Medicare coverage.  The practicality of doing so may be another matter, and will likely require planning and the commitment of others so that care needs may be adequately met.

For additional information about Medicare coverage for rehabilitation in a nursing home visit .

Karen Kaslow, RN, BSN