With Thanksgiving day fast approaching and Christmas a little over a month away, Medicare beneficiaries in skilled nursing facilities (SNF) can attend family gatherings without losing their coverage. In a Nov. 21 Alert, Toby S. Edelman, Ed.M., JD., Senior Policy Attorney at the Center for Medicare Advocacy (CMA), warns residents and their families to beef up on Medicare rules on Medicare Covered Stays.
According to CMA, the Medicare Benefit Policy Manual regulation allows residents to leave their facility without Medicare coverage. Here’s the caveat. Edelman says that “depending on the length of their absence, beneficiaries may be charged a “bed hold” fee by their SNF.
CMA Takes a Close Look at the Medicare Benefit Policy Manual
Edelman notes that the Manual (100-02, Ch. 8, §30.7.3., page 43, fourth paragraph) recognizes that although most beneficiaries are medically 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.”
Furthermore, Edelman notes that the Manual (100-02, Ch. 8, §30.7.3., page 43, fourth paragraph) explains: “Decisions in these cases should be based on information reflecting the care needed and received by the patient while in the SNF and on the arrangements needed for the provision, if any, of this care during any absences.”
However, Edelman states that a SNF should not notify patients that leaving the facility will lead to loss of Medicare coverage. This notice is viewed as “not appropriate (100-02, Ch. 8, §30.7.3, page 44, first paragraph).
Edelman adds that the Manual states that if the resident begins a leave of absence and returns to the facility by midnight of the same day, the facility can bill Medicare for the day’s stay (100-02, Ch. 3, §20.1.2, page 4). But if the resident leaves the facility overnight and comes back the following day, the day the resident leaves is considered by Medicare to be a leave of absence day, says CMA. Clarifying what seemed to be conflicting provisions in the Manuals, the Centers for Medicare & Medicaid Services (CMS) now confirms that the facility can bill a beneficiary for bed-hold days during a temporary SNF absence (100-04, Ch. 6, §18.104.22.168, pages 51-52), says Edelman.
Edelman notes that that Chapter 6 of the Medicare Claims Processing Manual (100-04, Ch. 6, §22.214.171.124., pages 51-52) provides that the SNF cannot bill a beneficiary during a leave of absence, “except as provided in Chapter 1 of the manual at §126.96.36.199.”
Taking a look at the federal Nursing Home Reform Law, Edelman explains that this section authorizes SNFs 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 billed (100-04, Ch. 1, §188.8.131.52, page 48).
According to Edelman, the Manual states that a facility “cannot simply deem a resident to have opted to make such payments and then automatically bill for them upon the resident’s departure from the facility (100-04, Ch. 1, §184.108.40.206, page 48). Charges to hold a bed and maintain the resident’s “personal effects in a particular living space that the resident has temporarily vacated… are calculated on the basis of a per diem bed-hold payment rate multiplied by however many days the resident is absent, as opposed to assessing the resident a fixed sum at the time of departure from the facility” (100-04, Ch. 1, §220.127.116.11, pages 48), she says.
So enjoy the upcoming holiday’s with your families or friends, knowing you won’t lose your Medicare coverage if you leave your SNF for a day or two. “SNFs are allowed to bill residents to reserve their beds so long as they advised residents in advance of the charges to hold the bed and the residents have agreed, in advance, to make the payments,” says Edelman.
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