Nursing Home Residents Can Go Home for the Holidays

As the holidays approach, nursing facility residents and their family members often worry about losing their rooms, or their Medicare or Medi-Cal status, if they leave a nursing facility for brief periods of time. While the rules for Medicare and Medi-Cal differ, both programs will permit, and reimburse the facility for, short leaves – depending on how long the leave is.

The Medicare Policy Manual, Chapter 8 §30.7.3, states that residents who leave the facility for 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 trial visit home” can do so without losing their coverage. If they return by midnight, the facility can bill Medicare for the day. If the resident is gone overnight (past midnight) and returns the next day, this is considered a leave of absence and the facility can bill the beneficiary to hold the bed during the absence. The facility must inform the resident of the option to make bed-hold payments, and the amount of the bedhold payments, prior to the leave of absence. Make sure you discuss this with the facility and are clear about cost, since the daily rate at a nursing home can be high.

Under Medi-Cal rules, a leave of absence (LOA) of up to 18 days per calendar year can be granted to a MediCal resident of a nursing home in accordance with the resident’s plan of care, and the facility will continue to be reimbursed for care. Up to 12 additional days of leave per year can also be granted under certain conditions. (See 22 CCR §51335) This is a much more liberal leave policy than Medicare, but it is also subject to certain restrictions. The resident, family members and/or friends should ensure that provisions for leaves of absences are included in the resident’s care plan.

(Excerpted from CANHR Advocate, Winter 2016).