Dad is a resident in a skilled nursing facility. The family wants to take him out of the facility for the Thanksgiving weekend so that he can share in the family dinner and visit with family and friends. How will this effect Dad’s coverage under Medicare or Medi-Cal?
Medicare Coverage
Medicare is the federal health care plan for persons age 65 and older who contributed to the Social Security System while working as well as the spouses of these individuals. Medicare only provides limited benefits for skilled nursing home stays. Generally, the first 20 days of care in a nursing home are covered. From day 21 through day 100, coverage is available, but only after the patients pays the daily deductible for 2018 of $167.50. For more information, visit the Medicare website. Coverage may be different if you are participating in a Medicare Advantage plan such as Secure Horizons, Blue Cross, Humana, Aetna or Kaiser.
Now back to our original question — will dad be covered? While the Medicare Benefits Policy Manual recognizes that most nursing home residents are unable to leave the facility, it 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 [nursing home] for the receipt of required skill care.” The Manual also states that is not appropriate for the facility to notify the patient that the visit home will result in a denial of coverage.
However, it is best if we limit the Thanksgiving holiday to one day if dad is covered by Medicare and that he return to the nursing home before midnight on the same day. This is because Medicare only pays for that one day away from the facility. If dad’s visit extends continues to the next day or longer, the nursing home can charge privately for the bed-hold for each day thereafter. In order to charge him the bed hold charge, the nursing home would have to have advised dad of that fact and told him what the daily cost would be. So, short visits to be with family for a holiday weekend are possible, and will not result in a loss of Medicare coverage, but the visit may require payment of the private bed hold rate after the first day.
Medi-Cal Coverage
The vast majority of patients in skilled nursing facilities in California are having their skilled nursing home costs paid for by Long Term Care Medi-Cal. The rules about leaving a nursing home if the stay is being for by Medi-Cal is more lenient than Medicare. Dad could be granted a leave of absence of up to eighteen days per calendar year, provided that his physician approves the leave of absence and writes it into his Plan of Care. Dad could even be absent for additional twelve days annually, but only under certain conditions. This is called a “therapeutic leave”.
However, Medi-Cal will only cover the first seven days of bed hold. Therefore, if dad is relying upon Medi-Cal for his nursing home coverage, he needs to request that his physician write the planned leave of absence into his Care Plan. If he doesn’t want to pay for the time he is gone, he has to limit his leave of absence to no more than seven days. He can potential be gone for up to thirty days in any given year, but he will have to pay the private pay bed hold rate if he plans to be gone for more than seven days.
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