Understanding How Medicare and Medicaid Treat Holiday “Leaves of Absence”

Here we are in November and it’s almost holiday time! Thanksgiving, Chanukah, Christmas, New Years…fun times abound!

During this time of year, we often gather with family and friends, and nursing home residents are no exception.

At Regency Nursing, our residents also wish to participate in family gatherings, but often worry how this may impact their Medicare/Medicaid benefits and coverage at the facility.

This is an excellent question and one which I shall address in this article.

The first thing to recognize is that a Medicare leave of absence and a Medicaid leave of absence are not subject to the same rules and regulations.

Medicare is synonymous with short term rehab, whereas Medicaid is associated with long term care.

Medicare leave of absence

By definition, a Medicare covered patient is only in the facility for a short period of time and Medicare would like to see them participate in a robust therapy regimen during this period, since the assumption is that said patient requires this level of care – otherwise they wouldn’t be in the facility to begin with.

Therefore, when a Medicare patient takes a prolonged leave of absence from the facility, Medicare begins to question the premise regarding the continued eligibility of the individual.

To this end, Medicare creates a distinction between a leave of absence where the patient goes out for the day and returns before midnight, versus a patient who spends the night outside of the facility.

In the Medicare manual, they write as follows: “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 (Skilled Nursing Facility) for the receipt of required skilled care.”

Therefore in Medicare’s lexicon, if the patient leaves the facility but returns before midnight, the facility can still bill Medicare for this day, as a ‘covered day of service,’ whereas if the patient stays away from the facility past midnight and returns the next day, the day the resident leaves is considered a day of absence and the facility will therefore bill the resident privately for this day since Medicare will not cover.

One caveat is in chapter 6 of the Medicare manual, where they instruct the facility that they may not bill the beneficiary during a leave of absence, unless the facility shall inform the patient in advance that this will be a privately paid ‘bed hold.’

Medicaid leave of absence

By definition, a Medicaid covered resident is an individual who is residing at the facility for long term custodial care and not for short term rehabilitation.

A Medicaid leave of absence is called a “therapeutic leave” and State laws regarding therapeutic leave vary quite significantly.

As a long term resident in a nursing home, the State doesn’t make the same assumption that the resident is there for extensive rehab (nor do they pay for such a level of care) and will therefore be more lenient in allowing for overnight visits outside of the facility.

Certain states will pay the facility for up to 24-30 cumulative days per calendar for the ‘bed-hold’ of a Medicaid resident on therapeutic leave.

Other states may only cover as little as 9 days per calendar year, while in some states there is no coverage at all.

It is therefore important to check on the specific ‘bed-hold’ policies in your particular State.

For a list of policies by State, click here.

Judah Gutwein

Judah Gutwein, LNHA, is the Director of Admissions, Administration, Marketing, Social Media for Regency Nursing and Post-acute Rehabilitation Centers, NJ. The Regency organization has become synonymous with the best in senior healthcare and has garnered a well deserved reputation for its unsurpassed commitment to its patients and residents. The Regency Nursing and Rehabilitation Centers and Facilities throughout New Jersey have achieved numerous industry ‘gold standard’ benchmarks an have received accolades from all corners of the HealthCare community.