As families gather this week, we at the Center are reminded of some of the many reasons we have to be thankful.
- The visionaries who designed, launched and supported Medicare to help all American families.
- That remarkable Medicare program for helping to keep older Americans out of poverty, and insuring people with disabilities who, like older Americans, were left behind by private insurance.
- The Affordable Care Act for provisions that strengthened Medicare coverage, and cut wasteful overpayments to private insurance companies… oh, and for giving millions of uninsured Americans coverage they never had before.
- The freedom, flexibility, choice and guaranteed benefits offered by the traditional Medicare program.
- Our partners and fellow advocates who help us open doors to health care for the 62 million people who rely on Medicare.
And, of course,
- Our supporters, who believe in the promise of a real, robust Medicare program, now and for the future.
Thank you for being a part of the Center for Medicare Advocacy community. We wish you all the best.
Home for the Holidays | Leaving the Nursing Home During a Medicare-Covered Stay During the Coronavirus Pandemic
Late November begins a time for gatherings with family and friends – Thanksgiving, soon followed by the December holidays. Nursing home residents often want to participate in these gatherings but may worry that they will lose Medicare coverage if they leave the facility to do so. In past years, the Center for Medicare Advocacy has advised residents and their families and friends to put their minds at ease. According to Medicare law, nursing home residents may leave their facility for family events without losing their Medicare coverage. The issue of concern, in the past, was whether residents would have to pay the facility. The answer depended on the length of their absence. Under certain circumstances, beneficiaries could be charged a “bed hold” fee by their skilled nursing facility (SNF).
On November 12, the Centers for Medicare & Medicaid Services (CMS) issued guidance for state survey agencies on visitation rules. While not specifically addressing the holidays, as last year’s Alert for families did, the November 2021 surveyor guidance recognizes residents’ right to leave their facilities and includes recommendations for when they return. This CMA Alert discusses the new CMS guidance and then longstanding provisions in the Medicare Manuals that govern Medicare coverage.
CMS Alert during the Coronavirus Pandemic
The new guidance confirms that “Facilities must permit residents to leave the facility as they choose.” The facility should remind the resident and any individual accompanying the resident “to follow all recommended infection prevention practices including wearing a face covering or mask, physical distancing, and hand hygiene and to encourage those around them to do the same.”
When residents return, they should be screened for signs or symptoms of COVID-19; tested, if they have been in close contact with someone who had COVID-19; and, if not fully vaccinated, placed on quarantine. Residents developing signs or symptoms should be placed on Transmission-Based Precautions, regardless of vaccination status.
Facilities may test unvaccinated residents without signs or symptoms if they have been absent for more than 24 hours. They may also consider quarantining unvaccinated residents who leave the facility if, “based on an assessment of risk, uncertainty exists about their adherence or the adherence of those around them to recommended infection prevention measures.”
Residents absent for 24 hours or more “should generally be managed as a new admission or readmission,” as recommended by the Centers for Disease Control and Prevention.
The Medicare Benefit Policy Manual recognizes that although most beneficiaries are 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.
The Manual elaborates: “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, a facility should NOT notify patients that leaving the facility will lead to loss of Medicare coverage. The Medicare Benefit Policy Manual says that such a notice is “not appropriate.”
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. If the resident is gone overnight (i.e., past midnight) and returns to the facility the next day, the day the resident leaves is considered a leave of absence day. 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.
Chapter 6 of the Medicare Claims Processing Manual provides that the facility cannot bill a beneficiary during a leave of absence, “except as provided in Chapter 1 of the manual at §220.127.116.11.” As required by the federal Nursing Home Reform Law, that section permits 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.
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.” 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.” CMS distinguishes bed-hold payments from payments for admission or readmission, which are “not allowable.”
In summary, the Medicare Manuals provide that residents can leave their SNFs for short periods, such as a day or two, to enjoy gatherings with their families and friends without losing Medicare coverage. However, 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.
The Center for Medicare Advocacy wishes you and yours a safe and healthy Thanksgiving.
 CMS Alert, https://www.cms.gov/files/document/covid-facility-holiday-recommendations.pdf
 CMS, “Nursing Home Visitation – COVID-19 (REVISED), QSO -20-39-NH (Revised 11/12/2021), https://www.cms.gov/files/document/qso-20-39-nh-revised.pdf
 Medicare Benefit Policy Manual, Pub. 100-02, Ch. 8, §30.7.3. (Example, second paragraph), https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c08pdf.pdf. Scroll down to page 43.
 Medicare Benefit Policy Manual, Pub. 100-02, Ch. 8, §30.7.3. (Example, third paragraph), https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c08pdf.pdf. Scroll down to page 44.
 Medicare Benefit Policy Manual, Pub. 100-02, Ch. 8, §30.7.3. (Example, third paragraph), https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c08pdf.pdf/. Scroll down to page 44.
 Medicare Benefit Policy Manual, Pub. 100-02, Ch. 3, §20.1.2, https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c03pdf.pdf. Scroll down to page 4.
 Medicare Claims Processing Manual, Pub. 100-04, Ch. 6, §18.104.22.168, https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c06.pdf. Scroll down to page 51. Note, unlike Medicaid in some states, the Medicare program does not provide any payment for “bed-hold.”
 Medicare Claims Processing Manual, Pub. 100-04, Ch. 6, §22.214.171.124, https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c06.pdf. Scroll down to page 51.
 42 U.S.C. §1395i-3(c)(1)(B)(iii), 42 C.F.R. §483.10(f)(10),(11).
 Medicare Claims Processing Manual, Pub. 100-04, Ch. 1, §126.96.36.199, https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c01.pdf. Scroll down to pages 49-50. CMS cites, as authority for this payment option, the Nursing Home Reform Law, 42 U.S.C. §1395i-3(c)(1)(B)(iii), and 42 C.F.R. §483.10(g)(17)-(18).
 Medicare Claims Processing Manual, Pub. 100-04, Ch. 1, §188.8.131.52, https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c01.pdf. Scroll down to page 50.
 Medicare Claims Processing Manual, Pub. 100-04, Ch. 1, §184.108.40.206, https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c01.pdf. Scroll down to page 49.
 Medicare Claims Processing Manual, Pub. 100-04, Ch. 1, §220.127.116.11 (http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c01.pdf). Scroll down to page 49.
We’ve sent this week’s CMA Alert with Thanksgiving greetings to all the members of our community to let you know how much we value you. If you are not among the thousands who receive our email communications each week, and would like to be, please sign up today at https://medicareadvocacy.org/join/. You can receive our weekly Alert, press releases, calls to action, and more.
Thank you again for being a part of the Center for Medicare Advocacy community