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. Over the 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).
During the coronavirus pandemic, the Centers for Medicare & Medicaid Services (CMS) issued guidance for state survey agencies on visitation rules. Current guidance, issued in November 2021 and revised on September 23, 2022, confirms the right of residents to leave their facility. What is different in 2022 is CMS recommendations about residents who return to the facility after an absence. This CMA Alert discusses the revised CMS guidance and then longstanding provisions in the Medicare Manuals that govern Medicare coverage.
CMS Guidance during the Coronavirus Pandemic
Last year’s November guidance, which is still in effect but somewhat revised, confirms that “Facilities must permit residents to leave the facility as they choose.” With slightly revised language in 2022, CMS advises that the facility should remind the resident and any individual accompanying the resident “to follow all recommended infection prevention practices such as wearing a face covering or mask, especially for those at high risk for severe illness and when community transmission is high, performing hand hygiene and encouraging those around them to do the same.”
When residents return, they should be screened for signs or symptoms of COVID-19 and tested, if they or a family member have been in close contact with someone who had COVID-19. If residents develop “signs or symptoms of COVID-19 after the outing,” the facility should follow CDC’s guidance for residents with symptoms.
The most significant change in CMS guidance in 2022 is the statement that “In most circumstances, quarantine is not recommended for residents who leave the facility for less than 24 hours . . . except in certain situations described in the CDC’s empiric transmission-based precautions guidance.” However, as in 2021, CMS recommends this year that “residents who leave for 24 hours or longer should generally be managed as a new admission, as recommended by the CDC in the Managing admissions and residents who leave the facility section.”
CMS’s testing guidance, originally issued in 2020 and also revised on September 23, 2022, reiterates that residents who leave the facility for 24 hours or longer should be treated like new admissions.
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 §188.8.131.52.” 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.
November 14, 2022 – T. Edelman
 The most recent guidance addresses face coverings and masks during visits and removes vaccination status. CMS, “Nursing Home Visitation – COVID-19 (REVISED),” QSO-20-39-NH (Sep 17, 2020) (revised Sep. 23, 2022), https://www.cms.gov/files/document/qso-20-39-nh-revised.pdf
 CMS, “Interim Final Rule (IFC), CMS-3401-IFC, Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency related to Long-Term Care (LTC) Facility Testing Requirements,” QSO-20-38-NH (Aug. 26, 2020) (revised Sep. 23, 2022), https://www.cms.gov/files/document/qso-20-38-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, §184.108.40.206, 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, §220.127.116.11, 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, §18.104.22.168, 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, §22.214.171.124, 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, §126.96.36.199, https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c01.pdf. Scroll down to page 49-50.
 Medicare Claims Processing Manual, Pub. 100-04, Ch. 1, §188.8.131.52 (http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c01.pdf). Scroll down to page 49.