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Billy Cunningham
Billy Cunningham
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Nursing Home Residents Can Enjoy the Holidays with Family

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The Center for Medicare Advocacy reports that residents in nursing homes- long term skilled nursing facilities can leave the nursing home during this holiday season without losing their Medicare coverage. 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 skilled nursing facility for the receipt of required skilled care.

The manual is clear that a facility should not notify patients that leaving the facility will lead to loss of Medicare coverage. Such a notification is not appropriate.

Generally, if the resident returns to the facility by midnight, the facility can bill Medicare for that 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. While the facility cannot bill Medicare for leave of absence days, it is today unclear whether the facility can bill the beneficiary for those days.

As the Center for Medicare Advocacy has reported in prior years, Chapter 6 of the Medicare Claims Processing Manual says that the facility cannot bill a beneficiary during a leave of absence. However, a provision in Chapter 1 of the Medicare Claims Processing Manual, issued May 30, 2008, authorizes skilled nursing facilities to bill a beneficiary for bed-hold during a temporary "SNF Absence" if the nursing home 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 charged. The Center for Medicare and Medicaid Services confirms 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.

Whether these apparently contradictory provisions in the Medicare Claims Processing Manual can be reconciled remains to be seen. I would recommend that if you desire to take a loved one out and you are approached by the facilty about payment to cite to the provision that syas the facilty cannot bill a beneficiary during a leave of absence. Stand firm. This facility is supposed to have your loved ones interest at heart not their pocket book. And have a great visit and holiday!

For more detailed information these websites may help: www.medicareadvocacy.org and

http://www.medicareadvocacy.org/Print/2009/SNF_09_11.19.HomeFortheHolidays.htm