Temporary Leaves and Medicare SNF Coverage

Patients in skilled nursing facilities (SNFs) who want to temporarily leave the facility can do so without endangering their Medicare Part A coverage. Examples include attending special religious services, joining families for holiday meals or other gatherings, or going on a car ride. SNFs can bill Medicare Part A for those days that include temporary departures, provided the individual has returned to the facility by the midnight census taking hour. However, if the temporary absence extends overnight, Medicare will not pay for the day, but the SNF may seek payment for a bed hold day from the patient.

Section 20.1.2 of the Medicare Benefit Policy Manual, Chapter 3 states as follows:

“The day on which the patient began a leave of absence is treated as a day of discharge, and is not counted as an inpatient day unless the patient returns to the facility by midnight of the same day. The day the patient returns to the hospital or SNF from a leave of absence is treated as a day of admission and is counted as an inpatient day if the patient is present at midnight of that day.” [emphasis added]

A more specific example that discusses Medicare coverage in this situation appears in Section 30.7.3 of the Medicare Benefit Policy Manual, Chapter 8:

“The 'practical matter' criterion should never be interpreted so strictly that it results in the automatic denial of coverage for patients who have been meeting all of the SNF level of care requirements, but who have occasion to be away from the SNF for a brief period of time. While most beneficiaries requiring a SNF level of care find that they are unable to leave the facility, 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 SNF for the receipt of required skilled care.” [emphasis added]

As long as the individual returns by midnight of the same day, the day is counted as an inpatient day, and a short visit does not affect Medicare Part A payment to the SNF. However, if the individual is absent from the SNF for one or more overnights, Medicare Part A will not pay for these day(s), since they would not meet the definition of inpatient days. In these cases, the SNF may charge the patient for bed hold day(s), consistent with the Medicare Claims Processing Manual, Chapter 1, Section 30.1.1.1:

“Under §1819(c)(1)(B)(iii) of the Act and 42 CFR 483.10(g)(17)-(18), the facility must inform residents in advance of their option to make bed-hold payments, as well as the amount of the facility’s charge. For these optional payments, the facility should make clear that the resident must affirmatively elect to make them prior to being billed. 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.” [emphasis added]

Contact: Dan Heim, dheim@leadingageny.org, 518-867-8866