Elder Law Attorneys Helping You Plan For The Future

Heading home for the holidays doesn’t mean loss of Medicare or Medicaid skilled nursing benefits

Many have loved ones recuperating in rehabilitation facilities or residing in skilled nursing facilities (SNFs). Decisions have to be made about how to handle holiday festivities.

Activity directors for nursing homes often plan seasonal activities for residents and encourage families to participate. The Federal Nursing Home Reform Act of 1987 says that facilities are to be as homelike as possible, so such celebrations should be encouraged. Families can be supportive by participating in the planned activities, especially for loved ones who cannot leave due to physical or mental limitations.

For those who are temporarily recuperating in rehabilitation facilities and who are physically and mentally able, they may wonder if it is possible to leave the facility and enjoy the holidays at home without losing their skilled nursing benefits under Medicare. If the patient is well enough to leave the facility temporarily without harming his or her health, then it is possible to spend the holiday at home.

First, Medicare benefits do stop when a patient has reached the point of no longer benefiting from care in the SNF. However, the Medicare Benefit Policy Manual says that “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.”

Second, care in an SNF is based on 24-hour periods that run from midnight to midnight. Therefore, if a patient leaves the facility for just a few hours but returns before midnight, it is as if they have been there all day and there is no loss of Medicare benefits.

However, Texas is a large state and sometimes the facility where the loved one is receiving care is a long way from home. What happens if the patient has to be away from the facility overnight to reunite with family over the holidays? In the instance of overnight absences, Medicare will not pay the SNF for days when the patient is absent from the facility at midnight, but nor will the patient be charged by Medicare for the cost of the day away. Be aware that the facility may charge the patient a fee to hold the bed to compensate for the loss of income if the bed is held empty, ready for the patient’s return.

There are other factors to consider when determining how to handle the holidays when your loved one is receiving SNF benefits. The patient’s mental and physical ability to tolerate a trip should be considered as well as whether the place where they are visiting can handle physical necessities such as a wheelchair. It is best to consider your loved one’s physician’s and therapists’ opinions in making a decision to spend time away from the facility and the care it provides.

For loved ones receiving Medicaid benefits while residing in long-term care facilities, the specific rules regarding absences from the facility differ. For instance, a Medicaid resident may leave the facility for up to three days and nights without an interruption in benefits. A day is counted midnight to midnight just as with Medicare benefits.

Thus, there is no reason why loved ones cannot be taken out of the facility for a family festivity over the holidays that they would enjoy as long as they are well enough and have the appropriate support they need while away.

Nothing contained in this publication should be considered as the rendering of legal advice to any person’s specific case but should be considered general information.