Q. Mom has been receiving care in a nursing home. She is currently covered by Medicare, but soon will switch to Medi-Cal. She would really like to come to our home for a short visit for family celebrations. However, I heard that she might lose her coverage if she does so. Is that true?
A. Not if her visit is handled correctly, including arranging for a “pass” from the nursing home for the visit and making sure that it is included in her Plan of Care. In this regard, the rules for Medicare are different from the rules for Medi-Cal. Here’s the way they work:
Medicare: While the Medicare Benefits Policy Manual recognizes that most beneficiaries needing nursing level care are unable to leave the facility, it recites that
“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 [nursing home] for the receipt of required skill care.”
The Manual also states that is not appropriate for the facility to notify the patient that the visit home will result in a denial of coverage. However, it is best if your mom returns before midnight on the same day, as Medicare will only pay for that one day away. If her visit extends out more than the same day, the facility can charge her privately for the bed-hold for each day thereafter, so long as it has advised her, in advance, that it will do so and the cost for same. So, short visits of one or two days to be with family is entirely appropriate, and will not result in a loss of Medicare coverage, but—after the first day away—the visit may require private payment to hold her bed.
Medi-Cal: The rules for persons on Medi-Cal are more lenient. If your mom’s stay is covered by Medi-Cal at the time of her visit, she could be granted a leave of absence (LOA) of up to 18 days per calendar year, provided that the physician approves the LOA and writes it into her Plan of Care. Further, she could be granted up to an additional 12 days of LOA per year under certain conditions. This is called a “therapeutic leave”. Medi-Cal will cover the first seven (7) days of “bed hold”. So, again, if your mom were relying upon Medi-Cal for nursing home coverage, her visit home should not be a problem, but be sure to request that the physician write the planned LOA into her Plan of Care.
Good wishes to your mom and family, and I hope that she enjoys her visit with those she loves.
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References: Medicare Benefit Policy Manual, scroll to §30.7.3, Example. at page 43 ;
Medi-Cal Rules at 22 CCR 51335 (i)
Center for Medicare Advocacy article “Home for the Holidays: Leaving the Nursing Home During a Medicare-Covered Stay”
California Advocates For Nursing Home Reform article: “Did You Know? Nursing Home Residents Can Go Home for the Holidays”
Medicaid Bed Hold Policies by State (September 2012), compiled by the National Long-Term Care Ombudsman Resource Center.