Will Mom Lose Medicare Or Medi-Cal Coverage If She Leaves The Nursing Home To Visit Family?
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 during the holidays. 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. Medi-Cal will cover the first seven (7) days of “bed hold” while she is away, and considers this a “therapeutic leave”. Further, she could be granted up to an additional 12 days of LOA per year under certain conditions. 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 writes the planned LOA into her Plan of Care.
Good wishes to your mom and family, and I hope that she enjoys the holidays with those she loves.