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  • Writer's pictureAmber Hinds

Medicaid vs Medicare: Don’t Let Coverage Concerns Ruin the Holidays

The holidays are upon us which means many nursing home residents will be worrying about whether leaving the facility for a family visit could jeopardize their coverage. After all, an online search elicits a slew of warnings about how a night away from your approved facility could lose you your bed or land you a hefty bill and the truth is, this can happen. Nevertheless, this worry is often overstated and owing to a misunderstanding between Medicaid vs Medicare. Let us explain.

The Importance of Getting Medicaid vs Medicare Right During the Holidays

Both Medicaid and Medicare provide nursing home care coverage but do so for different purposes and under different circumstances. Medicare only covers nursing home care in cases where it is needed for short term rehabilitation. Medicaid, in contrast, provides long term care coverage. While both programs are government run, they operate separately and the restrictions of one have no bearing on the other.

By definition, a Medicare-covered patient is only in a nursing home for a short period of time and thus the program expects them to participate in a robust rehabilitation regimen. For this reason, Medicare distinguishes between a situation where a patient leaves the nursing home facility and returns before midnight and one where they are absent for the night. The former does not jeopardize coverage while the latter does. If a patient leaves and does not return before midnight on a given day, this is considered a day of absence and the facility will bill the patient privately as Medicare will reject coverage. The same is not true of Medicaid.

Medicaid provides long-term nursing home care coverage and thus those who rely on the program are long-term residents of their respective facilities. They are not there for short, intensive rehab and accordingly, overnight visits are granted greater leniency.

A Medicaid leave of absence is referred to as a “therapeutic leave” and individual states differ on how much time can be taken for this purpose. Indiana’s Medicaid program, for instance, offers no ‘bed-hold’ coverage which means a resident may lose their bed at a nursing home if they take a therapeutic leave (yes, even if it’s to attend Christmas) while Michigan will hold a bed for up to 18 days per calendar year. Despite these differences, no state will issue a patient a private bill for any absences and anyone who loses their bed is entitled to the first available bed in a semi-private room upon their return.

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