Summary Plan Description

Skilled Nursing Facility

90% Network and 80% Non-Network
Services and Supplies Must Be Precertified Unless the Patient Is A Medicare-Eligible Retiree

Benefits are provided for services and supplies related to skilled care in a Medicare-participating skilled nursing facility with an annual maximum of 25 days. Skilled nursing facility care must be part of a formal written treatment plan prescribed by the attending physician who certifies that the care is medically necessary and that the patient needs skilled nursing or skilled rehabilitative services on a daily basis. To qualify for this benefit, care in the skilled nursing facility must be provided in lieu of inpatient hospital care and the patient must meet the following two conditions:

  • The patient's condition requires daily skilled nursing or skilled rehabilitation services which, as a practical matter, can only be provided in a skilled nursing facility.
  • A physician certifies that the patient needs, and receives, skilled nursing or skilled rehabilitation services on a daily basis.

Covered services and supplies include:

  • A semi-private room, meals and skilled nursing care.
  • Services and supplies furnished and used while in the skilled nursing facility including, but not limited to, physical, speech, respiratory, and occupational therapy, routine laboratory tests, special treatment rooms, medical supplies, and drugs.
  • Drugs, biologicals, supplies, appliances, and equipment for use in the facility and which are ordinarily furnished by the facility for the care and treatment of the patient.
  • Physician visits and mobile x-ray charges.

Benefits are not provided for:

  1. Custodial or maintenance care; nonmedical self-help or related testing; personal convenience items; vocational, educational, cognitive, or behavioral therapy; exercise programs; or therapy or maintenance which is solely for the purpose of slowing body degeneration rather than restoring functional improvement.
  2. Services or supplies received after the date the attending physician stops treatment or withdraws certification.
  3. Private duty nursing.
  4. Services from a skilled nursing facility that are not usually provided by such facilities, or where the care given during the confinement is not expected to lessen the disability and enable the patient to live outside the facility.