Skilled Nursing Facility – 90%

Benefits are provided for services and supplies related to skilled care in a Medicare-participating skilled nursing facility with an annual maximum of $10,000. If expenses exceed this $10,000 annual maximum, this plan will not pay the additional costs. 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 individual 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 individual must meet the following two conditions:

• The individual’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 individual 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, or 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 individual.
• Physician visits and mobile x-ray charges.

Benefits are not provided for:

1. Custodial 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 individual to live outside the facility, except that benefits will be provided for skilled nursing facility care for hospice care related to a terminal condition. These services must be preauthorized with the Trust Office.