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 $5,000.  If expenses exceed this $5,000 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 all of the following five 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.
• The individual was in a hospital at least three days in a row (not counting the day of discharge) before being admitted to a participating skilled nursing facility.
• The individual is admitted to the facility within a short time (generally within 30 days) after leaving the hospital.
• The individual’s care in the skilled nursing facility is for a condition that was treated in the hospital.
• 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, and special treatment rooms.
• 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. Services may be covered for skilled nursing facility care for terminal cases where the illness has reached a point of predictable end. In these situations, services must be preauthorized with the Trust Office.

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