2023 Blue Cross and Blue Shield Service Benefit Plan - Standard and Basic Option
Section 5(c). Services Provided by a Hospital or Other Facility, and Ambulance Services
Page 89
Section 5(c). Services Provided by a Hospital or Other Facility, and Ambulance Services
Page 89
Benefit Description
Extended Care Benefits/Skilled Nursing Care Facility Benefits (cont.)
When Medicare Part A is your primary payor:
When Medicare Part A is the primary payor (meaning it pays first) and has made a payment, Standard Option provides limited secondary benefits.
We pay the applicable Medicare Part A copayments incurred in full during the first through the 30th day of confinement for each benefit period (as defined by Medicare) in a qualified skilled nursing facility.
Note: See https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/ge101c03.pdf for complete Medicare benefit period definition.
If Medicare pays the first 20 days in full, Plan benefits will begin on the 21st day (when Medicare Part A copayments begin) and will end on the 30th day.
Note: See page 84 for benefits provided for outpatient physical, occupational, speech, and cognitive rehabilitation therapy, and manipulative treatment services when billed by a skilled nursing facility. See Section 5(f) for benefits for prescription drugs.
Note: If Medicare Part A is your primary payor, we will only provide benefits if Medicare provided benefits for the admission.
Standard Option - You Pay
Preferred facilities: Nothing (no deductible)
Member facilities: Nothing (no deductible)
Non-member facilities: Nothing (no deductible)
Note: You pay all charges not paid by Medicare after the 30th day.
Basic Option - You Pay
All charges
Extended Care Benefits/Skilled Nursing Care Facility Benefits (cont.)
When Medicare Part A is your primary payor:
When Medicare Part A is the primary payor (meaning it pays first) and has made a payment, Standard Option provides limited secondary benefits.
We pay the applicable Medicare Part A copayments incurred in full during the first through the 30th day of confinement for each benefit period (as defined by Medicare) in a qualified skilled nursing facility.
Note: See https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/ge101c03.pdf for complete Medicare benefit period definition.
If Medicare pays the first 20 days in full, Plan benefits will begin on the 21st day (when Medicare Part A copayments begin) and will end on the 30th day.
Note: See page 84 for benefits provided for outpatient physical, occupational, speech, and cognitive rehabilitation therapy, and manipulative treatment services when billed by a skilled nursing facility. See Section 5(f) for benefits for prescription drugs.
Note: If Medicare Part A is your primary payor, we will only provide benefits if Medicare provided benefits for the admission.
Standard Option - You Pay
Preferred facilities: Nothing (no deductible)
Member facilities: Nothing (no deductible)
Non-member facilities: Nothing (no deductible)
Note: You pay all charges not paid by Medicare after the 30th day.
Basic Option - You Pay
All charges
Benefit Description
Not covered:
Phone, television, personal comfort items, such as guest meals and beds, beauty and barber services, recreational outings/trips, stretcher or wheelchair transportation, non-emergent ambulance transport that is requested, beyond the nearest facility adequately equipped to treat the member’s condition, by patient or physician for continuity of care or other reason, custodial or long term care (see Definitions), and domiciliary care provided because care in the home is not available or is unsuitable
Standard Option - You Pay
All charges
Basic Option - You Pay
All charges
Not covered:
Phone, television, personal comfort items, such as guest meals and beds, beauty and barber services, recreational outings/trips, stretcher or wheelchair transportation, non-emergent ambulance transport that is requested, beyond the nearest facility adequately equipped to treat the member’s condition, by patient or physician for continuity of care or other reason, custodial or long term care (see Definitions), and domiciliary care provided because care in the home is not available or is unsuitable
Standard Option - You Pay
All charges
Basic Option - You Pay
All charges
Benefit Description
Hospice Care
Hospice care is an integrated set of services and supplies designed to provide palliative and supportive care to members with a projected life expectancy of six months or less due to a terminal medical condition, as certified by the member’s primary care provider or specialist.
Standard Option - You Pay
See pages 90-92
Basic Option - You Pay
See pages 90-92
Hospice Care
Hospice care is an integrated set of services and supplies designed to provide palliative and supportive care to members with a projected life expectancy of six months or less due to a terminal medical condition, as certified by the member’s primary care provider or specialist.
Standard Option - You Pay
See pages 90-92
Basic Option - You Pay
See pages 90-92
Hospice Care - continued on next page