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 88
Section 5(c). Services Provided by a Hospital or Other Facility, and Ambulance Services
Page 88
Benefit Description
Residential Treatment Center (cont.)
Note: Benefits are not available for noncovered services, including: respite care; outdoor residential programs; services provided outside of the provider’s scope of licensure; recreational therapy; educational therapy; educational classes; biofeedback; Outward Bound programs; equine/hippotherapy provided during the approved stay; personal comfort items, such as guest meals and beds, phone, television, beauty and barber services; custodial or long term care (see Definitions); and domiciliary care provided because care in the home is not available or is unsuitable.
Note: For outpatient residential treatment center services, see page 101.
Standard Option - You Pay
See previous page
Basic Option - You Pay
See previous page
Residential Treatment Center (cont.)
Note: Benefits are not available for noncovered services, including: respite care; outdoor residential programs; services provided outside of the provider’s scope of licensure; recreational therapy; educational therapy; educational classes; biofeedback; Outward Bound programs; equine/hippotherapy provided during the approved stay; personal comfort items, such as guest meals and beds, phone, television, beauty and barber services; custodial or long term care (see Definitions); and domiciliary care provided because care in the home is not available or is unsuitable.
Note: For outpatient residential treatment center services, see page 101.
Standard Option - You Pay
See previous page
Basic Option - You Pay
See previous page
Benefit Description
Extended Care Benefits/Skilled Nursing Care Facility Benefits
When Medicare Part A is not your primary payor:
For members who do not have Medicare Part A, we cover skilled nursing facility (SNF) inpatient care for a maximum of 30 days annually, when the member can be expected to benefit from short-term SNF services with a goal of returning home.
The following criteria must also be met:
Benefits are not available for inpatient SNF care solely for management of tube feedings, for home level dialysis treatment, as an interim transition to long term care placement, or for any other noncovered services.
Note: No inpatient benefits (such as room and board) will be provided if precertification is not obtained prior to admission (see page 21). Members are responsible for enrolling in case management (see page 21).
Standard Option - You Pay
Preferred facilities: $175 (no deductible) per admission
Member facilities: $275 plus 35% of the Plan allowance (no deductible) per admission
Non-member facilities: $275 plus 35% of the Plan allowance (no deductible), and any remaining balance after our payment, per admission
Basic Option - You Pay
All charges
Extended Care Benefits/Skilled Nursing Care Facility Benefits
When Medicare Part A is not your primary payor:
For members who do not have Medicare Part A, we cover skilled nursing facility (SNF) inpatient care for a maximum of 30 days annually, when the member can be expected to benefit from short-term SNF services with a goal of returning home.
The following criteria must also be met:
- Member is enrolled in case management prior to admission to the SNF (signed consent required), and actively participates in case management both prior to and during admission to the SNF.
- Precertification is obtained prior to admission (including overseas care).
- We approve the preliminary treatment plan prior to admission (plan must include proposed therapies and document the need for inpatient care).
- Member participates in all treatment and care planning activities, including discharge planning/transition to home.
Benefits are not available for inpatient SNF care solely for management of tube feedings, for home level dialysis treatment, as an interim transition to long term care placement, or for any other noncovered services.
Note: No inpatient benefits (such as room and board) will be provided if precertification is not obtained prior to admission (see page 21). Members are responsible for enrolling in case management (see page 21).
Standard Option - You Pay
Preferred facilities: $175 (no deductible) per admission
Member facilities: $275 plus 35% of the Plan allowance (no deductible) per admission
Non-member facilities: $275 plus 35% of the Plan allowance (no deductible), and any remaining balance after our payment, per admission
Basic Option - You Pay
All charges
Extended Care Benefits/Skilled Nursing Care Facility Benefits - continued on next page