Skilled Nursing Facility
Skilled nursing facility services under the NAP are covered at 90% of the negotiated rate, after deductible, when you use an Anthem Blue Cross PPO network provider. Non-network skilled nursing facility services are covered at 70% of Customary and Reasonable Charges (Eligible Expenses) after the deductible. A hospital stay of at least three consecutive days for the same condition is required prior to admission to a skilled nursing facility, and the admission to the skilled nursing facility must be within 30 days of your discharge from the hospital. Pre-authorization is also required. A penalty of $300 applies if no pre-authorization is obtained. Remember, either you or your doctor must contact Anthem Blue Cross for pre-authorization (see "Medical Management Programs") and meet all the stated criteria for coverage.
The services provided must be Medically Necessary Covered Health Services (and not considered custodial care) so as to require confinement in a skilled nursing facility, as determined by Anthem Blue Cross. (Custodial care is defined as care provided primarily to assist an individual in meeting the activities of daily living including, but not limited to, walking, bathing, dressing, eating, preparation of special diets, changing catheters, and supervision over self-administration of medications not requiring constant attention of trained medical personnel. It is care that can be taught to a lay person who does not have any professional qualifications, skills or training.)
Coverage of physician, hospital, ambulance and hemodialysis services, purchase or rental of durable medical equipment, medical supplies, drugs and medicines is provided as described elsewhere in this Handbook.