Skilled Nursing Facility
Skilled nursing facility services under the ROP are covered at 70% 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 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. When services are performed by a network provider, your provider will get the necessary pre-authorization. When services are performed by a non-network provider, it is your responsibility to contact Anthem Blue Cross for pre-authorization or make sure your provider has obtained the necessary pre-authorization (see "Medical Management Programs"). Pre-authorization is required for both Medicare and non-Medicare members.
The services provided must be 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.