2024 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 83
Section 5(c). Services Provided by a Hospital or Other Facility, and Ambulance Services
Page 83
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 Section 5(e).
Standard Option - You Pay
Preferred facilities: $350 per admission copayment for unlimited days (no deductible)
Member facilities: $450 per admission copayment for unlimited days, plus 35% of the Plan allowance (no deductible)
Non-member facilities: 35% of the Plan allowance (no deductible), and any remaining balance after our payment
Basic Option - You Pay
Preferred facilities: $250 per day copayment up to $1,500 per admission for unlimited days
Member/Non-member facilities: You pay all charges
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 Section 5(e).
Standard Option - You Pay
Preferred facilities: $350 per admission copayment for unlimited days (no deductible)
Member facilities: $450 per admission copayment for unlimited days, plus 35% of the Plan allowance (no deductible)
Non-member facilities: 35% of the Plan allowance (no deductible), and any remaining balance after our payment
Basic Option - You Pay
Preferred facilities: $250 per day copayment up to $1,500 per admission for unlimited days
Member/Non-member facilities: You pay all charges
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.
Note: Precertification is required prior to admission (including overseas care).
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.
Correction, 3/13/2024
Note: Inpatient benefits (such as room and board) may not be provided if precertification is not obtained prior to admission (see Section 3).Members are responsible for enrolling in case management.
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.
Note: Precertification is required prior to admission (including overseas care).
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.
Correction, 3/13/2024
Note: Inpatient benefits (such as room and board) may not be provided if precertification is not obtained prior to admission (see Section 3).
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
Benefit Description
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.
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
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.
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 - continued on next page