2024 Blue Cross and Blue Shield Service Benefit Plan - Standard and Basic Option
Section 5. Benefits
Section 5(c). Services Provided by a Hospital or Other Facility, and Ambulance Services
Extended Care Benefits/Skilled Nursing Care Facility Benefits
Section 5. Benefits
Section 5(c). Services Provided by a Hospital or Other Facility, and Ambulance Services
Extended Care Benefits/Skilled Nursing Care Facility Benefits
Note: For Standard Option, we state whether or not the calendar year deductible applies for each benefit listed in this Section. There is no calendar year deductible under Basic Option.
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.
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
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.
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.
Note: See earlier in this section 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
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 earlier in this section 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