Skilled Nursing Facility/ Inpatient Rehabilitation Facility Services
Facility services for an inpatient stay in a skilled nursing facility or inpatient rehabilitation facility are covered by the Plan. Benefits include:
  • Non-physician services and supplies received during the inpatient stay
  • Room and board in a semi-private room (a room with two or more beds)
Benefits are available when skilled nursing and/or inpatient rehabilitation facility services are needed on a daily basis. Benefits are also available in a skilled nursing facility or inpatient rehabilitation facility for treatment of a sickness or injury that would have otherwise required an inpatient stay in a hospital.
Benefits for other physician services, including anesthesiologists, consulting physicians, pathologists and radiologists, are covered as defined by the Plan.
UnitedHealthcare will determine if benefits are available by reviewing both the skilled nature of the service and the need for physician-directed medical management. A service will not be determined to be "skilled" simply because there is not an available caregiver.
Benefits are available only if:
  • The initial confinement in a skilled nursing facility or inpatient rehabilitation facility was or will be a cost effective alternative to an inpatient stay in a hospital; and
  • You will receive skilled care services that are not primarily custodial care.
Skilled care is skilled nursing, skilled teaching, and skilled rehabilitation services when:
  • It is delivered or supervised by licensed technical or professional medical personnel in order to obtain the specified medical outcome, and provide for the safety of the patient;
  • It is ordered by a physician;
  • It is not delivered for the purpose of assisting with activities of daily living, including but not limited to dressing, feeding, bathing or transferring from a bed to a chair;
  • It requires clinical training in order to be delivered safely and effectively; and
  • You are expected to improve to a predictable level of recovery. Benefits can be denied or shortened for covered members who are not progressing in goal-directed rehabilitation services or if discharge rehabilitation goals have previously been met.
Note:
  • The Plan does not pay benefits for custodial care or domiciliary care, even if ordered by a physician, as defined in "Medical Plan Definitions."
  • Any combination of network benefits and out-of-network benefits is limited to 120 days per calendar year.
Prior Authorization Requirement
Please remember for out-of-network benefits for:
  • A scheduled admission, you must obtain prior authorization five business days before admission.
  • A non-scheduled admission (or admissions resulting from an Emergency) you must provide notification as soon as is reasonably possible.
If authorization is not obtained as required, or notification is not provided, Benefits will be subject to a $400 penalty.