Group Health uses a network of contracted skilled nursing facilities (SNFs) to provide care when your stay is covered by Group Health Medicare Advantage or a Group Health commercial plan. Group Health care management nurses work with the doctor to authorize coverage for medically necessary stays in a SNF. Although you may be seen by different doctors and nurses, your Group Health care team will continue to monitor your care while you are in the SNF.
Payment for Nursing Home Services
Not all services at a nursing home are covered by your Group Health Plan. Admission to an inpatient skilled nursing facility or nursing home is a covered benefit only when it is medically necessary and authorized in advance by Group Health. If your admission to the facility is not covered it is called a residential or custodial facility stay, where some services, such as laboratory tests, X-rays, or intermittent rehabilitation services may be covered. Residential/custodial facility charges for room and board and other care related to custodial care are not covered by Group Health or Medicare. For these admissions, the facility fee is the patient’s financial responsibility.
Network of Contracted Facilities
For Group Health patients who meet the Group Health and Medicare approved medical necessity criteria, care will usually be provided in a Group Health contracted SNF. An exception may be made if you or your spouse resides in a nursing home prior to placement, and that nursing home provides Medicare certified Skilled Nursing Care. If your care is not provided at an approved SNF and the care is not authorized in advance, Group Health will not pay for any of the care that you receive at that SNF.
Inpatient Skilled Nursing Facility Coverage
Medicare coverage for SNF care requires a three-day hospital stay, or an acute condition otherwise meeting hospital criteria in the 30 days prior to admission to the SNF. Non-Medicare members do not have the same prior hospital stay requirement. All members must meet each of the following conditions:
- Medically necessary skilled nursing or skilled rehabilitation (physical, occupational, or speech therapy) services are required on a daily basis.
- The above daily skilled services can be provided only on an intensive inpatient basis in a SNF, and
- The services are reasonable and necessary for the treatment of the patient’s illness or injury.
Licensed professionals: The patient’s condition, or the complexity of the service, requires the judgment, knowledge, and skills of qualified licensed professionals.
Daily rehabilitation services: Coverage is based on an assessment of the patient’s restoration potential and meeting at least one of these expectations:
- The patient’s condition will improve in a reasonable and generally predictable period of time, or
- Daily services are necessary to establish a safe and effective home or long-term care program, or
- Daily services are necessary to prevent the patient's condition from getting worse.
Daily licensed nursing services are provided under these conditions:
- A patient requires the skills of professional nurses to assure safety and to achieve the medically desired result, or
- A nurse must observe and assess a patient who is not yet on a stabilized treatment regimen, and who may need changes in treatment or additional medical procedures, or
- The patient’s overall condition requires the skills of professional nurses to develop, evaluate, and manage a plan of care.
Medical standards apply: Services provided must be specific and effective treatment for the patient’s condition under accepted standards of medical practice. The amount, frequency, and duration of service must be reasonable and necessary for the treatment of the patient’s condition.
Care that is of a custodial (residential) nature does not meet skilled nursing facility criteria. Neither Medicare nor Group Health pays for residential care room and board. Examples include:
- Assistance with activities of daily living like grooming, bathing, going to the bathroom, taking medications and routine catheter, tube feeding, wound care or colostomy care.
- Teaching and training where the ability to learn or make progress is lacking.
- Repetitive exercise, help with walking, or reminding the patient to follow physician’s instructions, therapy services for overall fitness and well-being, or therapy to maintain function after a maintenance program has been established.
- Medical management that does not require daily monitoring by a licensed nurse.
Length of Stay
Some patients meet inpatient daily SNF criteria for only a few days, others for a few weeks or longer. Even though your coverage contract specifies a certain number of benefit days, your care must be medically necessary to access the covered days. For more information, please talk with the SNF staff, your physician or nurse, or the SNF care manager. Intermittent skilled physical, occupational, or speech therapy is available during custodial care or through Home Health in settings such as your home, an adult family home, or assisted living facility. Services like medications and tube feeding supplies may be covered during a custodial stay if your coverage contract includes separate benefits for these services.
Notification of NonCoverage at SNF Discharge
The SNF or nursing home will deliver a Notice of Medicare NonCoverage (for consumers accessing their Medicare SNF benefit), or Notice of NonCoverage (for consumers accessing their Group SNF benefit and staying Long Term Care in the Nursing Home) to you prior to the discontinuation of coverage for your stay. This letter will be delivered to you or to your legal representative if you are not capable of understanding the letter. You or your legal representative will be asked to sign the acknowledgement page. If you should disagree with the discharge, information on how to appeal the discharge decision is provided in the letter.
Group Health Customer Service
Medicare health plans and members: Tollfree: 1-888-901-4600; 8 a.m.-8 p.m., seven days a week.
All other plan and member inquiries: Tollfree: 1-888-901-4636; TTY: 1-800-833-6388; 8 a.m.-6 p.m., Monday through Friday and 9 a.m.-2 p.m. on Saturday.
Medicare also provides detailed information about nursing home facilities.