Coverage Factors

Care is covered if all four of the following factors are met:

  1. The member requires skilled nursing services or skilled rehabilitation services, i.e., services that must be performed by or under the supervision of professional or technical personnel, are ordered by a physician.
  2. These skilled services are required on a daily basis.
  3. As a practical matter, considering economy and efficiency, the daily skilled services can be provided only on an inpatient basis in a skilled nursing facility (SNF).
  4. The services delivered are reasonable and necessary for the treatment of a member’s illness or injury, i.e., are consistent with the nature and severity of the individual’s illness or injury, the individual’s particular medical needs and accepted standard medical practice. The services must also be reasonable in terms of duration and quantity.

           

Updated 03/2018