Anthem Blue Cross Blue Shield PPO Plan - Teamworks at Home ...

Extended skilled nursing care
The Plan covers BlueCard PPO providers Out-of-network providers
Extended skilled nursing care You pay 20% after you satisfy
the deductible�
Extended skilled nursing care is defned as the use of
skilled nursing services delivered or supervised by a
registered nurse (RN) or licensed practical nurse (LPN)
to obtain the specifed medical outcome and provide for
the safety of the patient� To be covered under the Plan:
• An attending physician must order extended skilled
nursing care�
• Certifcation of the RN or LPN providing the care
is required�
• The Plan, in its sole discretion, must determine
that the extended skilled nursing care is
medically necessary�
• The covered person and the provider must obtain
prior authorization from the Plan (contact member
services of the Plan to request prior authorization)�
Coverage is limited to 100 visits per person per
calendar year (combined with home health care and
skilled nursing care)� Each 24-hour visit (or shifts of up
to 24-hour visits) equals one visit and counts towards
the 100 combined visits� Any visit that lasts less than
24 hours, regardless of the length of the visit, will count
as one visit towards the 100 visit limitation (combined
with home health care and skilled nursing care�)
Services provided under the following circumstances
will be considered extended skilled nursing services:
• Transition of the covered person from an inpatient
setting to home�
• The covered person becomes acutely ill and the
additional skilled nursing care will prevent a
hospital admission�
• The covered person meets the clinical criteria for
confnement in a skilled nursing facility, but a skilled
nursing facility bed is not available� In this situation,
additional skilled nursing may be provided until a
skilled nursing facility bed becomes available�
• The covered person is on a ventilator or depends
on continuous positive airway pressure due to
respiratory insufciency at home�
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You pay 40% of eligible covered
expenses after you satisfy the deductible�
The following types of care are not covered:
• Nursing care that does not require the education,
training, and technical skills of an RN or LPN�
• Nursing care provided for skilled observation�
• Nursing care provided while the covered person is an
inpatient in a hospital or health care facility�
• Nursing care to administer routine maintenance
medications or oral medications, except where law
requires an RN or LPN to administer medicines�
• Custodial care for daily life activities such as but not
limited to:
– Transportation
– Meal preparation
– Vital sign charting
– Companionship activities
– Bathing
– Feeding
– Personal grooming
– Dressing
– Toileting
– Getting in or out of bed or a chair
• Services that can be safely and efectively performed
by a nonmedical person or self-administered without
the direct supervision of a licensed nurse� The
unavailability of a person to provide an unskilled
service does not allow for coverage for a nurse to
provide unskilled services�
Anthem Blue Cross Blue Shield PPO Plan