These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.
Prior authorization is required for skilled nursing facility admissions.
Coverage of skilled nursing facility (SNF) care is limited to services provided for post-acute treatment and rehabilitative care of an illness or injury. Services must meet the rehabilitative or skilled nursing definitions and the indications listed below.
Note: Member must be placed in a Medicare Certified bed in the SNF.
Indications that are covered
Care must meet the following criteria:
- The member must have a need that requires skilled nursing intervention three times daily. Examples of skilled nursing include wound care, injections, respiratory therapy treatments, vital sign monitoring or medication management. Services must require the skills of a skilled professional. OR
- The member must be participating in a comprehensive rehabilitative program which includes medically necessary therapy on at least a twice a day basis on at least 5 days of the week or equivalent to two 30 minute sessions 5 days of the week. Therapy services can be of the same type or a different type. Examples include physical therapy twice a day or physical therapy once a day and occupational therapy once a day. Members must make significant functional improvement towards their maximum potential for coverage to continue
- Therapy where significant functional improvement is not expected or progress has reached a plateau.
- Care that can be rendered at a lower level is not considered to meet the skilled nursing home level of services. The skilled portion of care will be covered but room and board will not.
- Custodial or respite care services.
- Services that can be safely performed by non-skilled personnel.
Custodial Care - This is supportive services focusing on activities of daily life that do not require the skills of qualified technical or professional personnel, including but not limited to, bathing, dressing and feeding.
Rehabilitative Care - This is a restorative service, which is provided for the purpose of obtaining significant functional improvement, within a predictable period of time, (generally within a period of two months) toward a patient's maximum potential ability to perform functional daily living activities.
Skilled Nursing Facility (SNF) - This is a licensed skilled nursing facility, lawfully performing medical services in accordance with governmental licensing privileges and limitations, and which is recognized as an appropriate facility by the Plan, to render inpatient post-acute hospital and rehabilitative care and services to covered persons, whose condition requires skilled nursing facility care. It does not include facilities that primarily provide treatment of mental or chemical health, or tuberculosis.
This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.
- 01/01/1994 - Date of origin
- 02/01/2017 - Effective date