Common use of Skilled Nursing Care Clause in Contracts

Skilled Nursing Care. All Skilled Nursing Care services, except home infusion and related services, require Prior Authorization by the Company in order to be eligible for benefits. If prior approval is not obtained, the Company has the right to request medical records to review to determine whether services are eligible under this Contract. a. Covered services that require that the patient be homebound: An Insured will be considered to be homebound if they have a condition due to illness or injury for which leaving the home is medically contraindicated. The Company has the right to determine whether the patient is homebound. (1) Skilled Nursing Care visits include services provided by a Medicare certified Home Health Agency. (2) Skilled Nursing Care services are covered when provided by a state licensed nursing agency or state licensed nurse on an hourly basis. b. Covered services that do not require that the patient be homebound: (1) Home care education associated with diabetes, colostomy care, wound care, IV therapy or any other condition or treatment which the Company has determined is appropriate for home care education, when provided by a Medicare certified Home Health Agency. Benefits for educational services will be limited to no more than three home care education visits per Benefit Period for which home care education is appropriate. (2) Home infusion and related services. These services can be provided by either a Medicare certified Home Health Agency, state licensed nursing agency or state licensed nurse. c. Skilled Nursing Care services do not include: (1) Services provided by a member of the Insured's immediate family. (2) Services provided by a person who normally lives in the Insured's home. (3) Custodial/Maintenance Care. The Company has the right to determine which services are Custodial/Maintenance Care.