Skilled Nursing Facility Care Sample Clauses

Skilled Nursing Facility Care. This benefit has one or more exclusions as specified in the Exclusions Section. Room and board and other necessary services furnished by a Skilled Nursing Facility are Covered and require Prior Authorization. Admission must be appropriate for your Medically Necessary care and rehabilitation. Refer to your Summary of Benefits and Coverage for your visit limitations.
Sample 1
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Skilled Nursing Facility Care. Care that is most appropriately provided in a Skilled Nursing Facility, but at MVP’s discretion is provided on an inpatient basis in a Hospital, may be covered under your Skilled Nursing Facility benefits.
Sample 1
Skilled Nursing Facility Care. ‌ This benefit has one or more exclusions as specified in the Exclusions Section. Room and board and other necessary services furnished by a Skilled Nursing Facility are Covered and require Prior Authorization. Admission must be appropriate for your Medically Necessary care and rehabilitation. Refer to your Summary of Benefits and Coverage for your visit limitations. Smoking Cessation Counseling/Program This benefit has one or more exclusions as specified in the Exclusions Section. Coverage is provided for Diagnostic Services, Smoking Cessation Counseling and pharmacotherapy. Medical services are provided by licensed Health Care Professionals with specific training in managing your Smoking Cessation Program. The program is described as follows: • Individual counseling at a Practitioner’s/Provider’s office is Covered under the medical benefit. The non-specialist Copayment applies. • Group counseling, including classes or a telephone Quit Line, are Covered through an In- network Practitioner/Provider. No Cost Sharing will apply and there are no dollar limits or visit maximums. Reimbursements are based on contracted rates. • Some organizations, such as the American Cancer Society and Tobacco Use Prevention and Control (XXXXX), offer group counseling services at no charge. You may want to utilize these services. For more information contact our Presbyterian Customer Service Center at‌‌‌ (000) 000-0000 or 0-000-000-0000, Monday through Friday from 7 a.m. to 6 p.m. Hearing impaired users may call TTY 711. Pharmacotherapy benefit Limitations • Prescription Drugs/Medications purchased at a Pharmacy • Two 90-day courses of treatment per Contract Year Refer to your Summary of Benefits and Coverage and your Formulary for your Cost Sharing amount. Special Inpatient Services Special inpatient services (including but not limited to private room and board and/or special duty nursing requires Prior Authorization. Telemedicine Services PIC provides coverage for telemedicine services to the same extent that this agreement covers the same services when provided in-person. PIC will not impose originating-site restrictions. Coverage maybe extended to out-of-network providers in instances where no in-network provider is accessible, as defined by network adequacy standards.
Sample 1

Related to Skilled Nursing Facility Care

  • Skilled Nursing Facilities a. The following Health Care Services may be Covered Services when you are a patient in a Skilled Nursing Facility: i. room and board;

  • Skilled Care in a Nursing Facility This plan covers skilled nursing services in a skilled nursing facility if: • the services are prescribed by a physician: • your condition needs skilled nursing services, skilled rehabilitation services or skilled nursing observation; • the services are provided by or supervised by licensed technical or professional medical personnel; and • the services are not custodial care, respite care, day care, or for the purpose of assisting with activities of daily living.

  • Urgent Care This plan covers services received at an urgent care center. For other services, such as surgery or diagnostic tests, the amount that you pay is based on the type of service being provided. See Summary of Medical Benefits for details. Follow-up care (such as suture removal or wound care) should be obtained from your primary care provider or specialist.

  • Durable Medical Equipment (DME), Medical Supplies, Prosthetic Devices, Enteral Formula or Food, and Hair Prosthesis (Wigs) This plan covers durable medical equipment and supplies, prosthetic devices and enteral formula or food as described in this section. Durable Medical Equipment (DME) DME is equipment which: • can withstand repeated use; • is primarily and customarily used to serve a medical purpose; • is not useful to a person in the absence of an illness or injury; and • is for use in the home. DME includes supplies necessary for the effective use of the equipment. This plan covers the following DME: • wheelchairs, hospital beds, and other DME items used only for medical treatment; and • replacement of purchased equipment which is needed due to a change in your medical condition or if the device is not functional, no longer under warranty, or cannot be repaired. DME may be classified as a rental item or a purchased item. In most cases, this plan only pays for a rental DME up to our allowance for a purchased DME. Repairs and supplies for rental DME are included in the rental allowance. Preauthorization may be required for certain DME and replacement or repairs of DME. Medical Supplies Medical supplies are consumable supplies that are disposable and not intended for re- use. Medical supplies require an order by a physician and must be essential for the care or treatment of an illness, injury, or congenital defect. Covered medical supplies include: • essential accessories such as hoses, tubes and mouthpieces for use with medically necessary DME (these accessories are included as part of the rental allowance for rented DME); • catheters, colostomy and ileostomy supplies, irrigation trays and surgical dressings; and • respiratory therapy equipment. Diabetic Equipment and Supplies This plan covers diabetic equipment and supplies for the treatment of diabetes in accordance with R.I. General Law §27-20-30. Covered diabetic equipment and supplies include: • therapeutic or molded shoes and inserts for custom-molded shoes for the prevention of amputation; • blood glucose monitors including those with special features for the legally blind, external insulin infusion pumps and accessories, insulin infusion devices and injection aids; and • lancets and test strips for glucose monitors including those with special features for the legally blind, and infusion sets for external insulin pumps. The amount you pay differs based on whether the equipment and supplies are bought from a durable medical equipment provider or from a pharmacy. See the Summary of Pharmacy Benefits and the Summary of Medical Benefits for details. Coverage for some diabetic equipment and supplies may only be available from either a DME provider or from a pharmacy. Visit our website to determine if this is applicable or call our Customer Service Department. Prosthetic Devices Prosthetic devices replace or substitute all or part of an internal body part, including contiguous tissue, or replace all or part of the function of a permanently inoperative or malfunctioning body part and alleviate functional loss or impairment due to an illness, injury or congenital defect. Prosthetic devices do not include dental prosthetics. This plan covers the following prosthetic devices as required under R.I. General Law § 27-20-52: • prosthetic appliances such as artificial limbs, breasts, larynxes and eyes; • replacement or adjustment of prosthetic appliances if there is a change in your medical condition or if the device is not functional, no longer under warranty and cannot be repaired; • devices, accessories, batteries and supplies necessary for prosthetic devices; • orthopedic braces except corrective shoes and orthotic devices used in connection with footwear; and • breast prosthesis following a mastectomy, in accordance with the Women’s Health and Cancer Rights Act of 1998 and R.I. General Law 27-20-29. The prosthetic device must be ordered or provided by a physician, or by a provider under the direction of a physician. When you are prescribed a prosthetic device as an inpatient and it is billed by a provider other than the hospital where you are an inpatient, the outpatient benefit limit will apply. Enteral Formulas or Food (Enteral Nutrition) Enteral formula or food is nutrition that is absorbed through the intestinal tract, whether delivered through a feeding tube or taken orally. Enteral nutrition is covered when it is the sole source of nutrition and prescribed by the physician for home use. In accordance with R.I. General Law §27-20-56, this plan covers enteral formula taken orally for the treatment of: • malabsorption caused by Crohn’s Disease; • ulcerative colitis; • gastroesophageal reflux; • chronic intestinal pseudo obstruction; and • inherited diseases of amino acids and organic acids. Food products modified to be low protein are covered for the treatment of inherited diseases of amino acids and organic acids. Preauthorization may be required. The amount that you pay may differ depending on whether the nutrition is delivered through a feeding tube or taken orally. When enteral formula is delivered through a feeding tube, associated supplies are also covered. Hair Prosthesis (Wigs) This plan covers hair prosthetics (wigs) worn for hair loss suffered as a result of cancer treatment in accordance with R.I. General Law § 27-20-54 and subject to the benefit limit and copayment listed in the Summary of Medical Benefits. This plan will reimburse the lesser of the provider’s charge or the benefit limit shown in the Summary of Medical Benefits. If the provider’s charge is more than the benefit limit, you are responsible for paying any difference. Early Intervention Services (EIS) This plan covers Early Intervention Services in accordance with R.I. General Law §27- 20-50. Early Intervention Services are educational, developmental, health, and social services provided to children from birth to thirty-six (36) months. The child must be certified by the Rhode Island Department of Human Services (DHS) to enroll in an approved Early Intervention Services program. Services must be provided by a licensed Early Intervention provider and rendered to a Rhode Island resident. Members not living in Rhode Island may seek services from the state in which they reside; however, those services are not covered under this plan. Early Intervention Services as defined by DHS include but are not limited to the following: • speech and language therapy; • physical and occupational therapy; • evaluation; • case management; • nutrition; • service plan development and review; • nursing services; and • assistive technology services and devices.

  • Outpatient Dental Anesthesia Services This plan covers anesthesia services received in connection with a dental service when provided in a hospital or freestanding ambulatory surgical center and: • the use of this is medically necessary; and • the setting in which the service is received is determined to be appropriate. This plan also covers facility fees associated with these services.

  • Hospice Care If you have a terminal illness and you agree with your physician not to continue with a curative treatment program, this plan covers hospice care services received in your home, in a skilled nursing facility, or in an inpatient facility.

  • Child Care A. Employees employed as of March 1 who meet the following criteria shall be eligible for a lump sum payment each year. Eligible employees may apply for this payment between March 1 and April 15 of each year. Payment shall be made within thirty (30) days of receipt of the completed application. Any application received after April 15 will be considered on a case by case basis and shall not be arbitrarily rejected.

  • Therapist Availability Therapist’s office is equipped with a confidential voice mail system that allows Patient to leave a message at any time. Therapist will make every effort to return calls within 24 hours (or by the next business day), but cannot guarantee the calls will be returned immediately. Therapist is unable to provide 24-hour crisis service. In the event that Patient is feeling unsafe or requires immediate medical or psychiatric assistance, he/she should call 911, or go to the nearest emergency room.

  • Private Duty Nursing Services This plan covers private duty nursing services, received in your home when ordered by a physician, and performed by a certified home healthcare agency. This plan covers these services when the patient requires continuous skilled nursing observation and intervention.

  • Dental Care a. Dental Care for Members over age 19 is limited to the following:

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