Inpatient Care. You can get inpatient care in a specialized rehabilitative unit of a hospital. If you are already an inpatient, this benefit will start when your care becomes mainly rehabilitative. You must get prior authorization from us before you get inpatient treatment. See Prior Authorization for details. This plan covers inpatient rehabilitative therapy only when it meets these conditions: You cannot get these services in a less intensive setting The care is part of a written plan of treatment prescribed doctor Outpatient Care This plan covers outpatient rehabilitative services only when it meets these conditions: This plan covers the following types of outpatient therapy: Physical, speech, hearing and occupational therapies Chronic pain care Cardiac and pulmonary therapy Cochlear implants Home medical equipment, medical supplies and devices This benefit does not cover: Recreational, vocational or educational therapy Exercise or maintenance-level programs Social or cultural therapy Treatment that the ill, injured or impaired member does not actively take part in Gym or swim therapy Custodial care Skilled Nursing Facility and Care This plan covers skilled nursing facility services. Covered services include room and board for a semi-private room, plus services, supplies and drugs you get while confined in a skilled nursing facility. Sometimes a patient goes from acute nursing care to skilled nursing care without leaving the hospital. When that happens, this benefit starts on the day that the care becomes primarily skilled nursing care. Skilled nursing care is covered only during certain stages of recovery. It must be a time when inpatient hospital care is no longer medically necessary, but care in a skilled nursing care facility is medically necessary. Your doctor must actively supervise your care while you are in the skilled nursing facility. We cover skilled nursing care provided after hospitalization at a long-term care facility (see Definitions) where you were residing at immediately prior to your hospitalization when your primary care provider determines that the medical care you need can be provided at that facility, and that facility satisfies our standards, terms and conditions for long-term care facilities, accepts our rates and has all applicable licenses and certifications. You must get prior authorization from us before you get treatment. See Prior Authorization for details. Home Medical Equipment (HME), Supplies, Devices, Prosthe...
Inpatient Care. Covered services include: • Room and board, general duty nursing and special diets • Doctor services and visits • Use of an intensive care or special care units • Operating rooms, surgical supplies, anesthesia, drugs, blood, dressing, durable medical equipment and oxygen • X-ray, lab and testing Outpatient Care Covered services include: • Operating rooms, procedure rooms and recovery rooms • Doctor services • Anesthesia • Services, medical supplies and drugs that the hospital provides for your use in the hospital • Lab and testing services billed by the hospital and done with other hospital services This benefit does not cover: • Hospital stays that are only for testing, unless the tests cannot be done without inpatient hospital facilities, or your condition makes inpatient care medically necessary • Any days of inpatient care beyond what is medically necessary to treat the condition Mental Health, Behavioral Health and Substance Abuse This plan covers mental health care and treatment for alcohol and drug dependence. This plan will also cover alcohol and drug services from a state- approved treatment program. You must also get these services in the lowest cost type of setting that can give you the care you need. When medically appropriate, services may be provided in your home. This plan will comply with federal mental health parity requirements. Some services require prior authorization. See Prior Authorization for details.
Inpatient Care. An overnight stay in a hospital, hospice, or residential medical care facility. • Inpatient care includes any period of incapacity or any subsequent treatment in connection with the overnight stay. Continuing Treatment by a Health Care Provider (any one or more of the following) Incapacity Plus Treatment: A period of incapacity of more than three consecutive, full calendar days, and any subsequent treatment or period of incapacity relating to the same condition, that also involves either: o Two or more in-person visits to a health care provider for treatment within 30 days of the first day of incapacity unless extenuating circumstances exist. The first visit must be within seven days of the first day of incapacity; or, o At least one in-person visit to a health care provider for treatment within seven days of the first day of incapacity, which results in a regimen of continuing treatment under the supervision of the health care provider. For example, the health provider might prescribe a course of prescription medication or therapy requiring special equipment.
Inpatient Care. An inpatient is defined as a patient who receives medical services at a medical facility and the treating physician has written an order to admit him/ her as an inpatient. A patient is an inpatient starting the day he/she is formally admitted to a medical facility. The last inpatient day is the day before the patient is discharged.
Inpatient Care. 184.108.40.206.1 Members enrolled in a CMO that are hospitalized in an inpatient facility will remain the responsibility of that CMO until they are discharged from the facility, even if they change to a different CMO, or they become eligible for coverage under FFS Medicaid during their inpatient stay.