2023 Blue Cross and Blue Shield Service Benefit Plan - FEP Blue Focus
Section 5(c). Services Provided by a Hospital or Other Facility, and Ambulance Services
Page 77
Section 5(c). Services Provided by a Hospital or Other Facility, and Ambulance Services
Page 77
Benefit Description
Residential Treatment Center (cont.)
Note: Residential treatment center benefits are not available for facilities licensed as skilled nursing facilities, group home, halfway house or similar type facilities.
You Pay
All charges
Residential Treatment Center (cont.)
- Outdoor residential programs
- Outward Bound programs
- Personal comfort items, such as guest meals and beds, phone, television, beauty and barber service
- Services provided outside of the provider’s licensure/scope of practice
Note: Residential treatment center benefits are not available for facilities licensed as skilled nursing facilities, group home, halfway house or similar type facilities.
You Pay
All charges
Benefit Description
Extended Care Benefits/Skilled Nursing Care Facility Benefits
There are no benefits for admissions to an extended care or skilled nursing facility.
You Pay
All charges
Extended Care Benefits/Skilled Nursing Care Facility Benefits
There are no benefits for admissions to an extended care or skilled nursing facility.
You Pay
All charges
Benefit Description
Benefits are available for the following covered services when provided as outpatient services and billed by a skilled nursing facility:
You Pay
Preferred facilities: 30% of the Plan allowance (deductible applies)
Non-preferred facilities (Member/Non-member): You pay all charges
Benefits are available for the following covered services when provided as outpatient services and billed by a skilled nursing facility:
- Oxygen
You Pay
Preferred facilities: 30% of the Plan allowance (deductible applies)
Non-preferred facilities (Member/Non-member): You pay all charges
Benefit Description
Benefits are available for the following covered professional services when provided as outpatient services and billed by a skilled nursing facility:
You Pay
Preferred: $25 copayment per visit (no deductible)
Non-preferred (Member/Non-member): You pay all charges
Note: You pay 30% of the Plan allowance (deductible applies) for agents, drugs, and/or supplies administered or obtained in connection with your care. (See page 128 for more information about “agents.”)
Benefits are available for the following covered professional services when provided as outpatient services and billed by a skilled nursing facility:
- Cognitive rehabilitation therapy, limited to 25 visits per calendar year, regardless of the provider billing the service
- Physical therapy, occupational therapy, or speech therapy or a combination of all three (regardless of the provider or facility billing for the services) limited to 25 visits per person, per calendar year
You Pay
Preferred: $25 copayment per visit (no deductible)
Non-preferred (Member/Non-member): You pay all charges
Note: You pay 30% of the Plan allowance (deductible applies) for agents, drugs, and/or supplies administered or obtained in connection with your care. (See page 128 for more information about “agents.”)
Benefit Description
Not covered:
You Pay
All charges
Not covered:
- Inpatient room and board billed by a skilled nursing facility
- Phone; television; personal comfort items, such as guest meals and beds, beauty and barber services, recreational outings/trips, stretcher or wheelchair transportation; non-emergent ambulance transport that is requested beyond the nearest facility adequately equipped to treat the member’s condition, by patient or physician for continuity of care or other reason; custodial or long-term care (see Definitions), and domiciliary care provided because care in the home is not available or is unsuitable.
You Pay
All charges
Benefit Description
Hospice Care
Hospice care is an integrated set of services and supplies designed to provide palliative and supportive care to members with a projected life expectancy of six months or less due to a terminal medical condition, as certified by the member’s primary care provider or specialist.
You Pay
See pages 78-79
Hospice Care
Hospice care is an integrated set of services and supplies designed to provide palliative and supportive care to members with a projected life expectancy of six months or less due to a terminal medical condition, as certified by the member’s primary care provider or specialist.
You Pay
See pages 78-79