Fee-for-Service Hospital and SNF Inpatient Services

Hospital and skilled nursing facility (SNF) services are covered on by Health Net plans. Hospital services are covered for unlimited days per admission. SNF standard coverage is limited to 100 days per benefit period according to Centers for Medicare and Medicaid Services (CMS)-defined standards as described in 42 CFR, section 409.60. Details on hospital and SNF inpatient services are as follows:

• Inpatient services in an acute care hospital are covered for unlimited days, subject to scheduled copayments
• Hospitalization of Health Net members is at the discretion of the participating physician group (PPG), if the member is affiliated with a capitated PPG that has responsibility for prudent hospital use or Health Net. Services can be in an acute, general or specialized care hospital
• Prior authorization is required for Health Net Medicare Advantage (MA) PPO members accessing the in-network level of coverage for all elective inpatient admissions
• Care in a semi-private room of two or more beds is covered. Special treatment units licensed by the state, such as intensive or coronary care units, are also covered, subject to scheduled copayments
• Benefits for hospital care are limited to the hospital's most common charge for a semi-private (two-bed) room. If the member elects to have a private room, the member is responsible for any amount over the semi-private room rate, plus the plan copayment. If the PPG or Health Net has authorized a private room as medically necessary, the member has no financial responsibility beyond the required copayment
• All inpatient services and supplies medically necessary and not specifically excluded for the condition necessitating confinement are covered, subject to the scheduled copayment

Inpatient Services in a Skilled Nursing Facility

Standard coverage for inpatient services in a SNF is limited to 100 days per benefit period (refer to the specific plan chart in the Schedule of Benefits for exceptions). To count as part of the basic 100-day SNF benefit, the member must be in a Medicare-certified facility.

The Medicare provisions governing qualification for skilled nursing benefits (for example, prior three-consecutive-day hospitalization within 30 days of SNF admission) do not apply to Health Net MA members. Although the Health Net MA plan waives the requirement of three-day hospitalization preceding admission to a SNF, the member's days in the SNF are counted towards the required 100-day maximum as long as the member is in a Medicare-certified facility.

Prior to the termination of SNF services, the valid written notice of the decision to terminate covered services is issued no later than two days before the proposed end of the services. If the member's services are expected to be fewer than two days in duration, the member is notified at the time of admission to the facility. A member who receives advance notice and agrees to the termination of SNF services earlier than 2 days, may waive the continuation of services.

Health Net and its delegated participating physician groups (PPGs) must provide medically necessary coverage of post-hospital extended care services to members through a home skilled nursing facility (SNF) according to the following:

• The member elects to receive the covered services through the home SNF
• The home SNF either has a contract with Health Net or the PPG, or the SNF agrees to accept substantially similar payment under the same terms and conditions that apply to contracting SNFs

A home SNF is defined as:

• The SNF in which the member resided at the time of admission to the hospital preceding the receipt of post-hospital extended care services
• A SNF that is providing post-hospital extended care services through a continuing care retirement community in which the member was a resident at the time of admission to the hospital. A continuing care retirement community is an arrangement under which housing and health-related services are provided (or arranged) through an organization for the enrollee under an agreement that is effective for the life of the enrollee or for a specified period
• The SNF in which the spouse of the enrollee is residing at the time of discharge from the hospital. The term spouse includes individuals of the same sex who are lawfully married under the laws of the state, as well as individuals of the same sex who are domiciled in a state that recognizes their relationship as a marriage

The post-hospital extended care scope of services, cost-sharing, and access to coverage provided by the home SNF is to be no less favorable to the member than post-hospital extended care services coverage that would be provided to a member by a SNF that would be otherwise covered under the plan. For MA PPO members, the in-network cost-sharing applies.

Health Net does not require a prior qualifying hospital stay before a medically necessary admission to a SNF. In applying the above definition of home SNF, refer to wherever the member resided immediately before admission for extended care services.