As communicated through Partners in Health UpdateSM on
December 20, 2017, the Federal Employee Program (FEP) Skilled Nursing Facility
(SNF) benefits were expanded on January 1, 2018, to include all Standard Option
members. FEP recently clarified its benefits for members with Medicare as a
secondary payor, as follows.
When Medicare Part A is NOT a member’s
primary payor
When Medicare Part A is not a member’s primary payor (this includes
members with Medicare as a secondary payor), FEP covers SNF inpatient care for
a maximum of 30 days annually, when the member can be expected to benefit from
short-term SNF services with a goal of returning home.
The following criteria must be met:
- Medical necessity for SNF/sub-acute level of care.
- The member must enroll in case management prior to admission to the SNF
(signed consent required) and actively participate in case management both
prior to and during admission to the SNF.
- The member must obtain precertification for SNF services prior to admission
(including overseas care).
- The payor must approve the preliminary treatment plan prior to SNF
admission. The treatment plan must include proposed therapies and document the
need for inpatient care.
- The member must participate in all treatment and care planning activities,
including discharge planning/transition to home.
When Medicare Part A IS a member’s
primary payor
FEP Standard Option provides limited secondary benefits when Medicare Part A
has made a payment as the primary payor. When Medicare Part A is the primary
payor, the above-mentioned criteria for case management, precertification, et
al. do not apply.
Note: FEP members with Basic Option do not have a
SNF/sub-acute benefit; however, Independence can facilitate their transition to
a lower level of care. Please call Customer Service at
1-800-ASK-BLUE for more information.
If you have any
questions, please contact Sharon Evans at 215-241-2877 or Tracey Carter
at 215-241-9739.