Benefits - Inpatient Services

Benefits

Primary and Preventive Health Services | Outpatient Services | Inpatient Services

Inpatient Services

The following services are covered on an inpatient basis when:

Medically necessary;
Provided or referred by your primary physician; and
Preapproved by Keystone, where specified.

NOTE:

All inpatient stays must be preapproved by Keystone at least five working days before admission, except for an Emergency admission.

Allergy Testing and Treatment
Allergy tests, testing materials and treatment.

Anesthesia
Anesthesia services when performed in connection with covered services.

Autologous Blood Drawing/Storage/Transfusion
Benefits are available for services provided in conjunction with a planned episode of care that requires transfusion.

Cardiac Rehabilitation Therapy (Preapproval)

Chemotherapy (Preapproval for administration in a facility)

Diabetic Supplies (Preapproval)
Benefits are provided for equipment and supplies which include blood glucose monitors, monitor supplies, insulin, injection aids, syringes, insulin infusion devices, and pharmacological agents for controlling blood sugar and orthotics.

Dialysis
Dialysis services are covered until you become eligible for Medicare coverage of dialysis. Keystone dialysis benefits will then be coordinated with such Medicare coverage.

Hospice Care (Preapproval)
Palliative and supportive services provided to a terminally ill member through a hospice program by a hospice provider given on an outpatient basis or in the member’s home in accordance with a plan of treatment preapproved by Keystone.

Hospital Services (Preapproval)
Benefits are provided for unlimited days in a hospital.

The following inpatient hospital services are covered hospital services:

	A.		Semi-private room and board (other accommodations if medically necessary);
	B.		General nursing care;
	C.		Prescription drugs, medications, and biologicals (Keystone reserves the right to apply age, gender and dispensing limits as conveyed by the FDA or FutureScripts^® Pharmacy and Therapeutics Committee for certain prescription drugs.);
	D.		Use of operating room and related services;
	E.		Use of intensive care or cardiac units and related services;
	F.		Oxygen services;
	G.		Administration of whole blood and blood plasma;
	H.		Other medically necessary supplies and equipment;
	I.		Diagnostic laboratory and x-ray; and
	j.		Rehabilitation therapy services.

Mastectomy Care
Benefits are provided for covered services following a mastectomy on one breast or both breasts for:

	A.		Reconstruction of the breast on which the mastectomy has been performed;
	B.		Surgery and reconstruction of the other breast to produce a symmetrical appearance; and
	C.		Prostheses and physical complications for all stages of mastectomy, including lymphedemas.

Medical Foods (Preapproval)
Benefits are provided for nutritional products which are specifically formulated for the therapeutic treatment of phenylketonuria, branch-chain ketonuria, galactosemia, and homocystinuria. These foods may be taken by mouth and may not be a person’s sole source of nutrition. This treatment must be administered by your primary care physician or referred specialist.

Newborn Care
Care of a newborn child, born to an enrolled female adultBasic member, is covered for a period of up to 31 days following birth. Such care shall include routine nursery care, prematurity services, preventive health care services, as well as coverage for injury or sickness, including the necessary care and treatment of medically diagnosed congenital defects and birth abnormalities. To ensure continuity of care for the newborn, the mother of the newborn should fill out an application for Medicaid or CHIP coverage as soon as the baby is born. The social services department at the hospital or the Caring Foundation can assist the mother of the newborn with this process.

Obstetrical Care
Obstetrical care, including prenatal and postnatal care, complications of pregnancy and childbirth.

Maternity care inpatient benefits will be provided for a minimum of 48 hours following a vaginal delivery. For a cesarean delivery, the minimum stay is 96 hours. This applies to the adultBasic member and her newborn child, except as otherwise approved by Keystone.

Oral Surgery (Preapproval in a facility)
Limited oral surgical procedures when required in connection with the following:

	A.		The removal or exposure of teeth which are partially or totally covered by bone;
	B.		Accidental injury to the jaw or structures contiguous to the jaw or injury related to sound natural teeth;
	C.		The correction of a non-dental physiological condition which has resulted in a severe functional impairment; or
	D.		Treatment for tumors and cysts requiring pathological examination of the jaws, cheeks, lips, tongue, roof and floor of the mouth.

Organ Transplants (Preapproval)
Benefits are provided for transplant services for a member recipient. Covered services include procedures that are generally accepted as not experimental or investigative by medical organizations of national reputation. These organizations are recognized by Keystone as having special expertise in the area of medical practice involving transplant procedures.

In addition, the determination of medical necessity for transplants will take into account the proposed procedure’s suitability for the potential recipient and the availability of an appropriate facility for performing the procedure.

If a member is an organ donor, expenses related to organ donation are not covered unless the recipient is also a Keystone member. If the recipient is a member, covered expenses of a member donor are:

Removal of the organ;
Preparatory pathologic and medical examinations; and
Post-surgical care.

Physician Care
Benefits are provided for covered services received during a preapproved inpatient admission.

Prosthetic Devices (Preapproval)
Benefits will be provided for the initial purchase and fitting (per medical episode) of prosthetic devices and supplies (except dental prosthetics), which replace all or part of an absent body organ and its adjoining tissues or replace all or part of the function of a permanently useless or malfunctioning body organ.

Pulmonary Rehabilitation Services (Preapproval)
Benefits are limited to treatment received within a 60 consecutive day period provided during a covered inpatient admission.

Radiation Therapy
Radiation therapy services when provided during a covered inpatient admission.

Reconstructive Surgery (Preapproval)
Covered services available when medically necessary following a covered surgical procedure.

Rehabilitation Therapy Services (Preapproval)
Inpatient rehabilitation therapy provided by a hospital, a skilled nursing facility, or a rehabilitation hospital. Services are provided for 60 days per episode for each of the following therapies:

Occupational;
Physical;
Hand; and
Speech.

Covered services include:

	A.		All therapeutic exercise, testing and soft tissue mobilization;
	B.		All physical modalities utilizing heat, cold, light, air, electricity, sound, all forms of water therapy, massage, mobilization and mechanical stimulation;
	C.		Checking out the fitting of splints, braces, prostheses and other orthotic devices (orthotic devices are not covered unless stated otherwise); and
	D.		Reconditioning, including work reconditioning.

Respiratory Therapy (Preapproval)Respiratory therapy services when provided by a licensed respiratory therapist.

Skilled Nursing Facility Services (Preapproval)
Benefits are provided for care in a skilled nursing facility for as long as the services are not considered custodial or domiciliary care. Benefits are limited to semi-private accommodations (or an allowance equal to this rate which may be applied to private accommodations). During a skilled nursing facility admission, members of Keystone’s patient care management team are monitoring your stay to assure that a plan for your discharge is in place. This is to make sure that you have a smooth transition from the facility to home or other setting. A Keystone case manager will work closely with your primary care physician or referred specialist to help with your discharge and if necessary, arrange for other medical services.

If your primary care physician or referred specialist agree with Keystone that continued stay in a skilled nursing facility is no longer required, you will be notified in writing of this decision. If you remain in the facility after notification, the facility has the right to bill you after the date of the notification. You may appeal this decision through the grievance process.

Specialist Services
Covered services provided by referred specialists. Services resulting from referrals to non-participating providers will be covered when the referral is issued by your primary care physician and preapproved by Keystone. The referral is valid for an enrolled member for 90 days from the date of issue. Self-referrals are excluded, except for emergency and routine gynecological and obstetrical care. Additional covered services recommended by the referred specialist will require another written referral from your primary care physician.

Surgery (Preapproval)
Surgical services required for treatment of disease or injury.