Skilled Nursing Facility
Security Health Plan BadgerCare and SSI members may use any skilled nursing facility located in Wisconsin that is Medicaid certified. Security Health Plan does not contract with skilled nursing facilities for BadgerCare and SSI.
Security Health Plan BadgerCare and SSI members have coverage for medically necessary skilled nursing facility services with no day limit (please review the Enrollment information section below). Services must meet requirements of DHS 107.09(2) and 109.07(4)(e). Covered nursing home services are medically necessary services provided by a certified nursing home to an inpatient and prescribed by a physician in a written plan of care. In determining whether a nursing service is skilled, the following criteria will be applied:
- Where the service prescribed for a member is such that it can be safely and effectively performed only by or under the direct supervision of technical or professional personnel, the service shall constitute a skilled service
- The restoration potential of a patient shall not be the deciding factor in determining whether a service is to be considered skilled or nonskilled. Even where full recovery or medical improvement is not possible, skilled care may be needed to prevent, to the extent possible, deterioration of the condition or to sustain current capacities. For example, even though no potential for rehabilitation exists, a terminal cancer patient may require skilled services as defined in this paragraph and par. (f)
- A service that is ordinarily nonskilled shall be considered a skilled service where, because of medical complications, its performance or supervision or the observation of the patient necessitates the use of skilled nursing or skilled rehabilitation personnel. For example, the existence of a plaster cast on an extremity generally does not indicate a need for skilled care, but a patient with a preexisting acute skin problem or with a need for special traction of the injured extremity might need to have technical or professional personnel properly adjust traction or observe the patient for complications. In these cases, the complications and special services involved shall be documented by physician's orders and nursing or therapy notes.
Prior authorization requirements:
- Inpatient skilled nursing facility services do not require prior authorization for Security Health Plan BadgerCare and SSI members.
- Outpatient therapy performed in a skilled nursing facility requires prior authorization (place of service 32 or 33; bill type 22x or 23x). For more information on prior authorization requirements see Security Health Plan Authorization Page – Outpatient Therapy Treatment Initial or Outpatient Therapy Treatment Concurrent
Security Health Plan will reimburse providers at 100% of the Wisconsin Medicaid rate.
Effective for dates of service on or after Jan. 1, 2022, Security Health Plan will follow ForwardHealth guidance to pay nursing home claims using the Health Insurance Prospective Payment Systems (HIPPS) code to reimburse claims on an acuity-specific basis. Information can be found in the ForwardHealth Update 2021-22, “Nursing Home Acuity-Based Billing.”
HIPPS codes must be submitted on the UB-04 Form Locator 44 (HCPCS/Rare/HIPPS Code). For non-developmentally disabled (DD) in-house residents, claims must be submitted with the revenue code 0022 and the appropriate HIPPS code for the patient’s acuity. For circumstances where a HIPPS code is unable to be determined, the default HIPPS code of ZZZZZ may be used but will be priced at the lowest possible reimbursement combination. Claims submitted without a HIPPS code or with an invalid HIPPS code will be denied.
There is no change to the billing requirements for claims submitted for non-DD bed-hold, DD in-house, or DD bed-hold.
A Security Health Plan BadgerCare Plus non-Childless Adult (non-CLA) member who has been in a nursing home for longer than 30 days will have their medical status code changed to an institutional code. This change will automatically disenroll them from the HMO. We encourage facilities to follow any DHS coverage requirements for stays beyond 30 days to ensure payment by DHS for days 31 and after.