Skip to Content

Provider Manual

Skilled Nursing Facility Care

Last Updated on October 01, 2019

Effective October 1, 2019, Centers of Medicare and Medicaid (CMS) implemented a new Skilled Nursing Patient-Driven Payment Model (PDPM).   PDPM is a fundamental shift from RUGs IV and will replace RUGs entirely for Medicare Part A payment to skilled nursing facilities.  Payment is based upon an array of patient characteristics, primarily medical information, associated with newly designed direct care components. 

Security Health Plan has implemented the new payment model to its skilled nursing facility Medicare Advantage contracts to stay compliant with Medicare Advantage contractual language and CMS reimbursement requirements.     

Additional information regarding the PDPPM can be found at the following locations.
  • Benefits are limited to the number of days specified in the member’s plan. Coverage is provided to members with a skilled nursing facility (SNF) benefit. The member's medical condition must also require daily nursing or therapy care for the same condition or diagnosis as the qualifying hospitalization. The patient must require daily skilled services as certified by the member’s physician. SNF must prior authorize skilled nursing facility admissions with naviHealth at (phone) 855-512-7002 or (fax) 855-847-7243. For more information about naviHealth click here.
  • Confinement in a swing bed in a hospital is considered the same as SNF confinement. Services require prior authorization and approval by Security Health Plan in order to be considered for coverage. Prior authorization is required by calling Security Health Plan at 1-800-548-1224 or by submitting a prior authorization.
  • Custodial care is excluded from coverage. This includes, but is not limited to, care provided by community based residential facilities (CBRF), intermediate care facilities (ICF), day care and group facilities, and residential hospice facilities 
  • To request a full version copy of a specific Security Health Plan Medical policy, call 1-800-548-1224 ext. 19671.