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Medical Care and Plan Providers
Hospital Care, SNF Care and Other Services
Hospital Care
If you need hospital care, we will arrange covered services for you. Covered services are listed in the Benefits Chart of your Evidence of Coverage under the heading "Inpatient Hospital Care". You can view the Evidence of Coverage on this website. Essence contracts with a number of hospitals in the service area. The Provider Directory lists which hospitals each physician uses. All routine hospital care must be delivered by contracted/network hospitals. (The term "hospital" does not include facilities that mainly provide custodial care, such as convalescent nursing homes or rest homes. By "custodial care", we mean help with bathing, dressing, using the bathroom, eating, and other activities of daily living.)
How does your prescription drug coverage work if you go to a hospital or skilled nursing facility?
Please see "Paying for Your Prescription Drugs" in the Part D section of this website.
What happens if you join or drop out of Essence during a hospital stay?
If you either join or leave Essence during an inpatient hospital stay, special rules apply to your coverage for the stay and to what you owe for this stay. If this situation applies to you, please call Member Services at the numbers shown below.
Skilled Nursing Facility Care (SNF Care)
If you need skilled nursing facility care, we will arrange these services for you. Covered services are listed in the Benefits Chart of your Evidence of Coverage under the heading "Skilled Nursing Facility Care".
A skilled nursing facility is a place that provides skilled nursing and/or skilled rehabilitation services. Skilled nursing care includes services that require the skills of a licensed nurse to perform or supervise. Skilled rehabilitation services include physical therapy, speech therapy, and occupational therapy. It can be a separate facility or part of a hospital or other health care facility. The term "skilled nursing facility" does not include places that mainly provide custodial care, such as convalescent nursing homes or rest homes. Skilled nursing services must be provided in SNF's that are contracted with Essence and therefore part of the Essence network.
To be covered, the care you get in an SNF must meet certain requirements.
To be covered, you must need daily skilled nursing or skilled rehabilitation care, or both. If you do not need daily skilled care, other arrangements for care would need to be made. Note that medical services and other skilled care will still be covered when you start needing less than daily skilled care in the SNF.
Stays that provide custodial care ONLY are not covered.
"Custodial care" is care for personal needs rather than medically necessary needs. Custodial care includes help with walking, dressing, bathing, eating, preparation of special diets, and taking medication. Custodial care is not covered by Essence unless it's provided as other care you are getting in addition to daily skilled nursing care and/or skilled rehabilitation services.
There are benefit period limitations on coverage of SNF care.
Inpatient skilled nursing facility coverage is limited to 100 days each benefit period. A "benefit period" begins on the first day you go to a Medicare-covered inpatient hospital or SNF. The benefit period ends when you have not been an inpatient at any hospital or SNF for 60 days in a row. If you go to a hospital (or SNF) after one benefit period has ended, a new benefit period begins. There is no limit to the number of benefit periods you can have.
Please note that after your SNF day limits are used up, physician services and other medical services will still be covered. These services are listed in the Benefits Chart under the heading "Inpatient services (when the hospital or SNF days are not or are no longer covered)".
In some situations, you may be able to get care in an SNF that is not a plan provider.
Generally, you will get your skilled nursing facility care from SNF's that are plan providers for Essence. However, if certain conditions are met, you may be able to get your skilled nursing facility care from an SNF that is not a plan provider. One of the conditions is that the SNF that is not a plan provider must be willing to accept Essence's rates for payment. At your request, we may be able to arrange for you to get your SNF care from one of the facilities listed below. (In these situations, the facility is called a "Home SNF".)
- A nursing home or continuing care retirement community where you were living right before you went to the hospital (as long as the place gives skilled nursing facility care).
- A SNF where your spouse is living at the time you leave the hospital.
What happens if you join or drop out of Essence during an SNF stay?
If you either join or leave Essence during an SNF stay, please call Member Services at the numbers shown below. Member Services can explain how your services are covered for this stay and what you owe to Essence, if anything, for the periods of your stay when you were not a plan member.
Home Health Agency Care
Home health care is skilled nursing care and certain other health care services that you get in your home for the treatment of an illness or injury. Covered services are listed in the Benefits Chart of your Evidence of Coverage under the heading "Home Health Care". If you need home health care services, we will arrange these services for you if certain requirements are met.
Hospice Care, Organ Transplants, Participating in a Clinical Trial, and Care in Religious Non-medical Health Care Institution
You can read more about the following services from the Evidence of Coverage:
- Hospice care for people who are terminally ill
- Organ transplants
- Participating in a clinical trial
- Care in religious non-medical health care institution