Secondary Payer
means a plan that will determine your medical benefits
after the primary payer.
Sickness or Illness
is a person's illness, disease or pregnancy (including
complications). For a newborn child after birth,
but before release from a medical facility, sickness
also includes a congenital defect, a birth abnormality
or a premature birth.
Skilled Nursing Facility is a
facility that fully meets all of these tests:
1. It is licensed to provide for persons convalescing
from injury or sickness and provides professional
nursing services on an inpatient basis. These
services must be rendered by a Registered Nurse
(R.N.) or by a Licensed Practical Nurse (L.P.N.)
under the direction of a Registered Nurse. Physical
restoration services to assist patients to reach
a degree of body functioning to permit self-care
in essential daily living activities must be provided.
2. Its services are provided for compensation
from its patients and under the full-time supervision
of a physician or a Registered Nurse.
3. It provides 24-hours-a-day nursing services
by Licensed Practical Nurses, under the direction
of a full-time Registered Nurse.
4. It maintains a complete medical record on each
patient.
5. It has an effective utilization review plan.
6. It is not, other than incidentally, a place
for:
a. rest
b. the aged
c. drug addicts
d. care of mental disorders
e. alcoholics
f. the mentally retarded
g. custodial or educational care
7. It is approved and licensed by Medicare or
is accredited as a Skilled Nursing Facility by
the Joint Commission on Accreditation of Hospitals.
Social Worker is an individual
who is performing covered services within the lawful
scope of practice; is certified under Education
Law Article 154; and, in addition, has:
1. Six or more years of supervised post degree
experience in psychotherapy. For the purposes
of this Plan, the experience must be in the use
of verbal methods in interpersonal relationships
with the intent of assisting a person or persons
to modify attitudes and behavior which are intellectually,
socially, or emotionally maladaptive, under supervision,
satisfactory to the State Board of Social Work,
in a facility licensed or incorporated by an appropriate
governmental department providing services for
diagnosis or treatment of mental, nervous, or
emotional disorders or ailments; or
2. Six or more years post degree experience in
psychotherapy under the supervision; satisfactory
to the State Board of Social Work, of a psychiatrist;
a certified and registered psychologist; or a
social worker qualified for reimbursement under
Section 4303(n) or the New York Insurance Law;
or
3. A combination of the experience, specified
in (1.) and (2.) above, totaling six years, satisfactory
to the State Board of Social Work.
The social worker's name must appear on the list
of all certified social workers who meet these qualifications
as maintained by the State Board of Social Work.
Spell of Illness or Injury begins
separately on the first day the participant is admitted
to a hospital, birthing center or skilled nursing
facility; or the participant receives home health
care. A Spell of Illness ends when you have not
been confined in any hospital, birthing center or
skilled nursing facility, or received home health
care, for at least 90 consecutive days. An admission
due to an accident will be considered a separate
and distinct Spell of Illness or Injury. |
