CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Skilled nursing facility / nursing facility care services — Coverage Criteria

Defines coverage, authorization, documentation, and coding requirements for skilled nursing facility (SNF) and nursing facility care for Neighborhood Health Plan of Rhode Island members across Medicaid, Commercial, and INTEGRITY products.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicySkilled nursing facility / nursing facility care services — Coverage Criteria

Policy CodePolicy N/A

Change TypeAuthorization and LTSS waiver requirement updates

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization for all INTEGRITY admissions and notify Utilization Management of admission, discharge, level changes, or status expirations.

SourceLink

POLICY UPDATE CHANGES

Added authorization language to prerequisite section.

Updated INTEGRITY Coverage Limitations and Exclusions to include LTSS waiver requirements.

Added custodial care coding grid and added to claims submission section.

30 daysRHP/RHE inpatient SNF stay coverage

365INTEGRITY combined skilled + custodial limit

90LTSS waiver trigger (INTEGRITY)

First 30 daysHospice coverage in nursing home

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Coverage Criteria by Product and Service

Product-specific coverage criteria

Coverage by product:

Medicaid SNF Coverage: Skilled nursing facility/nursing facility care services are covered for members while inpatient at a skilled nursing facility. Custodial and skilled levels of care (levels 1-4) are covered; admission to an in-network facility is required unless the network does not have the appropriate setting for the member.

Medicaid RHP/RHE specific: RHP and RHE members may stay up to 30 consecutive days in a SNF at skilled or custodial level; stays longer than 30 days result in disenrollment from RHP/RHE and enrollment in Medical Assistance.<=30 days

Commercial SNF Coverage: Care in a skilled nursing facility is covered when the network PCP refers the member to skilled nursing services, the member’s condition requires skilled nursing, skilled rehabilitation, or skilled nursing observation, and the services are required on a daily basis. Custodial, rest care, day care, or non-skilled care in any facility is not covered.

INTEGRITY SNF Coverage: Skilled nursing facility/nursing facility care services are covered for members while inpatient during an approved admission; skilled levels 1-4 are covered. Admission to an in-network facility is required unless the network does not have the appropriate setting. Skilled therapy services are reimbursed separately for INTEGRITY members in custodial care. All admissions require prior authorization and must meet medical necessity criteria.prior authorization required

INTEGRITY custodial LTSS requirement: If a member will need custodial care in a SNF longer than 90 days, the facility should submit an LTSS waiver application; Neighborhood may deny claims after 90 days if no LTSS waiver application has been submitted or if the application has been denied by EOHHS.>90 days

Coverage for skilled nursing facility (SNF) services varies by product. For Medicaid: RHP/RHE members may remain inpatient up to 30 consecutive days in a SNF or nursing facility at skilled or custodial levels; stays beyond 30 days result in disenrollment from RHP/RHE and enrollment in Medical Assistance. RIte Care covers all skilled levels of care when ordered by a health plan physician. Skilled nursing facility services are explicitly non-covered for Extended Family Planning (EFP) members.

For Commercial products: all SNF admissions ordered by a network physician must meet medical necessity criteria and admission to an in‑network facility is required unless an appropriate in‑network setting is unavailable. Custodial care, rest care, day care, or other non‑skilled care in any facility is not covered for Commercial members.

For INTEGRITY members: admissions must meet medical necessity and require prior authorization (see authorization section). Skilled levels of care (levels 1–4) are covered when the admission is approved by the plan and in‑network placement is expected unless unavailable.

Neighborhood does not cover custodial care, rest care, day care, or other non‑skilled care in any facility. This exclusion applies across facility types including convalescent homes, nursing homes, homes for the aged, halfway houses, and other residential facilities.

For Medicaid specifically, although custodial levels may be part of a covered stay for certain members (for example RHP/RHE up to 30 days), skilled therapy services are not covered for members in custodial care, and Extended Family Planning (EFP) members have SNF services listed as non‑covered.

Admission Criteria for SNF/NF

SNF — admission criteria

Admission requirements: Admissions must be ordered by a network physician, meet medical necessity criteria, and for INTEGRITY require prior authorization; admission to an in‑network skilled nursing facility is required unless the network does not have the appropriate skilled nursing facility setting for the member.

Continued Stay / Ongoing Medical Necessity

SNF — continued stay criteria

Continued stay and extended custodial care: Continued stay limits and requirements vary by product: RHP/RHE members are limited to 30 consecutive inpatient days in a SNF (after which EOHHS disenrolls and enrolls the member in Medical Assistance); INTEGRITY members have coverage up to 365 days when ordered by a health plan physician, but if custodial care will extend beyond 90 days the facility should submit an LTSS waiver application or Neighborhood may deny claims after 90 days.RHP/RHE <=30 days; INTEGRITY custodial >90 days triggers LTSS waiver

Discharge Criteria

The facility must notify Neighborhood's Utilization Management Department of any discharge. Notification of admission, discharge, level of care changes, or expirations is the facility's responsibility regardless of the length of stay.

Documentation supporting the discharge must be available; Neighborhood may request medical records to verify the discharge services and medical necessity. Records must support billed services and meet applicable documentation standards.

Coverage Day Limits and Product Differences

SNF — day limits (RHP/RHE 30 days; INTEGRITY up to 365 days with plan physician order and LTSS rules)

RHP / RHE day limitUp to 30 consecutive days inpatient at skilled or custodial level; members with stays >30 days are disenrolled from RHP/RHE and enrolled in Medical Assistance.

INTEGRITY combined skilled/custodial limitCoverage up to 365 days per year when ordered by a health plan physician; not subject to stop-loss provisions.

INTEGRITY extended custodial ruleIf custodial care in a SNF is expected >90 days, facility should submit an LTSS waiver application; Neighborhood may deny claims after 90 days if no waiver submitted or if denied by EOHHS.

Custodial care extended stay LTSS waiver trigger (> 90 days for INTEGRITY)

Trigger thresholdCustodial care in a skilled nursing facility expected to exceed 90 days (INTEGRITY).

Required action

Provider Responsibilities, Authorization, and Documentation

Prior Authorization

Prior Authorization Required

All admissions, as ordered by a network physician, must meet medical necessity criteria. Notify Neighborhood's Utilization Management (UM) Department of any changes to the member's status (admission, discharge, level of care change, expiration, etc.) regardless of the length of time of the status change. For INTEGRITY admissions, prior authorization is required — notify UM on admission, discharge, level changes, expirations.

Notify UM of admission, discharge, level changes, expirations
INTEGRITY admissions require prior authorization

Prior Authorization

Prior authorization / in‑network admission expectations

All SNF admissions ordered by a network physician must meet medical necessity criteria. Custodial care, rest care, day care, or non-skilled care in any facility is not covered. For INTEGRITY members coverage includes skilled and custodial levels of care when ordered by a health plan physician up to 365 days a year and is not subject to stop loss provisions.

In-network admissions must be medically necessary

Coding Grid and Billing Codes

Definitions and Key Terms

Skilled nursing facility/nursing facility care services — definition and components

DefinitionServices rendered to a member while inpatient at a skilled nursing facility or nursing facility, which may include skilled nursing and/or rehabilitation care, room and board, therapies (physical, occupational, speech), medical social services, pharmaceuticals, durable medical equipment, additional nursing and personal care, and other necessary routine services.

Covered levels of care (Medicaid)Custodial and skilled levels of care (levels 1–4) are covered for members while inpatient at a skilled nursing facility; admission to an in‑network facility is required unless appropriate setting unavailable.

Hospice in nursing home (RHP/RHE)Neighborhood covers the first 30 days of hospice care delivered in a nursing home for RHP and RHE members; beginning day 31, Medical Assistance FFS reimburses hospice care and room & board.

Custodial care — definition and coverage interaction with skilled services

DefinitionCustodial care refers to non‑skilled care provided in a facility (assistance with activities of daily living, routine supervision), distinct from skilled nursing or rehabilitation services.

Background

Skilled nursing facility care comprises services provided to an inpatient in a SNF or nursing facility and typically includes skilled nursing, rehabilitation therapies, medical social services, pharmaceuticals, durable medical equipment, room and board, and other routine inpatient services. Coverage distinguishes between skilled and custodial care and varies by product (Medicaid, Commercial, INTEGRITY).

For payers and providers, the key operational distinction is that skilled services must be medically necessary and often required on a daily basis, whereas custodial care (non‑skilled) is excluded in many circumstances or reimbursed differently depending on product rules.

Revision History

2025-11-07policy_reviewLatest

Policy reviewed on 2025-11-07 with no content changes recorded in the source document.

2025-06-09material_revision

Updated INTEGRITY Coverage Limitations and Exclusions to include LTSS waiver requirements for custodial stays exceeding 90 days, and Neighborhood may deny claims after 90 days if no LTSS waiver application is submitted or if denied by EOHHS.

2024-12-11