Public Statement:

Effective Date:

a)    This policy will apply to all services performed on or after the above Revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

Most QualChoice plans do not cover residential care; refer to your Benefit Summary. 

If your plan covers residential treatment for mental health and substance abuse disorders, see BI449.

For CHI covered enrollees see BI208

Residential facilities may be legally constituted to provide medical and other services to live-in residents. Programs that do not provide skilled medical services on a daily basis are not covered under any circumstances.  Examples of residential facilities include, but are not limited to:

• Substance abuse after-care facilities
• Spinal cord, brain injury, independent living facilities
• Adolescent psychiatric residential facility

Medical Policy Statement:

Residence in and care provided by a residential facility is typically not covered. Although residential facilities may be legally constituted to provide medical and other services to live-in residents, programs that do not provide skilled medical services on a daily basis are not covered. 

In certain cases, at the sole discretion of QualChoice, the care that is provided by a provider in a residential facility may be covered even if facility charges are not.  Preauthorization is required.

There may be specific cases that warrant creation of an exception to this policy, based on this care being an alternative to care at an acute or sub acute inpatient facility. All such cases should be referred to case management.

Application to Products:

Unless indicated otherwise, this policy applies to all QCA Health Plans, unless a specific limitation exists.  Consult individual plan sponsor benefit descriptions for self-insured plans.  In the event of a discrepancy between this policy and a self-insured customer’s benefit description, the benefits plan will be followed.  Applicable state mandates will be followed with respect to self-funded non-ERISA plans and fully insured plans.  Federal mandates will apply to all plans.