Readmission policy for State Health Benefits Program (SHBP)/School Employees’ Health Benefits Program (SEHBP) members

We work closely with the SHBP and SEHBP to improve the quality of care, lower the costs for their members and avoid hospital readmissions. With this in mind, SHBP/SEHBP has asked us to change how we reimburse hospitals and providers for hospital readmissions of SHBP/SEHP members. Effective October 1, 2021, we will no longer reimburse providers for any health care costs related to a hospital readmission for SHBP and SEHBP members that happens less than 30 calendar days from the first admission and the readmission is for the same or similar condition, diagnosis or related reason. This change is based on the SHBP/SEHBP Inpatient Readmission Reimbursement administrative policy guidelines.

Horizon will review all hospital readmission cases to determine if the readmissions are:

• Medically necessary
• A result of premature discharge of the patient from the same hospital
• A result of a lack of coordination in the transition of care between the acute care facility and the outpatient setting
• Due to services that could have been provided during the initial admission

This policy will have no direct impact on our members’ financial responsibility for the care provided, and members will not be charged for hospital readmissions. The full policy is available on the Administrative Policies section at HorizonBlue.com/provider.