21. Hospitalization due to traumatic injury
A member will be considered eligible for a TSGLI benefit for hospitalization due to traumatic injury if the member has been hospitalized for 15 consecutive days* as a result of an injury other than a traumatic brain injury.
*Duration of hospitalization includes the dates on which a member is transported from the injury site to a hospital as defined in 42 U.S.C. 1395x(e) or skilled nursing facility as defined in 42 U.S.C. 13951-3(a), admitted to the hospital or facility, transferred between a hospital or facility, leave the hospital or facility for a therapeutic trip, and discharged from the hospital or facility.
Hospitalization is an inpatient stay in one of the following facilities:
- An inpatient acute care facility - provides care for a short duration, generally 30 days or less, to treat a serious injury, an episode of illness/disease, or the residuals of surgery, and meets the criteria listed below.
- An inpatient rehabilitation facility - a healthcare institution that meets federal criteria for Medicaid and Medicare reimbursement for inpatient rehabilitation, provides intensive rehabilitation to inpatients, and meets the criteria listed below.
- A skilled nursing facility - a healthcare institution that meets federal criteria for Medicaid and Medicare reimbursement for nursing care, provides skilled rehabilitative services and other related health services, and meets the criteria listed below.
- Any Armed Forces medical facility that is authorized to provide inpatient acute care, inpatient rehabilitation, or skilled nursing care to eligible service members.
The hospital facility must meet the following criteria:
- Accredited by the Joint Commission or its predecessor, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), or accredited or approved by a program of the qualified governmental unit in which such institution is located if the Secretary of Health and Human Services has found that the accreditation or comparable approval standards of such qualified governmental unit are essentially equivalent to those of the Joint Commission or JCAHO;
- Used primarily to provide, by or under the supervision of physicians, to inpatients, diagnostic services and therapeutic services for medical diagnosis, treatment, and care of injured, disabled, or sick persons;
- Requires every patient to be under the care and supervision of a physician; and
- Provides 24-hour nursing services rendered or supervised by a registered professional nurse and has a licensed practical nurse or registered nurse on duty at all times.
Reviewed/Updated Date: April 14, 2023
