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UTILIZATION MANAGEMENT GUIDELINE – 11.01.510
Skilled Nursing Facility (SNF): Admission, Continued Stay,
and Transition of Care Guideline
Effective Date: Nov. 1, 2019
Last Revised: Oct. 4, 2019
Replaces: N/A
RELATED MEDICAL POLICIES:
None
Select a hyperlink below to be directed to that section.
COVERAGE GUIDELINES | DOCUMENTATION REQUIREMENTS | CODING
RELATED INFORMATION | REFERENCES | HISTORY
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Introduction
Skilled nursing care is a high level of care that can only be
provided by trained and licensed
professionals, like registered nurses (RNs), licensed
professional nurses (LPNs), medical directors,
and physical, occupational, and speech therapists. Skilled care
is short-term and helps people
get back on their feet after injury or illness. It is often
given in a skilled nursing facility. A skilled
nursing facility can be a separate facility or a distinct unit
within another institution. After being
released from the hospital, a person is transferred to a skilled
nursing facility for the hands-on
care. This can be either medical care or rehabilitation care —
and sometimes both. A broad
definition of skilled care is medically necessary care that can
only be done by a skilled, trained,
and licensed nurse or therapist. If the care can be done by a
home health aide (someone who
assists with the activities of daily living, like eating or
bathing) or a person who doesn’t need to
be licensed, it’s not considered to be skilled nursing or
skilled rehabilitation care. This policy
describes when skilled care in a skilled nursing facility may be
considered medically necessary.
Note: The Introduction section is for your general knowledge and
is not to be taken as policy coverage criteria. The
rest of the policy uses specific words and concepts familiar to
medical professionals. It is intended for
providers. A provider can be a person, such as a doctor, nurse,
psychologist, or dentist. A provider also can
be a place where medical care is given, like a hospital, clinic,
or lab. This policy informs them about when a
service may be covered.
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Coverage Guidelines
Subject Medical Necessity
Clinical Indications for Admission
Admission Admission to a skilled nursing facility (SNF) may be
considered
medically necessary when ALL of the following criteria are
met:
• Skilled services are provided under the supervision of a
physician and delivered by a qualified and licensed provider
AND
• Care plans specify individual realistic goals and discharge
plans
AND
• Skilled services are medically necessary and cannot be
provided
in a lower level of care setting
AND
• Provided services are expected to result in measurable and
significant improvement in the patient’s condition within a
reasonable time frame
AND
• Patient is medically stable
AND
• One or more skilled therapies or skilled nursing services
are
given at least daily
Skilled nursing services must include ALL of the following:
• Services are at an intensity and frequency that cannot be
provided at a lower level of care
• Documented weekly physician face-to-face evaluations
performed, including consults as needed
• Patient and/or caregiver demonstrate ability and willingness
to
participate in care plan, including training.
• Physician supervised, skilled nursing services for
monitoring,
evaluation and intervention to address recent illness,
injury,
disease or surgical procedure are required
AND
• Skilled nursing services may include ONE or more of the
following:
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Subject Medical Necessity
Clinical Indications for Admission
o IV* or IM* injection of drugs given at least every 12
hours
(and they cannot be provided at a lower level of care)
o Parental feeding (TPN) or enteral feeding, (eg,
nasogastric,
gastrostomy or jejunostomy)** requiring intervention or
management of a complication
o Active management of a complex medication regimen (may
be oral) to include documented monitoring
o Active management of an exacerbation of chronic disease
conditions
o Complex wound care of stage 3 or 4 or multiple stage 2
decubitus ulcer(s) (see definition below) or other
complicated wounds requiring aseptic, daily dressing
changes
o Ostomy complication requiring intervention which may
include patient/care-giver training that cannot be provided
in an alternative care setting (home, outpatient, etc.)
o Device or drain management, including initial care of
urinary or wound drain catheters (such as bladder
irrigation,
nephrostomy tube, suprapubic catheter or JP***/biliary
drains)
o Ventilator and/or tracheostomy weaning
o New respiratory treatment or new use of oxygen; or
nasopharyngeal or deep tracheal suctioning (superficial,
oropharyngeal suctioning is not a skilled service) to
stabilize an acute medical/respiratory condition
AND/OR
Skilled therapy services must include ALL of the following:
• One or more therapy modality given at least 5 days/week for
at
least 1hour daily to treat a documented decline in
functional
status due to recent illness, injury, disease, or surgical
procedure
• Prior level of function is described in skilled therapy
evaluation.
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Subject Medical Necessity
Clinical Indications for Admission
• A functional impairment requiring at least minimum
assistance
for skilled therapy services
AND
• Rehabilitation services may include ONE or more of the
following :
o Gait evaluation and training
o Transfer training
o ADL training
o Speech and swallowing restoration
o Cognitive training
o Therapeutic treatment to ensure patient safety
AND
• Patient is able to actively participate (ie, responsive to
verbal/visual stimuli and able to follow simple commands)
and
demonstrates rehabilitation potential.
* IV (intravenous), IM (intramuscular)
** NG (nasogastric), G-tube (gastrostomy), J-tube,
(jejunostomy)
***JP (Jackson-Pratt drain)
Admission or continued stay to a skilled nursing facility
may
be considered NOT medically necessary when:
• Skilled services can be managed at a lower level of care
• Services are for a custodial level of care or for a
maintenance
program when no further functional progress has been made
within a reasonable period of time, nor is expected
• Patient is not willing or able to participate in a
therapeutic
treatment program
• Services are for routine medication administration (including
IV,
IM, and SQ) for medically stable individuals without other
skilled needs
• Care is for routine indwelling bladder catheters or
established
colostomy or ileostomy, gastrostomy tube feedings,
tracheostomy site care, oxygen therapy
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Subject Medical Necessity
Clinical Indications for Admission
• Care of the confused or disoriented patient who is under
an
established medication regimen
• Care is primarily for assisting in activities of daily
living
Subject Medical Necessity
Clinical Indications for Continued Stay
Continued Stay Ongoing assessment and management of an
unstable
condition or complex medical condition is considered
medically necessary when the above criteria and ONE of the
following criteria is met:
Skilled Nursing Services
• IV or IM* injection of drugs given at least every 12 hours
(and
they cannot be provided at a lower level of care)
• Initiation of IV TPN feeding or tube feedings (NG, G-tube, or
J-
tube**) or when documented difficulties or complications
exist
requiring changes in intervention.
• Complex medication (may be oral) adjustment in dosage or
type of medication with documentation (such as lab values,
vital signs, etc.) of the unstable condition or
complications
being treated
• Treatment of a Stage 3 or 4 or multiple stage 2 decubitus
ulcer(s) (see definition below) or other complicated wound
requiring daily, aseptic dressing changes that cannot be
provided at a lower level of care.
o At least weekly wound assessment with progression of
healing documented
▪ If there is lack of progression, a change in management
of the wound is documented
• Ostomy care, related to complications that cannot be
provided
in an alternative care setting (home, outpatient, etc.)
• Ventilator and/or tracheostomy weaning, with documented
trials and progression towards weaning of respiratory
support.
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Subject Medical Necessity
Clinical Indications for Continued Stay
• New respiratory treatment at least 3 times/day; or new use
of
oxygen; or nasopharyngeal or deep tracheal suctioning
(superficial, oropharyngeal suctioning is not a skilled service)
to
stabilize an acute medical/respiratory condition.
• New or worsening mental status change with documented
physician-supervised intervention
• New or worsening behavioral symptoms with documented
physician-supervised intervention for behavior modification
and/or mental health consult as needed.
* IV (intravenous), IM (intramuscular)
** NG (nasogastric), G-tube (gastrostomy), J-tube,
(jejunostomy)
OR
Skilled Therapy Services
• The patient demonstrates documented measurable,
restorative
and continuing gains towards outlined therapy goals (of at
least one discipline) which cannot be provided at a lower
level
of care ; OR
o There is documented medical instability affecting
participation or progression along with intervention to
resolve or stabilize it (this is short term for 1-3 days).
Clinical Indications for Transition of Care
Transition of care Transition from a skilled nursing facility
(SNF) to an alternate
level of care may be considered medically necessary when ALL
of the following criteria are met:
• Ongoing skilled nursing services needed can be safely
provided
in a home setting with home health or outpatient care
AND
• The patient has no signs of infection or is stable on an
anti-
infective regimen which can be administered outpatient
AND
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Clinical Indications for Transition of Care
• The patient is clinically stable
AND
• The patient is stable on an adequate nutritional program
(eg,
parenteral infusion can be managed by a home infusion
provider or enteral feedings can safely be provided at home)
AND
• Pain management is adequate without need for frequent
change in medication or dose
AND
• Neurologic status is stable with mentation at baseline,
appropriate for patient’s clinical condition.
AND
• If patient is in SNF primarily for rehabilitative
services:
o Further progress toward rehabilitation goals is not
expected
or can be achieved at a lower level of care or
o Patient is no longer willing or able to participate in a
therapeutic treatment program
Documentation Requirements The patient’s medical records
submitted for review for all conditions should document that
medical necessity criteria are met. The record should include
the following:
• Transferring facility/provider (ie, hospital) admission and
discharge assessment; therapy
assessment
• The preliminary treatment plan
AND
• Post SNF admission documentation in the form of clinical notes
and/or treatment logs
including the following:
o Clinical and rehabilitation status as applicable
o Treatment(s) received, including frequency and length of
treatment period, as applicable
o Patient participation and progress toward clinical and
rehabilitation goals
o Patient/caregiver training progress towards goals
o Patient/caregiver participation in discharge planning; and
o Status of the discharge plan, including targeted site, date,
and skilled needs, if applicable
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Coding
N/A
Related Information
This guideline incorporates clinical, facility, and care based
indicators to determine the
appropriateness of admission to a skilled nursing facility level
of care. In addition, transitions of
care guidelines are given as indicators to determine if the
patient may be appropriate for safe
transfer from a skilled nursing facility to a home or an
alternate setting.
A skilled nursing facility (SNF) is a facility, or distinct part
of a facility, that provides skilled
nursing care and/or skilled rehabilitative therapy. Usually a
patient will transition to a SNF from
an acute care facility when ongoing skilled needs cannot be
provided in a home or other
alternate setting.
Definition of Terms
Pressure Injury Stages (National Pressure Ulcer Advisory Panel,
2016)7
Pressure Injury: A pressure injury is localized damage to the
skin and/or underlying soft tissue
usually over a bony prominence or related to medical or other
devices. The injury occurs as a
result of intense and/or prolonged pressure or pressure in
combination with shear. The
tolerance of soft tissue for pressure and shear may also be
affected by microclimate, nutrition,
perfusion, co-morbidities and conditions of soft tissue.
Pressure Injury Stages
• Stage 1 Pressure Injury - Non-Blanchable Erythema Of Intact
Skin:
Intact skin with a localized area of non-blanchable erythema,
which may appear differently in
darkly pigmented skin. Presence of blanchable erythema or
changes in sensation, temperature,
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or firmness may precede visible changes. Color changes do not
include purple or maroon
discoloration; these may indicate deep tissue pressure
injury.
• Stage 2 Pressure Injury - Partial-Thickness Skin Loss With
Exposed Dermis:
Partial-thickness loss of skin with exposed dermis. The wound
bed is viable, pink or red, moist,
and may also present as an intact or ruptured serum-filled
blister. Adipose (fat) is not visible and
deeper tissues are not visible. Granulation tissue, slough and
eschar are not present. These
injuries commonly result from adverse microclimate and shear in
the skin over the pelvis and
shear in the heel. This stage should not be used to describe
moisture associated skin damage
(MASD) including incontinence associated dermatitis (IAD),
intertriginous dermatitis (ITD),
medical adhesive related skin injury (MARSI), or traumatic
wounds (for example, skin tears,
burns, abrasions).
• Stage 3 Pressure Injury - Full-Thickness Skin Loss:
Full-thickness loss of skin, in which adipose (fat) is visible
in the ulcer and granulation tissue and
epibole (rolled wound edges) are often present. Slough and/or
eschar may be visible. The depth
of tissue damage varies by anatomical location; areas of
significant adiposity can develop deep
wounds. Undermining and tunneling may occur. Fascia, muscle,
tendon, ligament, cartilage
and/or bone are not exposed. If slough or eschar obscures the
extent of tissue loss this is an
unstageable Pressure Injury.
• Stage 4 Pressure Injury- Full-Thickness Skin And Tissue
Loss:
Full-thickness skin and tissue loss with exposed or directly
palpable fascia, muscle, tendon,
ligament, cartilage or bone in the ulcer. Slough and/or eschar
may be visible. Epibole (rolled
edges), undermining and/or tunneling often occur. Depth varies
by anatomical location. If
slough or eschar obscures the extent of tissue loss this is an
unstageable Pressure Injury.
• Unstageable Pressure Injury- Obscured Full-Thickness Skin And
Tissue Loss:
Full-thickness skin and tissue loss in which the extent of
tissue damage within the ulcer cannot
be confirmed because it is obscured by slough or eschar. If
slough or eschar is removed, a Stage
3 or Stage 4 pressure injury will be revealed. Stable eschar
(that is, dry, adherent, intact without
erythema or fluctuance) on the heel or ischemic limb should not
be softened or removed.
• Deep Tissue Pressure Injury- Persistent Non-Blanchable Deep
Red, Maroon Or Purple
Discoloration:
Intact or non-intact skin with localized area of persistent
non-blanchable deep red, maroon,
purple discoloration or epidermal separation revealing a dark
wound bed or blood filled blister.
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Pain and temperature change often precede skin color changes.
Discoloration may appear
differently in darkly pigmented skin. This injury results from
intense and/or prolonged pressure
and shear forces at the bone-muscle interface. The wound may
evolve rapidly to reveal the
actual extent of tissue injury, or may resolve without tissue
loss. If necrotic tissue, subcutaneous
tissue, granulation tissue, fascia, muscle or other underlying
structures are visible, this indicates a
full thickness pressure injury (Unstageable, Stage 3 or Stage
4). Do not use DTPI to describe
vascular, traumatic, neuropathic, or dermatologic
conditions.
References
1. Centers for Medicare and Medicaid Services. Criteria for
skilled services and the need for skilled service. 42 CFR Pt.
409.32
Washington DC October 2017. Available online at:
https://www.gpo.gov/fdsys/pkg/CFR-2017-title42-vol2/pdf/CFR-2017-
title42-vol2-sec409-32.pdf Accessed October 2019.
2. Centers for Medicare and Medicaid Services. Examples of
skilled nursing and rehabilitative services. 42 CFR Pt. 409.33
Washington DC October 2017. Available online at:
https://www.gpo.gov/fdsys/pkg/CFR-2017-title42-vol2/pdf/CFR-2017-
title42-vol2-sec409-33.pdf Accessed October 2019.
3. Centers for Medicare and Medicaid Services. The skilled
nursing facility manual. Revised October 13, 2016. Available online
at:
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c08.pdf
Accessed October 2019.
4. Kane RL. Finding the right level of post hospital care.
Journal of the American Medical Association 2011;305(3):284-93.
DOI:
10.1001/jama.2010.2015.
5. BlueCross BlueShield of North Carolina Corporate Medical
Policy: Skilled Nursing Facility Care. At:
https://www.bcbsnc.com/assets/services/public/pdfs/medicalpolicy/skilled_nursing_facility_care.pdf
Accessed October
2019.
6. Centers for Medicare and Medicaid Services. Skilled services
requirements. 42 CFR Pt. 409.44 Washington DC October 2017.
Available online at:
https://www.gpo.gov/fdsys/pkg/CFR-2017-title42-vol2/pdf/CFR-2017-title42-vol2-sec409-44.pdf
Accessed October 2019.
7. National Pressure Ulcer Advisory Panel. Pressure injury
staging system. Revised 2016. Available at:
https://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages
Accessed October
2019.
History
Date Comments 01/01/18 New Policy, returned from archived
status, approved December 12, 2017. Policy is
reinstated and replaces InterQual criteria.
https://www.gpo.gov/fdsys/pkg/CFR-2017-title42-vol2/pdf/CFR-2017-title42-vol2-sec409-32.pdfhttps://www.gpo.gov/fdsys/pkg/CFR-2017-title42-vol2/pdf/CFR-2017-title42-vol2-sec409-32.pdfhttps://www.gpo.gov/fdsys/pkg/CFR-2017-title42-vol2/pdf/CFR-2017-title42-vol2-sec409-33.pdfhttps://www.gpo.gov/fdsys/pkg/CFR-2017-title42-vol2/pdf/CFR-2017-title42-vol2-sec409-33.pdfhttps://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c08.pdfhttps://www.bcbsnc.com/assets/services/public/pdfs/medicalpolicy/skilled_nursing_facility_care.pdfhttps://www.gpo.gov/fdsys/pkg/CFR-2017-title42-vol2/pdf/CFR-2017-title42-vol2-sec409-44.pdfhttps://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages
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Date Comments 02/01/18 Interim Review, approved January 16,
2018. Added medically necessary criteria for
continued stay in a SNF. References 6, 7 added. Added additional
statements under
admission, and edited statements under not medically necessary
and transition of care
for clarity.
12/01/18 Annual Review, approved November 6, 2018. References
removed and references 6-7
added. No change to policy statement.
11/01/19 Annual Review, approved October 4, 2019. Reference 3
updated. Policy statements
unchanged.
Disclaimer: This medical policy is a guide in evaluating the
medical necessity of a particular service or treatment. The
Company adopts policies after careful review of published
peer-reviewed scientific literature, national guidelines and
local standards of practice. Since medical technology is
constantly changing, the Company reserves the right to review
and update policies as appropriate. Member contracts differ in
their benefits. Always consult the member benefit
booklet or contact a member service representative to determine
coverage for a specific medical service or supply.
CPT codes, descriptions and materials are copyrighted by the
American Medical Association (AMA). ©2019 Premera
All Rights Reserved.
Scope: Medical policies are systematically developed guidelines
that serve as a resource for Company staff when
determining coverage for specific medical procedures, drugs or
devices. Coverage for medical services is subject to
the limits and conditions of the member benefit plan. Members
and their providers should consult the member
benefit booklet or contact a customer service representative to
determine whether there are any benefit limitations
applicable to this service or supply. This medical policy does
not apply to Medicare Advantage.
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Informationen in Ihrer Sprache zu erhalten. Rufen Sie an unter
800-596-3440 (TTY: 800-842-5357). Hmoob (Hmong): Tsab ntawv tshaj
xo no muaj cov ntshiab lus tseem ceeb. Tej zaum tsab ntawv tshaj xo
no muaj cov ntsiab lus tseem ceeb txog koj daim ntawv thov kev pab
los yog koj qhov kev pab cuam los ntawm LifeWise Health Plan of
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lus no uas tau muab sau ua koj hom lus pub dawb rau koj. Hu rau
800-596-3440 (TTY: 800-842-5357). Iloko (Ilocano): Daytoy a Pakdaar
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nga adda ket naglaon iti napateg nga impormasion maipanggep iti
apliksayonyo wenno coverage babaen iti LifeWise Health Plan of
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pakdaar. Mabalin nga adda rumbeng nga aramidenyo nga addang sakbay
dagiti partikular a naituding nga aldaw tapno mapagtalinaedyo ti
coverage ti salun-atyo wenno tulong kadagiti gastos. Adda
karbenganyo a mangala iti daytoy nga impormasion ken tulong iti
bukodyo a pagsasao nga awan ti bayadanyo. Tumawag iti numero nga
800-596-3440 (TTY: 800-842-5357). Italiano (Italian): Questo avviso
contiene informazioni importanti. Questo avviso può contenere
informazioni importanti sulla tua domanda o copertura attraverso
LifeWise Health Plan of Oregon. Potrebbero esserci date chiave in
questo avviso. Potrebbe essere necessario un tuo intervento entro
una scadenza determinata per consentirti di mantenere la tua
copertura o sovvenzione. Hai il diritto di ottenere queste
informazioni e assistenza nella tua lingua gratuitamente. Chiama
800-596-3440 (TTY: 800-842-5357).
-
日本語 (Japanese): この通知には重要な情報が含まれています。この通知には、LifeWise Health Plan
of Oregon
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LifeWise Health Plan of Oregon를 통한 커버리지에 관한 정보를 포함하고 있을 수 있습니다. 본
통지서에는 핵심이 되는 날짜들이 있을 수 있습니다. 귀하는 귀하의 건강 커버리지를 계속 유지하거나 비용을 절감하기 위해서
일정한 마감일까지 조치를 취해야 할 필요가 있을 수 있습니다. 귀하는 이러한 정보와 도움을 귀하의 언어로 비용 부담없이
얻을 수 있는 권리가 있습니다. 800-596-3440 (TTY: 800-842-5357) 로 전화하십시오. ລາວ
(Lao): ແຈ້ງການນ້ີມີຂ້ໍມູນສໍາຄັນ.
ແຈ້ງການນ້ີອາດຈະມີຂ້ໍມູນສໍາຄັນກ່ຽວກັບຄໍາຮ້ອງສະໝັກ ຫືຼ
ຄວາມຄຸ້ມຄອງປະກັນໄພຂອງທ່ານຜ່ານ LifeWise Health Plan of Oregon.
ອາດຈະມີວັນທີສໍາຄັນໃນແຈ້ງການນ້ີ.
ທ່ານອາດຈະຈໍາເປັນຕ້ອງດໍາເນີນການຕາມກໍານົດເວລາສະເພາະເພ່ືອຮັກສາຄວາມຄຸ້ມຄອງປະກັນສຸຂະພາບ
ຫືຼ ຄວາມຊ່ວຍເຫືຼອເລ່ືອງຄ່າໃຊ້ຈ່າຍຂອງທ່ານໄວ້.
ທ່ານມີສິດໄດ້ຮັບຂ້ໍມູນນ້ີ ແລະ
ຄວາມຊ່ວຍເຫືຼອເປັນພາສາຂອງທ່ານໂດຍບ່ໍເສຍຄ່າ. ໃຫ້ໂທຫາ 800-596-3440
(TTY: 800-842-5357). ភាសាែខមរ (Khmer): េសចកត
ីជូនដំណឹងេនះមានព័ត៌មានយ៉ាងសំខាន់។ េសចកត ីជូនដំណឹងេនះរបែហល
ជាមានព័ត៌មានយ៉ាងសំខាន់អំពីទរមង់ែបបបទ ឬការរ៉ាប់រងរបស់អនកតាមរយៈ
LifeWise Health Plan of Oregon ។ របែហលជាមាន កាលបរេិចឆទសំខាន់េនៅកន
ុងេសចកត ីជូនដំណឹងេនះ។ អនករបែហលជារតវូការបេញចញសមតថភាព ដល់កំណត់ៃថង
ជាក់ចបាស់នានា េដើមបីនឹងរកសាទុកការធានារ៉ាប់រងសុខភាពរបស់អនក
ឬរបាក់
ជំនួយេចញៃថល។ អនកមានសិទធិទទួលព័ត៌មានេនះ និងជំនួយេនៅកន
ុងភាសារបស់អនក
េដាយមិនអសលុយេឡើយ។ សូមទូរស័ពទ 800-596-3440 (TTY: 800-842-5357)។
ਪੰਜਾਬੀ (Punjabi): ਇਸ ਨੋਿਟਸ ਿਵਚ ਖਾਸ ਜਾਣਕਾਰੀ ਹੈ. ਇਸ ਨੋਿਟਸ ਿਵਚ
LifeWise Health Plan of Oregon ਵਲ ਤੁਹਾਡੀ ਕਵਰੇਜ ਅਤੇ ਅਰਜੀ ਬਾਰੇ
ਮਹੱਤਵਪੂਰਨ ਜਾਣਕਾਰੀ ਹੋ ਸਕਦੀ ਹੈ . ਇਸ ਨੋਿਜਸ ਜਵਚ ਖਾਸ ਤਾਰੀਖਾ ਹੋ ਸਕਦੀਆਂ
ਹਨ. ਜੇਕਰ ਤੁਸੀ ਜਸਹਤ ਕਵਰੇਜ ਿਰੱਖਣੀ ਹੋਵ ੇਜਾ ਓਸ ਦੀ ਲਾਗਤ ਜਿਵੱਚ ਮਦਦ ਦੇ
ਇਛੱੁਕ ਹੋ ਤਾਂ ਤੁਹਾਨੰੂ ਅੰਤਮ ਤਾਰੀਖ਼ ਤ ਪਿਹਲਾਂ ਕੁੱ ਝ ਖਾਸ ਕਦਮ ਚੁੱ ਕਣ ਦੀ
ਲੋੜ ਹੋ ਸਕਦੀ ਹੈ ,ਤਹੁਾਨੰੂ ਮੁਫ਼ਤ ਿਵੱਚ ਤੇ ਆਪਣੀ ਭਾਸ਼ਾ ਿਵੱਚ ਜਾਣਕਾਰੀ ਅਤੇ ਮਦਦ
ਪ੍ਰਾਪਤ ਕਰਨ ਦਾ ਅਿਧਕਾਰ ਹੈ ,ਕਾਲ 800-596-3440 (TTY: 800-842-5357).
:(Farsi) فارسی فرم درباره مھم اطالعات ممکن است حاوی اعالميه اين
.ميباشد مھم اطالعات یوحا اعالميه اين
تاريخ به باشد. LifeWise Health Plan of Oregonشما از طريق ای بيمه
پوشش يا و تقاضادر بيمه تان يا کمک پوشش حقظ برای است ممکن شما
.نماييد توجه اعالميه اين در مھم ھای
خاصی احتياج داشته انجام کارھای مشخصی برای ھای تاريخ به پرداخت
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اطالعات اين که داريد را اين حق شما .باشيد
800- 596-3440 نماييد. برای کسب اطالعات با شماره تماس برقرار
نماييد. )800-842-5357تماس باشماره TTY(کاربران
Polskie (Polish): To ogłoszenie może zawierać ważne informacje.
To ogłoszenie może zawierać ważne informacje odnośnie Państwa
wniosku lub zakresu świadczeń poprzez LifeWise Health Plan of
Oregon. Prosimy zwrócic uwagę na kluczowe daty, które mogą być
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utrzymania polisy ubezpieczeniowej lub pomocy związanej z kosztami.
Macie Państwo prawo do bezpłatnej informacji we własnym języku.
Zadzwońcie pod 800-596-3440 (TTY: 800-842-5357). Português
(Portuguese): Este aviso contém informações importantes. Este aviso
poderá conter informações importantes a respeito de sua aplicação
ou cobertura por meio do LifeWise Health Plan of Oregon. Poderão
existir datas importantes neste aviso. Talvez seja necessário que
você tome providências dentro de determinados prazos para manter
sua cobertura de saúde ou ajuda de custos. Você tem o direito de
obter esta informação e ajuda em seu idioma e sem custos. Ligue
para 800-596-3440 (TTY: 800-842-5357).
Română (Romanian): Prezenta notificare conține informații
importante. Această notificare poate conține informații importante
privind cererea sau acoperirea asigurării dumneavoastre de sănătate
prin LifeWise Health Plan of Oregon. Pot exista date cheie în
această notificare. Este posibil să fie nevoie să acționați până la
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sănătate sau asistența privitoare la costuri. Aveți dreptul de a
obține gratuit aceste informații și ajutor în limba dumneavoastră.
Sunați la 800-596-3440 (TTY: 800-842-5357). Pусский (Russian):
Настоящее уведомление содержит важную информацию. Это уведомление
может содержать важную информацию о вашем заявлении или страховом
покрытии через LifeWise Health Plan of Oregon. В настоящем
уведомлении могут быть указаны ключевые даты. Вам, возможно,
потребуется принять меры к определенным предельным срокам для
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Fa’asamoa (Samoan): Atonu ua iai i lenei fa’asilasilaga ni
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fa’asilasilaga o se fesoasoani e fa’amatala atili i ai i le tulaga
o le polokalame, LifeWise Health Plan of Oregon, ua e tau fia maua
atu i ai. Fa’amolemole, ia e iloilo fa’alelei i aso fa’apitoa olo’o
iai i lenei fa’asilasilaga taua. Masalo o le’a iai ni feau e tatau
ona e faia ao le’i aulia le aso ua ta’ua i lenei fa’asilasilaga ina
ia e iai pea ma maua fesoasoani mai ai i le polokalame a le Malo
olo’o e iai i ai. Olo’o iai iate oe le aia tatau e maua atu i lenei
fa’asilasilaga ma lenei fa’matalaga i legagana e te malamalama i ai
aunoa ma se togiga tupe. Vili atu i le telefoni 800-596-3440 (TTY:
800-842-5357). Español (Spanish): Este Aviso contiene información
importante. Es posible que este aviso contenga información
importante acerca de su solicitud o cobertura a través de LifeWise
Health Plan of Oregon. Es posible que haya fechas clave en este
aviso. Es posible que deba tomar alguna medida antes de
determinadas fechas para mantener su cobertura médica o ayuda con
los costos. Usted tiene derecho a recibir esta información y ayuda
en su idioma sin costo alguno. Llame al 800-596-3440 (TTY:
800-842-5357). Tagalog (Tagalog): Ang Paunawa na ito ay naglalaman
ng mahalagang impormasyon. Ang paunawa na ito ay maaaring
naglalaman ng mahalagang impormasyon tungkol sa iyong aplikasyon o
pagsakop sa pamamagitan ng LifeWise Health Plan of Oregon. Maaaring
may mga mahalagang petsa dito sa paunawa. Maaring mangailangan ka
na magsagawa ng hakbang sa ilang mga itinakdang panahon upang
mapanatili ang iyong pagsakop sa kalusugan o tulong na walang
gastos. May karapatan ka na makakuha ng ganitong impormasyon at
tulong sa iyong wika ng walang gastos. Tumawag sa 800-596-3440
(TTY: 800-842-5357). ไทย (Thai): ประกาศนีมี้ข้อมลูสําคญั
ประกาศนีอ้าจมีข้อมลูท่ีสําคญัเก่ียวกบัการการสมคัรหรือขอบเขตประกนัสขุภาพของคณุผ่าน
LifeWise Health Plan of Oregon และอาจมีกําหนดการในประกาศนี
้คณุอาจจะต้องดําเนินการภายในกําหนดระยะเวลาท่ีแน่นอนเพ่ือจะรักษาการประกนัสขุภาพของคณุหรือการช่วยเหลือท่ีมีค่าใช้จ่าย
คณุมีสิทธิท่ีจะได้รับข้อมลูและความช่วยเหลือนีใ้นภาษาของคณุโดยไม่มีค่าใช้จ่าย
โทร 800-596-3440 (TTY: 800-842-5357) Український (Ukrainian): Це
повідомлення містить важливу інформацію. Це повідомлення може
містити важливу інформацію про Ваше звернення щодо страхувального
покриття через LifeWise Health Plan of Oregon. Зверніть увагу на
ключові дати, які можуть бути вказані у цьому повідомленні. Існує
імовірність того, що Вам треба буде здійснити певні кроки у
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xin tham gia hoặc hợp đồng bảo hiểm của quý vị qua chương trình
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