Skilled nursing facility services are paid at the inpatient rate. The plan must preauthorize services before you are admitted to a skilled nursing facility (see the “Limits on plan coverage” section). In addition, the facility must notify the plan within 24 hours of your admission (see page 105). This benefit covers skilled nursing facility charges for services, supplies, and room and board, including charges for services such as general nursing care made in connection with room occupancy. The plan covers up to 150 days per calendar year. Room and board is limited to the skilled nursing facility’s average semiprivate room rate, except where a private room is determined to be medically necessary. The plan does not cover stays at a skilled nursing facility that are primarily convalescent or custodial in nature. Private duty nursing furnished by a licensed home health agency may be substituted as an alternative to placement at a skilled nursing facility only if: • Skilled nursing facility care is medically necessary, not primarily convalescent or custodial in nature, and would be covered by the plan; • Private duty nursing is the most cost-effective setting (private duty nursing must be an equal or lesser cost compared to a nursing facility); and • The member's provider agrees that private duty nursing is medically appropriate and will adequately meet the member's needs. Private duty nursing is shift-based, hourly nursing care at home for adults and children, typically with a chronic illness, injury, or disability. Substitution of private duty nursing in lieu of placement in a skilled nursing facility has the same requirements and limitations as the facility benefit. For example, all deductibles and coinsurances apply and the benefit is limited to the equivalent of a maximum of 150 skilled nursing facility days per calendar year. Sleep therapy Preauthorization is required for any facility-based diagnostic or titration study (free-standing or hospital), and for sleep treatment equipment and related supplies, such as: • Initial treatment order and supplies (APAP, CPAP, BiPAP). • In-lab sleep study (PSG, MSLT, MWT). • Ongoing Treatment Order (APAP, CPAP, BiPAP). • Titration study. Exception The following supplies do not require a preauthorization: • Ongoing APAP supplies • Ongoing BiPAP supplies • Ongoing CPAP supplies Locations where sleep therapy services are not covered Sleep therapy services are not covered: • In the emergency room • At urgent-care facilities • During inpatient hospitalization 70 2024 UMP Plus–PSHVN (PEBB) Certificate of Coverage