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. Skilled nursing care limits for Medicare retirees FOR MEDICARE RETIREES: This section provides information for Medicare retirees only. Medicare covers the first 100 days during a benefit period. A Medicare benefit period begins the day of hospital or skilled nursing facility admission and ends based on the time between hospital or skilled nursing facility admissions. There may be multiple benefit periods in a year. The benefit period ends when you have not received any inpatient hospital care or skilled care in a nursing facility for 60 days in a row. If you go into a hospital or skilled nursing facility after one benefit period has ended, a new benefit period begins. There is no limit to the number of benefit periods in a year. If Medicare is your primary coverage, this plan covers your first 100 days in a skilled nursing facility as your secondary insurer. Those 100 days count against the 150-day calendar year maximum allowed by the plan. After you have reached your Medicare maximum of 100 days, the plan covers an additional 50 days during the same calendar year if services are medically necessary and meet the plan’s criteria for skilled nursing facility coverage. 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 2024 UMP Classic (PEBB) Certificate of Coverage 69