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

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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.

Page | 6 of 11 ∞

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

Page | 8 of 11 ∞

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,

Page | 9 of 11 ∞

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.

Page | 10 of 11 ∞

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

Page | 11 of 11 ∞

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.

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本通知有重要的訊息。本通知可能有關於您透過 LifeWise Assurance Assurance Company. Potrebbero esserci date chiave in questo avviso.

Company 提交的申請或保險的重要訊息。本通知內可能有重要日期。您可能 Potrebbe essere necessario un tuo intervento entro una scadenza

需要在截止日期之前採取行動，以保留您的健康保險或者費用補貼。您有權 determinata per consentirti di mantenere la tua copertura o sovvenzione.

利免費以您的母語得到本訊息和幫助。請撥電話 800-971-1491 Hai il diritto di ottenere queste informazioni e assistenza nella tua lingua

(TTY: 800-842-5357)。 gratuitamente. Chiama 800-971-1491 (TTY: 800-842-5357).

037404 (07-2016)

https://www.hhs.gov/ocr/office/file/index.htmlhttps://ocrportal.hhs.gov/ocr/portal/lobby.jsfmailto:AppealsDepartmentInquiries@LifeWiseHealth.com

้

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 Assurance Company の申請または補償範囲に関する重要な情報が含まれている場合があります。この通知に記載されている可能性がある重要な日付

をご確認ください。健康保険や有料サポートを維持するには、特定の期日

までに行動を取らなければならない場合があります。ご希望の言語による

情報とサポートが無料で提供されます。 800-971-1491 (TTY: 800-842-5357)までお電話ください。

한국어 (Korean): 본 통지서에는 중요한 정보가 들어 있습니다 . 즉 이 통지서는 귀하의 신청에 관하여 그리고 LifeWise Assurance Company 를 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 . 800-971-1491 (TTY: 800-842-5357) 로 전화하십시오 .

ລາວ (Lao): ແຈ້ງການນີ້ ນສໍ າຄັນ. ແຈ້ງການນີ້ ອາດຈະມີ ນສໍ າຄັນກ່ຽວກັບຄໍ າຮ້ອງສະ ກ ຫຼື ຄວາມຄຸ້ມຄອງປະກັນໄພຂອງທ່ານຜ່ານ LifeWise Assurance Company.

ອາດຈະມີ ນທີ າຄັນໃນແຈ້ງການນີ້ . ທ່ານອາດຈະຈໍ າເປັ ນຕ້ອງດໍ າເນີ ນການຕາມ ານົດເວລາສະເພາະເພ່ື ອຮັກສາຄວາມຄຸ້ມຄອງປະກັນສຸຂະພາບ ຫຼື ຄວາມຊ່ວຍ

ເຫຼື ອເລື່ ອງຄ່າໃຊ້ າຍຂອງທ່ານໄວ້ . ທ່ານມີ ດໄດ້ ບຂ້ໍ ນນີ້ ແລະ ຄວາມຊ່ວຍເຫຼື ອ ເປັ ນພາສາຂອງທ່ານໂດຍບໍ່ ເສຍຄ່າ. ໃຫ້ໂທຫາ 800-971-1491 (TTY: 800-842-5357).

ភាសាែខមរ (Khmer):

ມູ

ມູ ຂໍ້

ຮັ ສິ ຈ່

ມູ

ສໍ

ຂໍ້ ມີ

ວັ ໝັ

ກໍ

Română (Romanian): Prezenta notificare conține informații importante. Această notificare poate conține informații importante privind cererea sau acoperirea asigurării dumneavoastre de sănătate prin LifeWise Assurance Company. Pot exista date cheie în această notificare. Este posibil să fie nevoie să acționați până la anumite termene limită pentru a vă menține acoperirea asigurării de sănătate sau asistența privitoare la costuri. Aveți dreptul de a obține gratuit aceste informații și ajutor în limba dumneavoastră. Sunați la 800-971-1491 (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 Assurance Company. В настоящем уведомлении могут быть указаны ключевые даты. Вам, возможно, потребуется принять меры к определенным предельным срокам для сохранения страхового покрытия или помощи с расходами. Вы имеете право на бесплатное получение этой информации и помощь на вашем языке. Звоните по телефону 800-971-1491 (TTY: 800-842-5357).

Fa’asamoa (Samoan): Atonu ua iai i lenei fa’asilasilaga ni fa’amatalaga e sili ona taua e tatau ona e malamalama i ai. O lenei fa’asilasilaga o se fesoasoani e fa’amatala atili i ai i le tulaga o le polokalame, LifeWise Assurance Company, 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 800-971-1491 (TTY: 800-842-5357).

Español (Spanish): នដំ ងេនះមានព័ ី

ជាមានព័ ៌ ៉ ងសំ ់អពី ់ ៉ តមានយា ខាន ំ ទរមងែបបបទ ឬការរាប

ជូ ត៌ ណឹ

អន

អន ខភាពរបស់

នួ ិ ួលព័ ៌ ិងជំ យេនៅកុងភាសារបស់ ទទ តមានេនះ ន ន

នដ

រងរបស់អន

LifeWise Assurance Company ។ របែហលជាមានកាលបរ ិ ឆ ំ ់ ន ុង េចទសខានេនៅក

េសចកតជី ូ មានយ៉ា ំ ់ ត ងសខាន។ េសចក ំណឹងេនះរបែហល Este Aviso contiene información importante. Es posible que este aviso contenga información importante acerca de su solicitud o cobertura a través de LifeWise Assurance Company. 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 800-971-1491 (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 Assurance Company. 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 800-971-1491 (TTY: 800-842-5357).

ไทย (Thai):

់ កតាមរយៈ

េសចកត ី នដំណងេនះ។ អករបែហលជារតូ ច ញសមតភាព ដល់ ំណត់ ឹ ន វការបេញ ថ ក ៃថង ជូ

ជាក់ ់ ើ ី ឹ ុ ៉ ប់ ុ ចបាសនានា េដមបនងរកសាទកការធានារា រងស ក ឬរបាក់

ំ យេចញៃថ កមានសិ

េដាយមិ ុ ើ ូ ូ នអសលយេឡយ។ សមទ

ទធ នួ ជ

ក

រស័

800-971-1491 (TTY: 800-842-5357)។

ਜਾਬੀ (Punjabi): ਇਸ ਨੋ ਿਟਸ ਿਵਚ ਖਾਸ ਜਾਣਕਾਰੀ ਹੈ. ਇਸ ਨੋ ਿਟਸ ਿਵਚ LifeWise Assurance Company ਵਲ ਤੁ ਜ ਅਤੇ ਅਰਜੀ ਬਾਰੇ ਮਹਤਵਪਰਨ ਜਾਣਕਾਰੀ ਹੋ ਸਕਦੀ ਹੈ . ਇਸ ਨਿਜਸ ਜਵਚ

ពទ

ਹਾਡੀ ਕਵਰੇ ੱ ੂ ੋ

ਅੰ ਖਾਸ ਤਾਰੀਖਾ ਹੋ ਂ ਹਨ. ਜੇ ੁ ੇ ੱ ਖਣੀ ਹੋ ੇ ਸਕਦੀਆ ਕਰ ਤਸੀ ਜਸਹਤ ਕਵਰਜ ਿਰ ਵ ਜਾ ਓਸ ਦੀ ਲਾਗਤ ਜਿਵੱਚ ਮਦਦ ਦੇ ੱ ੁ ੋ ਤਾਂ ਤੁ ੰ ੂ ਤਮ ਤਾਰੀਖ਼ ਤ ਪਿਹਲਾਂ ਕੁ ੱ ੁ ੋੜ ਹੋ ਇਛਕ ਹ ਹਾਨ ੱ ਝ ਖਾਸ ਕਦਮ ਚਕਣ ਦੀ ਲ ਸਕਦੀ ਹੈ ,ਤੁ ੰ ੂ ਮਫ਼ਤ ਿਵਚ ਤੇ ੱ ਚ ਜਾਣਕਾਰੀ ਅਤੇ ਮਦਦ ਪਾਪਤ ਕਰਨ ਦਾ ਹਾਨ ੁ ੱ ਆਪਣੀ ਭਾਸ਼ਾ ਿਵ ੍ਰ ਅਿਧਕਾਰ ਹੈ ,ਕਾਲ 800-971-1491 (TTY: 800-842-5357).

ਪੰ

ល។ អន

ประกาศน ้ีมีข้อมลูสําคญั ประกาศน ้ีอาจมีข้อมลูที่สําคญัเกี่ยวกบัการการสมคัรหรือขอบเขตประกนั สขุภาพของคณุผ่าน LifeWise Assurance Company และอาจมีกําหนดการในประกาศน ี คณุ อาจจะต้องดําเนินการภายในกําหนดระยะเวลาที่แน่นอนเพื่อจะรักษาการประกนัสขุภาพของคณุหรือการ

(Farsi): فارسی فرم بارهدر ھمم اطالعات حاوی است ممکن يهمالعا اين . ميباشد ھمم اطالعات یوحا يهمالعا اين

طريق از ماش ای مهبي وششپ يا و تقاضا LifeWise Assurance Company تاريخ به .باشد ماش .

اشته د اج احتي صیاخ کارھای انجام برای صی مشخ ای ھ خيتار به تان، انیمرد ھای زينهھ پرداخت فتيارد رايگان ورط به ودخ زبان به را مکک و اطالعات اين که داريد را اين حق شما . باشيد

ช่วยเหลือที่มีค่าใช้จ่าย คณุมีสิทธิที่จะได้รับข้อมลูและความช่วยเหลือน يدماين جهتو اعالميه اين در ھمم ھای در کمک يا تان بيمه وششپ حقظ برای است ممکن ้ีในภาษาของคณุโดยไม่มีค่าใช้จ่าย โทร 800-971-1491 (TTY: 800-842-5357)

مارهش با العاتاط کسب برای . نماييد 800-971-1491 . اييد نم برقرار استم ) 5357-842-800 مارهباش اس تم TTY کاربران(

Polskie (Polish): To ogłoszenie może zawierać ważne informacje. To ogłoszenie może zawierać ważne informacje odnośnie Państwa wniosku lub zakresu świadczeń poprzez LifeWise Assurance Company. Prosimy zwrócic uwagę na kluczowe daty, które mogą być zawarte w tym ogłoszeniu aby nie przekroczyć terminów w przypadku utrzymania polisy ubezpieczeniowej lub pomocy związanej z kosztami. Macie Państwo prawo do bezpłatnej informacji we własnym języku. Zadzwońcie pod 800-971-1491 (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 Assurance Company. 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 800-971-1491 (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 Assurance Company. Зверніть увагу на ключові дати, які можуть бути вказані у цьому повідомленні. Існує імовірність того, що Вам треба буде здійснити певні кроки у конкретні кінцеві строки для того, щоб зберегти Ваше медичне страхування або отримати фінансову допомогу. У Вас є право на отримання цієї інформації та допомоги безкоштовно на Вашій рідній мові. Дзвоніть за номером телефону 800-971-1491 (TTY: 800-842-5357).

Tiếng Việt (Vietnamese): Thông báo này cung cấp thông tin quan trọng. Thông báo này có thông tin quan trọng về đơn xin tham gia hoặc hợp đồng bảo hiểm của quý vị qua chương trình LifeWise Assurance Company. Xin xem ngày quan trọng trong thông báo này. Quý vị có thể phải thực hiện theo thông báo đúng trong thời hạn để duy trì bảo hiểm sức khỏe hoặc được trợ giúp thêm về chi phí. Quý vị có quyền được biết thông tin này và được trợ giúp bằng ngôn ngữ của mình miễn phí. Xin gọi số 800-971-1491 (TTY: 800-842-5357).