Your Skilled Nursing Facility Benefit

Members of Dean Health Plan (DHP) who have been hospitalized or are very ill have the opportunity to use a skilled nursing facility (SNF). SNFs are nursing homes or rehabilitation facilities licensed by the State of Wisconsin as a skilled nursing facility. These facilities provide short-term support to help people transition from the hospital to their home. Skilled care may be needed following a variety of serious conditions, including a stroke, hip fracture, knee replacement or traumatic brain injury, or if you need services for complicated wound care or IV medications.

What You Need to Know

Be sure to familiarize yourself with the following before seeking care in an SNF:

• Your SNF benefit has a maximum number of days.
• Care must meet DHP’s definition of skilled care. Skilled care is medical services that are rendered for the purpose of providing restorative and recuperative care by registered or licensed nurses or physical, occupational or speech therapists.
• In the majority of cases, skilled care is necessary for only a limited period of time. After that, most patients have improved enough to be cared for by nonskilled persons, such as a spouse, a child or another relative, or have reached a plateau where further skilled care will be needed to maintain activities of daily living.

You should discuss your situation with your practitioner. However, your practitioner does not decide whether an SNF stay will be approved. This decision is made by DHP.

While You Are in the Hospital

Most people enter an SNF following care in a hospital for a serious condition. While in the hospital, a discharge planner or social worker will discuss your needs with you and what steps are necessary for you to go home. Some questions they may ask include: Do you live alone? Do you have anyone to help you at home? Do you have stairs?

Keep in mind that these questions are to help your provider and discharge planner assist you with your discharge arrangements. You will not know at the time you are admitted to the hospital whether DHP will authorize an SNF stay for you. You will first need to be evaluated by the medical and rehabilitation staff at the hospital.

While You Are in the Skilled Nursing Facility

To continue to qualify for your SNF benefit, you need to make progress and meet specific goals. The SNF is responsible for providing regular reports of your progress to DHP. The reports include information about how you are doing in therapy and/or medical information about your condition and the progress you are making.

It is the responsibility of the SNF to assist you in your discharge plan and help you get ready for your return home or transfer to a nonskilled level of care.

What’s Not Covered?

DHP does not cover care in an SNF in certain situations, including:

• Respite care.

   This is unskilled care that would be delivered in an alternative setting while your usual caregiver is unable to provide your care. An example would be if your caregiver is on vacation or needs rest.

• Custodial or domiciliary care.

   This care is given when the basic goal is to help a person in the activities of daily life, including but not limited to bathing, dressing, eating, taking medications and 24-hour supervision for potentially unsafe behavior. This includes assisted living or community-based residential facilities.

Please refer to your Group Member Certificate and Benefit Summary for additional information about this benefit. If you have additional questions regarding your SNF benefit, call Customer Service at 608-828-1301 or 800-279-1301 or visit our Website at www.deancare.com.

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