100-Day Skilled Nursing Benefit
PHEC is an Oregon Health Plan (OHP)benefit. It covers up to 100 days in a nursing facility following hospitalization. It is for daily skilled nursing care or rehabilitation services when:
- The member is discharging from a hospital, and
- The member needs more daily skilled care than OHP's home health and outpatient benefits cover, and
- The care can only be provided through a skilled nursing facility.
PHEC is often the best way to ensure the member gets the care they need. PHEC helps members avoid health or safety risks related to going home after a hospital stay.
Who Qualifies?
This benefit is for OHP members who:
- Do not qualify for Medicare,
- Completed an OHP-covered inpatient stay of three or more days at an acute care hospital,
- Meet Medicare's
skilled nursing care criteria, and
- Can transfer to the nursing facility within 30 days of discharge from the hospital.
Members must have a condition that requires daily skilled care at a nursing facility, such as:
- Risk of falling, dehydration, or malnutrition,
- Need for daily transportation by ambulance to a hospital or rehabilitation facility, or
- Not living in an area where they can get skilled care at home.
To access this benefit, fee-for-service (open card) members must complete a pre-admission screening.
PHEC Approval Process
To be approved for a PHEC stay at a skilled nursing facility, the member's hospital discharge team and discharging medical provider must get approval.
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For fee-for-service (open card) members, the local Aging and People with Disabilities or Area Agency on Aging office must complete a pre-admission screening.
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For coordinated care organization (CCO) members, the member's CCO will approve the stay.
Other Ways People Can Qualify for Nursing Facility Care
Medicare
OHP members with Medicare have a skilled nursing benefit through Medicare.
- OHP covers only the Medicare deductibles and cost-sharing for Qualified Medicare Beneficiaries (OHP benefit packages "BMM" and "MED").
- The facility must be a Medicare-approved facility.
To learn more about this benefit, read Medicare Coverage of Skilled Nursing Facility Care.
Long-Term Services and Supports
People receiving long-term services and supports through the Oregon Department of Human Services
Aging and People with Disabilities Program can also access nursing facility care. They do not need a qualifying hospitalization and can stay more than 20 days.