Home health care
Home health care is a term that’s used to encompass a wide variety of health and social services that can be provided at home.
Who can benefit from home health care services?
Home health care is generally appropriate whenever a person is recuperating and returning to health after an illness or injury and is going to need ongoing skilled nursing or skilled rehabilitation care. Some examples of those who can benefit from home health care services are people who:
- Are discharged from a hospital or a nursing facility, but still need some skilled nursing and/or rehabilitative treatment.
- Require short-term medical assistance during recuperation from surgery.
- Have a medical condition that would otherwise require admission to a health care facility.
If your condition stabilizes and reaches a point where further recovery is not expected, your home health care is no longer covered under your health policy. You may still need ongoing care, but you need it to preserve your current health state, prevent deterioration, and help meet your personal needs. We call this custodial care, and custodial services are generally covered only under long term care policies.
Who provides home health care services?
A home health care team may include some or all of the following types of providers:
- Physicians
- Registered nurses
- Physical, speech, and occupational therapists
- Social workers
- Durable medical equipment suppliers
- Registered or certified dietitians
- Pharmacists
Who qualifies to receive the home health care benefit?
To qualify for this benefit, you must first obtain our preauthorization. Your physician must certify that:
- Your care would otherwise require you to be confined in a health care facility, and
- The services you require are not available from members of your family or others living in your home without causing undue hardship.
If we approve the plan, we have the right to select the most cost-effective vendor to coordinate and/or to deliver the services you need.
What types of home health care services are covered?
Here are examples of home health care services we may preauthorize based on your medical needs:
- Evaluation of the need for home health care and development of a home care plan by a registered nurse or medical social worker, when approved or requested by your physician.
- Part-time or intermittent skilled nursing care provided by, or under the supervision of, a registered nurse.
- Part-time or intermittent home health aide services provided under the supervision of a registered nurse or medical social worker if skilled services are required.
- Skilled rehabilitation services.
- Prescribed medical supplies, drugs and medications, and laboratory services.
- Home infusion services.
- Prescribed intravenous or feeding tube nutritional support systems.
- Nutritional counseling provided or supervised by a registered or certified dietitian.
What home health care services are not covered?
The following are examples of home health care services that we never cover:
- Services which are provided by the covered employee, covered dependents, or others who ordinarily reside in the patient’s home.
- Services that, after instruction and demonstrated competence, can be reasonably and safely performed by the patient or the patient’s family. Examples include, but are not limited to, routine insulin injection, self-urinary catheterization, wound care, and and long-term feeding by gastrostomy or jejunostomy tube.
How are home health care services reimbursed?
We have established a network of select organizations to provide home health care services to our participants at excellent negotiated rates. These negotiated rates are our reimbursement limits for home health care services.
If you receive your preauthorized home health care services from one of these providers, we will reimburse the services in full, less any applicable deductible and coinsurance amounts. However, if you choose to receive preauthorized services from a non-network provider, you will be responsible for any amount that exceeds what we would have paid one of our network providers. |
|