Common use of Home Health Benefits Clause in Contracts

Home Health Benefits. The following services are covered for a Homebound Member when provided by a Participating home health care agency. Pre-authorization must be obtained from the HMO by the Member’s attending Participating Physician. HMO shall not be required to provide home health benefits when HMO determines the treatment setting is not appropriate, or when there is a more cost effective setting in which to provide covered health care services. Coverage for Home Health Services is not determined by the availability of caregivers to perform the services; the absence of a person to perform a non-skilled or Custodial Care service does not cause the service to become covered. If the Member is a minor or an adult who is dependent upon others for non-skilled care (e.g. bathing, eating, toileting), coverage for Home Health Services will only be provided during times when there is a family member or caregiver present in the home to meet the Member’s non-skilled needs. Coverage is subject to the maximum number of visits, if any, shown on the Schedule of Benefits. Skilled Nursing services that require the medical training of and are provided by a licensed nursing professional are a covered benefit. Services must be provided during intermittent visits of 4 hours or less with a daily maximum of 3 visits. Up to 12 hours (3 visits) of continuous Skilled Nursing services per day within 30 days of an inpatient Hospital or Skilled Nursing Facility discharge may be covered, when all home health care criteria are met, for transition from the Hospital or Skilled Nursing Facility to home care. Services are subject to the limits, if any, listed in the Outpatient Home Health Visits section of the Schedule of Benefits. Services of a home health aide are covered only when they are provided in conjunction with Skilled Nursing services and directly support the Skilled Nursing. Services must be provided during intermittent visits of 4 hours or less with a daily maximum of 3 visits. Services are subject to the limits, if any, listed in the Outpatient Home Health Visits section of the Schedule of Benefits. Medical social services are covered only when they are provided in conjunction with Skilled Nursing services and must be provided by a qualified social worker. Outpatient home health short-term physical, speech, or occupational therapy is covered when the above home health care criteria are met. Coverage is subject to the conditions and limits listed in the Outpatient Rehabilitation Benefit section of the Certificate and the Outpatient Rehabilitation section of the Schedule of Benefits.

Home Health Benefits. The following services are covered for a Homebound Member when provided by a Participating home health care agency. Pre-authorization must be obtained from the HMO by the Member’s attending Participating Physician. HMO shall not be required to provide home health benefits when HMO determines the treatment setting is not appropriate, or when there is a more cost effective setting in which to provide covered health care services. Coverage for Home Health Services is not determined by the availability of caregivers to perform the services; the absence of a person to perform a non-skilled or Custodial Care service does not cause the service to become covered. If the Member is a minor or an adult who is dependent upon others for non-skilled care (e.g. bathing, eating, toileting), coverage for Home Health Services will only be provided during times when there is a family member or caregiver present in the home to meet the Member’s non-skilled needs. Coverage is subject to the maximum number of visits, if any, shown on the Schedule of Benefits. Skilled Nursing services that require the medical training of and are provided by a licensed nursing professional are a covered benefit. Services must be provided during intermittent visits of 4 hours or less with a daily maximum of 3 visits. Up to 12 hours (3 visits) of continuous Skilled Nursing services per day within 30 days of an inpatient Hospital or Skilled Nursing Facility discharge may be covered, when all home health care criteria are met, for transition from the Hospital or Skilled Nursing Facility to home care. Services are subject to the limits, if any, listed in the Outpatient Home Health Visits section of the Schedule of Benefits. Services of a home health aide are covered only when they are provided in conjunction with Skilled Nursing services and directly support the Skilled Nursing. Services must be provided during intermittent visits of 4 hours or less with a daily maximum of 3 visits. Services are subject to the limits, if any, listed in the Outpatient Home Health Visits section of the Schedule of Benefits. Medical social services are covered only when they are provided in conjunction with Skilled Nursing services and must be provided by a qualified social worker. Outpatient home health short-term physical, speech, or occupational therapy is covered when the above home health care criteria are met. Coverage is subject to the conditions and limits listed in the Outpatient Rehabilitation Benefit section of the Certificate Evidence of Coverage and the Outpatient Rehabilitation section of the Schedule of Benefits. Covered Home Health Care benefits do not include charges for infusion therapy.

Home Health Benefits. The following services are covered for a Homebound Member when provided by a Participating home health care agency. Pre-authorization must be obtained from the HMO by the Member’s attending Participating Physician. HMO shall not be required to provide home health benefits when HMO determines the treatment setting is not appropriate, or when there is a more cost cost-effective setting in which to provide covered health care services. Coverage for Home Health Services is not determined by the availability of caregivers to perform the services; the absence of a person to perform a non-skilled or Custodial Care service does not cause the service to become covered. If the Member is a minor or an adult who is dependent upon others for non-skilled care (e.g. bathing, eating, toileting), coverage for Home Health Services will only be provided during times when there is a family member or caregiver present in the home to meet the Member’s non-skilled needs. Coverage is subject to the maximum number of visits, if any, shown on the Schedule of Benefits. Skilled Nursing services that require the medical training of and are provided by a licensed nursing professional are a covered benefit. Services must be provided during intermittent visits of 4 hours or less with a daily maximum of 3 visits. Up to 12 hours (3 visits) of continuous Skilled Nursing services per day within 30 days of an inpatient Hospital or Skilled Nursing Facility discharge may be covered, when all home health care criteria are met, for transition from the Hospital or Skilled Nursing Facility to home care. Services are subject to the limits, if any, listed in the Outpatient Home Health Visits section of the Schedule of Benefits. Skilled home behavioral health care provides intermittent skilled services for treatment of behavioral disorders in the home. These services are rendered in lieu of hospitalization, confinement in a Skilled Nursing Facility, or going outside of the home for the service. HMO considers provision of skilled behavioral health services in the home Medically Necessary when all of the following conditions are met: • The services are ordered by a Participating Provider and are directly related to an active treatment plan of care established by the Participating Provider; and • The skilled behavioral health care is appropriate for the active treatment of a physical or mental condition to avoid placing the Member at risk for serious complications; and • The skilled behavioral health care is intermittent or hourly in nature; and • The services are provided in lieu of a continued hospitalization, confinement in a residential or rehabilitation facility (RTF), or receiving outpatient services outside of the home; and • The treatment provided is appropriate for the Member's condition including the amount of time spent providing the service as well as the frequency, type and duration of the services; and • The Member is homebound because of a physical or mental condition (i.e., the Member leaves home only with considerable and taxing effort and absences from home are infrequent, or of short duration, or to receive medical care); and • The behavioral health services provided are not for the comfort or convenience of the Member or custodial in nature. Services of a home health aide are covered only when they are provided in conjunction with Skilled Nursing services and directly support the Skilled Nursing. Services must be provided during intermittent visits of 4 hours or less with a daily maximum of 3 visits. Services are subject to the limits, if any, listed in the Outpatient Home Health Visits section of the Schedule of Benefits. Medical social services are covered only when they are provided in conjunction with Skilled Nursing services and must be provided by a qualified social worker. Outpatient home health short-term physical, speech, or occupational therapy is covered when the above home health care criteria are met. Coverage is subject to the conditions and limits listed in the Outpatient Rehabilitation Benefit section of the Certificate Evidence of Coverage and the Outpatient Rehabilitation section of the Schedule of Benefits. Covered Home Health Care benefits do not include charges for infusion therapy.