Home Health Care Services (Skilled. Home Health Care). All Home Health Care Services require Prior Authorization.
a. The Home Health Care Services listed below are covered when the following criteria are met:
i. A Member is unable to leave home without considerable effort and the assistance of another person because the Member is:
1) bedridden or chair bound, or restricted in ambulation whether or not assistive devices are used; or
2) significantly limited in physical activities due to a Condition; and
ii. the Home Health Care Services rendered have been prescribed by a Physician by way of a formal written treatment plan. The written treatment plan must be reviewed and renewed by the prescribing Physician at least every 30 days until benefits are exhausted. AvMed reserves the right to request a copy of any written treatment plan in order to determine whether such services are covered under this Contract; and
iii. the Home Health Care Services are provided directly by (or indirectly through) a home health agency; and
iv. the Member is meeting or achieving the desired treatment goals set forth in the treatment plan as documented in the clinical progress notes.
b. Home Health Care Services are limited to:
i. intermittent visits (i.e., up to, but not exceeding, two hours per day) for:
1) nursing care by a registered nurse or licensed practical nurse, and home health aide services;
2) medical social services;
3) nutritional guidance;
4) respiratory or inhalation therapy (e.g., oxygen); and
5) short-term physical therapy by a physical therapist, occupational therapy by an occupational therapist, and speech therapy by a speech therapist. Such therapies provided in the home are subject to any rehabilitative outpatient physical, occupational and speech therapy visit limits.
c. Services must be consistent with a plan of treatment ordered by the Member’s Physician. Nursing and home health aide services must be rendered under the supervision of a registered nurse. See Part X. LIMITATIONS OF COVERED MEDICAL SERVICES for applicable Limitations.
Home Health Care Services (Skilled. Home Health Care). Services are limited to 20 visits per calendar year, including:
a. intermittent visits (i.e., up to, but not exceeding, two hours per day) for:
i. nursing care by a registered nurse or licensed practical nurse, and home health aide services;
ii. medical social services;
iii. nutritional guidance;
iv. respiratory or inhalation therapy (e.g., oxygen) and;
v. short-term physical therapy by a physical therapist, occupational therapy by an occupational therapist, and speech therapy by a speech therapist. Such therapies are subject to any rehabilitative outpatient physical, occupational and speech therapy visit limits.
b. Services must be consistent with a plan of treatment ordered by the Member’s Physician. Nursing and home health aide services must be rendered under the supervision of a registered nurse.
Home Health Care Services (Skilled. Home Health Care) means Physician-directed professional, technical and related medical and personal care services provided on an intermittent or part-time basis directly by (or indirectly through) a home health agency in your home or residence. Such services include professional visiting nurses or other Health Professionals for services covered under this Contract. For purposes of this definition, a Hospital, Skilled Nursing Facility, nursing home or other facility will not be considered a home or residence.
