Home Health Care – 100%

Benefits are provided for home health care services provided by an approved home health care agency and prescribed by a physician if inpatient care in a hospital or skilled nursing facility would otherwise be required. There is an annual maximum of $5,000 for non-Medicare individuals and $1,500 for Medicare individuals. If expenses exceed this $5,000 or $1,500 annual maximum, this plan will not pay the additional costs. The individual must be “homebound” meaning the individual cannot leave his or her home without a considerable and taxing effort and is unable to use public transportation without the assistance of another.

Home health care must be preauthorized with the Trust Office and the physician’s written treatment plan must be submitted to the Trust Office within 48 hours of discharge from the hospital or, if not hospitalized, before home health care begins. The physician must periodically review the treatment plan and certify that the individual’s condition and treatment continue to meet benefit criteria.

Helpful Hint

If your physician recommends home health care, you must call the Trust Office to preauthorize benefits.

Benefits are limited to the following home health care services and supplies which must be provided by employees of, and billed by, an approved home health care agency:

• Nursing services provided by a registered nurse (RN) or licensed practical nurse (LPN).
• Physical therapy provided by a physical therapist.
• Speech therapy provided by a speech therapist.
• Occupational therapy provided by an occupational therapist.
• Respiratory therapy provided by a respiratory therapist.
• Medical supplies that would have been provided on an inpatient basis.

Key Point

Prescription drugs and medicines, infusion therapy and IV antibiotics, and durable medical equipment are covered under separate benefits and are not limited to the $5,000 annual home health care maximum for non-Medicare individuals or $1,500 annual home health care maximum for Medicare individuals.

Benefits are not provided for:

1. Custodial care; nonmedical self-help or related testing; vocational, educational, cognitive, or behavioral therapy; exercise programs; or therapy or maintenance which is solely for the purpose of slowing body degeneration rather than restoring functional improvement.
2. Home health aide services.
3. Services provided by volunteers, household members, family, or friends.
4. Food, clothing, housing, or transportation.
5. Supportive environmental services or equipment such as, but not limited to, wheelchair ramps or support railings.
6. Social services or treatment for mental health.
7. Services or supplies not included in the written treatment plan or not otherwise specifically covered.
8. Homemaker or housekeeping services.

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