Health & Security Plan > SPD > Home Health Care – 100%

Summary Plan Description

Home Health Care—100%

Services and Supplies Must Be Preauthorized With the Trust Office

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 30 home health care visits. If charges for more than 30 home health care visits are submitted, those charges will be denied. To qualify for benefits, the patient must be "homebound," meaning the patient 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 patient's condition and treatment continue to meet benefit criteria.

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.

Benefits are not provided for:

  1. Custodial or maintenance 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.