When skilled nursing visits associated with the Direct Ship Injectables Program are required, up to two visits are authorized at the time of facilitating the request for shipment.
Physical and occupational therapies provided by a home health agency (HHA) in the home setting are not included in capitation.
Laboratory specimens collected by an HHA should always be submitted to a participating laboratory or the individual's capitated laboratory, as appropriate, for the individual to receive the highest level of benefits.
The information in this policy does not supersede the terms outlined in Company HHA contracts.
BENEFIT CONTRACT EXCLUSION
The following are examples of, but are not limited to, situations when home health care services are not covered by the Company because they are benefit contract exclusions and, therefore, not eligible for reimbursement consideration:
- Custodial care, which is care provided primarily for maintenance of the individual or care that is designed essentially to assist the individual in meeting his/her activities of daily living; and which is not primarily provided for its therapeutic value in the treatment of an illness, disease, bodily injury, or condition.
- The hours requested exceed the benefit limits, if any.
Subject to the terms and conditions of the applicable benefit contract, home health care services are covered under the medical benefits of the Company’s products when the medical necessity criteria listed in this medical policy are met.
This policy is consistent with applicable state mandates. The laws of the state where the group benefit contract is issued determine the mandated coverage.