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Date Printed: December 18, 2017: 11:37 AM

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This medical policy (medical coverage guideline) is Copyright 2017, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2017 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association. The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

Subject: Home Health Care

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This medical coverage guideline is not an authorization, certification, explanation of benefits, or a guarantee of payment, nor does it substitute for or constitute medical advice. All medical decisions are solely the responsibility of the patient and physician. Benefits are determined by the group contract, member benefit booklet, and/or individual subscriber certificate in effect at the time services were rendered. This medical coverage guideline applies to all lines of business unless otherwise noted in the program exceptions section.

 

DESCRIPTION

This guideline addresses coverage for the various types of health care services that could be provided in the home, as permitted by the member’s contract.

Home health care provides health care services to you in your home. The goal of home health care is to help you achieve and maintain the best possible level of health and independence.

Doctors, nurses, therapists or home health aides may provide these services.

Home health care services include:

• Skilled nursing care

• Physical therapy

• Occupational therapy

• Speech therapy

• Medical social services or counseling

• Home health aide services

• Nutrition guidance

• Respiratory therapy

• Medical supplies

• Drugs and biologicals administration

Visit the Clinical View of this guideline for more information.

COVERAGE

 

Note: For all medical decisions about this service, Florida Blue uses the Position Statement in the Clinical View of this medical coverage guideline. To make the best decision for your health needs, talk to your doctor. The services covered vary from health plan to health plan. Refer to your health plan contract for complete information about your coverage.

 

Each category of home health care has specific requirements. Home health care services may be covered if the care you receive meets one or more of the following:

Either…

Your doctor documents that you are unable to leave your home without great effort because:

• You are bedridden

• You are chair bound

• Your walking is restricted

• Your physical activity is significantly limited due to a medical condition.

or…

Receiving care in your home costs less than care in another health care setting.

and…

Your doctor prescribes home health care every 60 days and the needed care:

• Requires a state-licensed health care professional and is rendered within the scope of the license

• Is necessary for the treatment of your condition

• Is needed intermittently or part time

• shows continued measurable and documented progress by you to achieve the desired results from the treatment or care.

Note: All custodial care and respite care are generally excluded in health plan contracts and are not covered.

Visit the Clinical View of this guideline for specific coverage information.

PROGRAM EXCEPTIONS

• Federal Employee Program (FEP): Certain exceptions apply.

• State Account Organization (SAO): Certain exceptions apply.

• Medicare Advantage products: Certain exceptions apply.

Visit the Clinical View of this guideline for more coverage information.

Refer to your health plan contract for complete information about your coverage.

Date Printed: December 18, 2017: 11:37 AM