(h) HOME HEALTH CARE. The following Services are covered upon prior written referral from a [Member]'s Primary Care Provider. When home health care can take the place of Inpatient care, We cover such care furnished to a [Member] under a written home health care plan. We cover all Medically Necessary and Appropriate services or supplies, such as: Routine Nursing Care furnished by or under the supervision of a registered Nurse; physical therapy; occupational therapy; medical social work; nutrition services; speech therapy; home health aide services; medical appliances and equipment, drugs and medications, laboratory services and special meals to the extent such items and services would have been covered under this Contract if the [Member] had been in a Hospital; and any Diagnostic or therapeutic service, including surgical services performed in a Hospital Outpatient department, a Practitioner's office or any other licensed health care Facility, provided such service would have been covered under the Contract if performed as Inpatient Hospital services. Payment is subject to all of the terms of this Contract and to the following conditions: a. The [Member’s] Practitioner must certify that home health care is needed in place of Inpatient care in a recognized Facility. Home health care is covered only in situations where continuing hospitalization or confinement in a Skilled Nursing Facility or would otherwise have been required if home health care were not provided. b. The services and supplies must be: ordered by the [Member’s] Practitioner; included in the home health care plan: and furnished by, or coordinated by, a Home Health Agency according to the written home health care plan. The services and supplies must be furnished by recognized health care professionals on a part-time or intermittent basis, except when full-time or 24 hour service is needed on a short-term (no more than three-day) basis. c. The home health care plan must be set up in writing by the [Member’s] Practitioner within 14 days after home health care starts. And it must be reviewed by the [Member’s] Practitioner at least once every 60 days. e. We do not pay for: services furnished to family members, other than the patient; or services and supplies not included in the home health care plan. Any visit by a member of a home health care team on any day shall be considered as one home health care visit. Benefits for Home Health Care are provided for no more than 60 visits per [Calendar] [Plan] Year.
(h) HOME HEALTH CARE. The following Services are covered upon prior written referral from a [Member]'s Primary Care Provider. When home health care can take the place of Inpatient care, We cover such care furnished to a [Member] under a written home health care plan. We cover all Medically Necessary and Appropriate services or supplies, such as: Routine Nursing Care furnished by or under the supervision of a registered Nurse; physical therapy; occupational therapy; medical social work; nutrition services; speech therapy; home health aide services; medical appliances and equipment, drugs and medications, laboratory services and special meals to the extent such items and services would have been covered under this Contract if the [Member] had been in a Hospital; and any Diagnostic or therapeutic service, including surgical services performed in a Hospital Outpatient department, a Practitioner's office or any other licensed health care Facility, provided such service would have been covered under the Contract if performed as Inpatient Hospital services. Payment is subject to all of the terms of this Contract and to the following conditions: a. The [Member’s] Practitioner must certify that home health care is needed in place of Inpatient care in a recognized Facility. Home health care is covered only in situations where continuing hospitalization or confinement in a Skilled Nursing Facility or would otherwise have been required if home health care were not provided. b. The services and supplies must be: ordered by the [Member’s] Practitioner; included in the home health care plan: and furnished by, or coordinated by, a Home Health Agency according to the written home health care plan. The services and supplies must be furnished by recognized health care professionals on a part-time or intermittent basis, except when full-time or 24 hour service is needed on a short-term (no more than three-day) basis. c. The home health care plan must be set up in writing by the [Member’s] Practitioner within 14 days after home health care starts. And it must be reviewed by the [Member’s] Practitioner at least once every 60 days. e. We do not pay for: services furnished to family members, other than the patient; or services and supplies not included in the home health care plan. Any visit by a member of a home health care team on any day shall be considered as one home health care visit. Benefits for Home Health Care are provided for no more than 60 visits per [Calendar] [Plan] Year.
hmo_poscontract.docx