Summary Plan Description

Home Health Care

100% Network and Non-Network
Services and Supplies Must Be Precertified Unless the Patient Is A Medicare-Eligible Retiree

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 visits. 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.

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.

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 care; nonmedical self-help or related testing; vocational, educational, cognitive, or behavioral therapy; or exercise programs.
  2. Home health aide services.
  3. Private duty nursing.
  4. Services provided by volunteers, household members, family, or friends.
  5. Food, clothing, housing, or transportation.
  6. Supportive environmental services or equipment such as, but not limited to, wheelchair ramps or support railings.
  7. Social services or treatment for mental health.
  8. Services or supplies not included in the written treatment plan or not otherwise specifically covered.
  9. Homemaker or housekeeping services.