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Dave K

Distinguished member
Jul 13, 2015
Nowadays it isn't easy to find health plans with no caps on home health coverage, but if you're covered under a federal employee HMO plan, you should check the plan documents to see if it is a "federally qualified" HMO. No limits on the frequency or duration of visits are permitted on home health care coverage in a federally qualified HMO. See 42 C.F.R. 417.101(a)(7).

For example, Health Net of California (for federal employees) states that it has received certification as a Federally Qualified HMO. The cost of nurse and aide visits under the plan is nothing for the first 30 visits, $10 per visit thereafter. Note that this is not a benefit to be abused. Not covered are "Nursing care requested by, or for the convenience of, the patient or the patient’s family" or "Home care primarily for personal assistance that does not include a medical component and is not diagnostic, therapeutic, or rehabilitative." In other words, the care must be deemed medically necessary for the patient, and the family will be expected to shoulder a reasonable amount of the care. Accordingly, a PALS must exercise good judgment in determining when to demand a prescription for greater frequency or duration of home health visits.

Nevertheless, the time may come when such demands should be made. In advanced stages of ALS, it has been deemed appropriate for 16 hours per day of licensed (LVN or above) in-home nursing assistance due to the need for continuous and/or unscheduled need for invasive care such as tracheostomy suctioning and administering or removing contents from a G-tube. This would not be provided by the HMO for the family's "convenience" but may be medically necessary for the patient to maximize continuity of care, minimize miscommunication between patient and nursing as well as among nursing staff, minimize the development of nosocomial infection, maximize husband-wife relationship, and optimize psychological stability. It would be inappropriate for a physician to delegate around the clock skilled care to a single CALS, because it is not medically appropriate for a single caregiver to manage high level care in such a complex individual for more than eight hours in a 24-hour period.

p.s. Being "federally qualified" used to be a prerequisite for any HMO that wished to contract with Medicare. I'm currently trying to find out if, when, how, and why that stopped being a prerequisite. In the meantime, there are definitely some federally qualified HMOs out there, and any PALS who has one should take comfort in knowing they have an unlimited scope of home health coverage.
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