What is Home Health Care?

Home health care provides medical services in your own home. It's an alternative to hospital or skilled nursing facility stays. The goal is to help you recover or manage an illness or injury at home.

Skilled Nursing Care

This includes services from registered nurses (RNs) or licensed practical nurses (LPNs). They administer medications, manage wounds, and monitor vital signs.

Therapy Services

Physical therapy, occupational therapy, and speech therapy are common. These help you regain mobility, improve daily living skills, or enhance communication.

Home Health Aide Services

Aides assist with personal care. This includes bathing, dressing, and meal preparation. They also help with light housekeeping related to your health needs.

Medical Social Services

These services help you cope with the emotional and social aspects of illness. A social worker can connect you with community resources.

Blue Cross Blue Shield Coverage Overview

Blue Cross Blue Shield (BCBS) plans generally cover home health care. However, coverage details vary significantly by plan. Your specific policy dictates what is covered and under what conditions.

Plan Variations

BCBS offers many different plans. These include PPO, HMO, and EPO options. Each plan has its own set of benefits and limitations.

Network Providers

Most BCBS plans require you to use in-network providers. This means you must choose home health agencies that are part of your BCBS network. Out-of-network care may not be covered or may cost you more.

Medical Necessity

A key factor for coverage is medical necessity. Your doctor must certify that home health care is medically necessary for your condition. This means it's required for your treatment and recovery.

Eligibility Requirements for Home Health Care

To qualify for home health care coverage, you typically must meet certain criteria. These are established by both Medicare guidelines and your specific BCBS plan.

Doctor's Order

You need a doctor's order for home health services. This order must state that you need skilled care at home.

Homebound Status

You generally must be homebound. This means leaving your home requires considerable effort. It does not mean you cannot leave your home at all.

• Short, infrequent absences are usually permitted.
• Attending religious services or doctor's appointments may not disqualify you.

Skilled Care Need

You must require skilled nursing care or therapy services on a part-time or intermittent basis. This is not for custodial care alone.

Face-to-Face Encounter

Often, a doctor or other qualified healthcare professional must have a face-to-face encounter with you. This encounter must be related to the reason you need home health care.

Types of Covered Home Health Services

When approved, BCBS plans can cover a range of services. These are designed to support your health and recovery at home.

Skilled Nursing

This includes wound care, medication management, and patient education. It also covers monitoring of chronic conditions.

Therapy

• Physical Therapy: Helps with walking, balance, and strength.
• Occupational Therapy: Aids in performing daily tasks like dressing and eating.
• Speech Therapy: Assists with communication and swallowing difficulties.

Home Health Aide

Aides provide assistance with personal care. This includes bathing, grooming, and toileting. They can also help with light meal preparation.

Medical Social Worker

These professionals offer counseling and connect you with community resources. They help manage the emotional impact of illness.

Durable Medical Equipment (DME)

While not directly a home health service, DME is often related. This can include walkers, wheelchairs, and hospital beds. Coverage for DME varies by plan.

How to Verify Your Specific Coverage

It is essential to confirm your benefits directly with Blue Cross Blue Shield. Do not assume coverage based on general information.

Contact Your Insurance Provider

Call the member services number on your BCBS insurance card. Ask specific questions about home health care coverage.

• Inquire about covered services.
• Ask about any limitations or restrictions.
• Understand your copayments, deductibles, and coinsurance.

Review Your Policy Documents

Your Evidence of Coverage or Summary Plan Description contains detailed information. Read these documents carefully.

Consult Your Doctor

Discuss your need for home health care with your physician. They can help determine if you meet the medical necessity criteria.

Your doctor's office can also assist in navigating the insurance approval process.

Check with the Home Health Agency

Reputable home health agencies can often help verify your insurance benefits. They have experience working with various insurance providers.

Common Questions About Home Health Care

Does Blue Cross Blue Shield cover long-term home care?

Typically, BCBS plans cover home health care for skilled medical needs. Long-term custodial care is usually not covered. Custodial care focuses on daily personal needs without a medical component.

What if my doctor recommends home health care, but my plan denies it?

You have the right to appeal the decision. Your doctor can provide additional documentation to support the medical necessity of the care. Follow your plan's appeals process carefully.

Are there limits on the number of home health visits covered?

Yes, there can be limits. These depend on your specific plan and the medical necessity of the care. Your doctor's orders and the insurance company's review will determine the number of approved visits.

Do I need pre-authorization for home health care?

Pre-authorization is often required. Your home health agency or doctor's office usually handles this process. Always confirm if pre-authorization is needed for your specific services.

What is the difference between home health care and private duty nursing?

Home health care is medically necessary skilled care. Private duty nursing is typically for ongoing care needs that are not necessarily medically required by insurance standards. Coverage for private duty nursing varies greatly.

Making the Most of Your Benefits

To ensure you receive the home health care you need, be proactive. Understand your policy and communicate clearly.

Be Prepared

Gather all necessary medical documentation. Have your doctor's orders readily available.

Ask Questions

Do not hesitate to ask your doctor, the home health agency, and your insurance provider questions. Clarity prevents misunderstandings.

Keep Records

Maintain records of all communications with your insurance company. Keep copies of bills and explanations of benefits.

Understand Your Role

You play an active role in your healthcare. Being informed helps you advocate for your needs.