(a) Every health care service plan that covers hospital, medical or surgical expenses and which is not qualified as a health maintenance organization under Title XIII of the federal Public Health Service Act (42 U.S.C. Sec. 300e, et seq.) shall make available and offer to include in every group contract entered into on or after January 1, 1979, benefits for home health care as set forth in this section provided by a licensed home health agency subject to the right of the subscriber group to reject the benefits or to select any alternative level of benefits as may be offered by the health care service plan.
In rural areas where there are no licensed home health agencies or in which the supply of home health agency services does not meet the needs of the community, the services of visiting nurses, if available, shall be offered under the health care service plan subject to the terms and conditions set forth in subdivision (b).
(b) As used in this section:
(1) “Home health care” means the continued care and treatment of a covered person who is under the direct care and supervision of a physician but only if (i) continued hospitalization would have been required if home health care were not provided, (ii) the home health treatment plan is established and approved by a physician within 14 days after an inpatient hospital confinement has ended and such treatment plan is for the same or related condition for which the covered person was hospitalized, and (iii) home health care commences within 14 days after the hospital confinement has ended. “Home health services” consist of, but shall not be limited to, the following: (i) part-time or intermittent skilled nursing services provided by a registered nurse or licensed vocational nurse; (ii) part-time or intermittent home health aide services which provide supportive services in the home under the supervision of a registered nurse or a physical, speech or occupational therapist; (iii) physical, occupational or speech therapy; and (iv) medical supplies, drugs and medicines prescribed by a physician and related pharmaceutical services, and laboratory services to the extent such charges or costs would have been covered under the plan if the covered person had remained in the hospital.
(2) “Home health agency” means a public or private agency or organization licensed by the State Department of Health Services in accordance with the provisions of Chapter 8 (commencing with Section 1725) of Division 2 of the Health and Safety Code.
(c) The plan may contain a limitation on the number of home health visits for which benefits are payable, but the number of such visits shall not be less than 100 in any calendar year or in any continuous 12-month period for each person covered under the plan. Except for a home health aide, each visit by a representative of a home health agency shall be considered as one home health care visit. A visit of four hours or less by a home health aide shall be considered as one home health visit.
(d) Home health benefits in this section shall be subject to all other provisions of this chapter. In addition, such benefits may be subject to an annual deductible of not more than fifty dollars ($50) for each person covered under a plan, and may be subject to a coinsurance provision which provides coverage of not less than 80 percent of the reasonable charges for such services.
(e) Nothing in this section shall preclude a plan offering other health care benefits provided in the home.
(f) Nothing in this section shall relieve any plan from providing all basic health care services as required by subdivision (i) of Section 1367 except that a plan subject to this section may fulfill that requirement with respect to home health services in connection with any particular group contract by providing benefits for home health care as set forth in this section if the subscriber group has not rejected such benefits.
(Added by Stats. 1978, Ch. 1130.)
Last modified: October 25, 2018