Maine § 2320. - Home health care coverage

§ 2320.. Home health care coverage

Every nonprofit hospital and medical service organization which issues group and individual health care contracts providing coverage for inpatient hospital care to residents of this State shall make available coverage for home health services by a home health care provider which has contracted with the nonprofit hospital or medical service organization under terms and conditions which the organization deems satisfactory to its membership.   [PL 1977, c. 696, §201 (AMD).]

The contract providing coverage for home health care services may contain reasonable limitation on the number of home care visits and other services provided, but the number of such visits shall not be less than 90 in any continuous period of 12 months for each person covered under the contract. Each visit by an individual member of a home health care provider shall be considered as one home care visit.   [PL 1977, c. 470, §1 (NEW).]

1.  Home health care services.  "Home health care services" means those health care services rendered in a place of residence on a part-time basis to a covered person only if:

A. Hospitalization or confinement in a skilled nursing facility as defined in Title XVIII of the Social Security Act, 42 U.S.C. § 1395, et seq., would otherwise have been required if home health care was not provided; and   [PL 1977, c. 470, §1 (NEW).]

B. The plan covering the home health services is established as prescribed in writing by a physician.   [PL 1977, c. 470, §1 (NEW).]

There may not be a requirement that hospitalization be an antecedent to coverage under the policy.  

2.  Home health care services included.  Home health care services shall include:

A. Visits by a registered nurse or licensed practical nurse to carry out treatments prescribed, or supportive nursing care and observation as indicated;   [PL 1977, c. 470, §1 (NEW).]

B. A physician's home or office visits or both;   [PL 1977, c. 470, §1 (NEW).]

C. Visits by a registered physical, speech, occupational, inhalation or dietary therapist for services or for evaluation of consultation with and instruction of nurses in carrying out such therapy prescribed by the attending physician, or both;   [PL 1977, c. 470, §1 (NEW).]

D. Any prescribed laboratory tests and x-ray examination using hospital or community facilities, drugs, dressings, oxygen or medical appliances and equipment as prescribed by a physician but only to the extent that such charges would have been covered under the contract if the covered person had remained in the hospital; and   [PL 1977, c. 470, §1 (NEW).]

E. Visits by persons who have completed a home health aide training course under the supervision of a registered nurse for the purpose of giving personal care to the patient and performing light household tasks as required by the plan of care, but not including services.   [PL 1977, c. 470, §1 (NEW).]

3.  Home health care provider.  "Home health care provider" means a home health care agency which is certified under Title XVIII of the Social Security Act of 1965, as amended, which:

A. Is primarily engaged in and licensed or certified to provide skilled nursing and other therapeutic services;   [PL 1977, c. 470, §1 (NEW).]

B. Has standards, policies and rules established by a professional group, associated with the agency or organization, which professional group must include at least one physician and one registered nurse;   [PL 1977, c. 470, §1 (NEW).]

C. Is available to provide the care needed in the home 7 days a week and has telephone answering service available 24 hours per day;   [PL 1977, c. 470, §1 (NEW).]

D. Has the ability to and does provide, either directly or through contract, the services of a coordinator responsible for case discovery and planning and assuring that the covered person receives the services ordered by the physician;   [PL 1977, c. 470, §1 (NEW).]

E. Has under contract the services of a physician-advisor licensed by the State or a physician;   [PL 1977, c. 470, §1 (NEW).]

F. Conducts periodic case conferences for the purpose of individualized patient care planning and utilization review; and   [PL 1977, c. 470, §1 (NEW).]

G. Maintains a complete medical record on each patient.   [PL 1977, c. 470, §1 (NEW).]

4.  Exclusions. 

A. No contract shall require home health care coverage to persons eligible for medicare; and   [PL 1977, c. 470, §1 (NEW).]

B. No payment shall be made for services provided by a person who resides in the covered person's residence or who is a member of the covered person's family.   [PL 1977, c. 470, §1 (NEW).]