Humana Home Health Form

Home health care refers to intermittent skilled services rendered by personnel of a state licensed and/or Medicare certified home health agency to an individual at their place of residence. Sometimes home health care services follow discharge from a hospital, skilled nursing facility or may be needed in place of an inpatient admission. The purpose of home health care is to restore health or independence while reducing the effects of disability and disease, including terminal illness.

Skilled care

Skilled care refers to health care that is managed, observed and evaluated by nursing or rehabilitation staff. Examples of skilled care includes, but may not be limited to:

• Applications of dressings involving prescription medications and aseptic technique
• Insertion/replacement of catheters and sterile irrigations of catheters
• Intravenous (IV) injections
• Recent or complicated ostomy requiring extensive care
• Speech therapy
• Therapeutic exercises, which must be performed by, or under the supervision of, a licensed physical or occupational therapist

Custodial care

Custodial care refers to things that most individuals do themselves (eg, nonskilled care), as part of normal daily activities, such as getting in and out of bed, bathing, eating, dressing and using the bathroom. Taking medicine, such as eye drops, using oxygen or routine care of colostomy or bladder catheters is also considered custodial. (Refer to Coverage Limitations section)

Private duty care

Private duty care describes a wide variety of home care services that includes non- medical services such as home care aides, companion care and homemaker services, as well as some traditional skilled nursing and therapy services. Typically the private duty caregiver provides continuous one on one care rather than caring for multiple individuals. (Refer to Coverage Limitations section)

For information regarding coverage determination/limitations not addressed in this medical coverage policy, please refer to the following:

Service Corresponding Medical Coverage Policy

• Chelation therapy Complementary and Alternative Medicine
• Home births Home Births and Birth Doulas
• History of prothrombin time Monitoring of prothrombin time Durable Medical Equipment
• Speech therapy Speech Therapy
• Therapeutic exercises, performed by, or under the supervision of, a licensed physical or occupational therapist Physical Therapy and Occupational Therapy

Home Health Effective Date: 06/22/2023

Revision Date: 06/22/2023

Review Date: 06/22/2023

Policy Number: HUM-0329-029

Page: 3 of 23

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

Coverage Determination

Services provided by a psychiatrist, psychologist or other behavioral health professionals are subject to the provisions of the applicable behavioral health benefit.

Refer to specific certificate language regarding home health care.

Most certificates limit the duration or number of visits. Any state mandates for home health take precedence over this medical coverage policy. Humana members may be eligible under the Plan for home health services, with the exception of home infusion therapy, when ALL of the following criteria are met:

• Individual must be confined to the home or the condition is such that leaving the home for required services would require considerable effort or expose the individual to undesirable risk; AND
• Service(s) must be prescribed by the attending physician or other licensed healthcare professional acting within their state specific licensure and scope of practice in their licensed jurisdiction where the services are provided as part of a written plan of care; AND
• Plan of care must be established and approved by a physician or other licensed healthcare professional acting within their state specific licensure and scope of practice in their licensed jurisdiction where the services are provided; AND
• In-home intermittent skilled care is provided by or under the supervision of the following:
  • Occupational therapist
  • Physical therapist
  • Registered or licensed practical (vocational) nurse
  • Respiratory therapist
  • Social worker
  • Speech therapist

Home Health Effective Date: 06/22/2023
Revision Date: 06/22/2023
Review Date: 06/22/2023
Policy Number: HUM-0329-029
Page: 4 of 23

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

Unless otherwise specified in the certificate of coverage, a visit for home health services of two hours or less in 24 hours will be counted as one visit. Each additional two hours of home health services in 24 hours would be considered an additional visit. (Example: Five hours of home health services in 24 hours would be considered three visits.) (Refer to individual certificate language for specific information as this may vary).

Recertification for home health visits by the attending physician may be required at a minimum of every 21-30 days.

Note: The criteria for home health care are not consistent with the Medicare National Coverage Policy, and therefore may not be applicable to Medicare members. Refer to the CMS website for additional information.

Coverage Limitations

Humana members may NOT be eligible under the Plan for the following services, as these are generally excluded by certificate:

• Custodial care (eg, nonskilled care) including, but may not be limited to:
  • Domestic housekeeping services unrelated to care of the individual; OR
  • Meals on Wheels or similar food arrangements; OR
  • Medication administration that would normally not require assistance; OR
  • Respite care services; OR
  • Services designed to help an individual meet the needs of daily living, whether or not a disability exists (inability to walk or get out of bed); OR
• Home health aides; OR
• Maintenance care consists of activities that generally are intended to preserve the individual’s present level of function and/or prevent regression of that level of function including, but may not be limited to:

Home Health Effective Date: 06/22/2023
Revision Date: 06/22/2023
Review Date: 06/22/2023
Policy Number: HUM-0329-029
Page: 5 of 23

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version.

Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

• Maintenance begins when the therapeutic goals of the treatment program are achieved or when no further significant progress is made or reasonably seen as occurring; AND
• Individual has achieved generally accepted normal levels of function and/or muscle strength and has reached a plateau (generally a period of 4 weeks or less, depending on the specific condition and/or individual situation); OR

Private duty care (may be custodial or skilled but is one on one and more continuous in nature than intermittent home health services)

Humana members may NOT be eligible under the Plan for home health services for any indications other than those listed above, including, but may not be limited to, the following:

• Administration of home health services simply for member, family or caregiver convenience; OR
• Services performed by a physical therapist assistant or occupational therapist assistant when reported separately from supervising therapist; OR
• Treatment plan does not demonstrate continued need for skilled home care

All other indications are considered not medically necessary as defined in the member’s individual certificate. Please refer to the member’s individual certificate for the specific definition.

Background

Additional information about home health care, hospital discharge planning or transitioning to home after being in a skilled nursing facility may be found from the following websites:

• Family Caregiver Alliance
• National Library of Medicine

Home Health Effective Date: 06/22/2023
Revision Date: 06/22/2023
Review Date: 06/22/2023
Policy Number: HUM-0329-029
Page: 6 of 23

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

Medical Alternatives

Alternatives to home health care include, but may not be limited to, the following:

• Receipt of services in a hospital, laboratory, outpatient facility, physician’s office or skilled nursing facility

Physician consultation is advised to make an informed decision based on an individual’s health needs.

Any CPT, HCPCS or ICD codes listed on this medical coverage policy are for informational purposes only. Do not rely on the accuracy and inclusion of specific codes. Inclusion of a code does not guarantee coverage and or reimbursement for a service or procedure.