SMALL EMPLOYER HEALTH BENEFITS PROGRAM
20 West State Street, 10th Floor
PO Box 325
Trenton, NJ 08625
Phone: 609-633-1882, ext. 50302
June 18, 1999
To: SEH Program Member Carriers
From: Ellen F. DeRosa, Deputy Executive Director
Re: HMO-based Coverage for Home Health Care and Private Duty Nursing
With respect to private duty nursing and home health care, the standard HMO plan and the in-network portion of the standard HMO-POS plan provide coverage for the following:
As with other services and supplies covered under the standard HMO and HMO-POS plans, the carrier is only required to provide coverage for those services and supplies that are medially necessary and appropriate. In addition, the carrier would require a referral from the primary care physician or care manager, if applicable.
If a member has received a referral, as required, and private duty nursing and/or home health services and supplies are and continue to be medically necessary and appropriate then the carrier must cover services and supplies. The language in the standard plans does not support the imposition of any sort of a limit, for example, number of days or hours, on these services.
Any HMO carrier found to be imposing a limit on such medically necessary and appropriate services will be considered in knowing violation of New Jersey law, and subject to penalties as provided under New Jersey law.
Please note that this Bulletin responds to an inquiry concerning the nature of Home Health Services coverage and Private Duty Nursing Coverage provided under a standard HMO plan or a standard HMO-POS plan and the guidance provided herein applies only to such plans. The nature and extent of coverage for Private Duty Nursing and/or Home Health Care under a plan issued by a carrier that is not an HMO is specified in the standard plans. Please refer to the text of Plans B, C, D and E found in Appendix Exhibit B of N.J.A.C. 11:21 for information concerning such coverage under a non-HMO plan.
If you have any questions, feel free to contact me.
Published: July 1, 1999