Section 1374.10 Of Article 5. Standards From California Health And Safety Code >> Division 2. >> Chapter 2.2. >> Article 5.
1374.10
. (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.