Home Health Care and Hospice Care
Home health care and hospice care under the CAP are covered at 90% of the negotiated rate, after deductible, if you use an Anthem Blue Cross PPO network provider. Non-network home health care and hospice care is covered at 90% of Customary and Reasonable Charges (Eligible Expenses) after deductible. Pre-authorization is required, and a penalty of $300 applies if no pre-authorization is obtained.
The CAP will cover the services of an approved home health care agency or hospice agency, provided the services are Medically Necessary Covered Health Services, not custodial in nature, ordered by your attending physician and rendered under a written treatment plan approved by Anthem Blue Cross. Custodial care, which is not covered, is defined as care provided primarily to assist an individual in meeting the activities of daily living including, but not limited to, walking, bathing, dressing, eating, preparation of special diets, changing catheters, and supervision over self-administration of medications not requiring constant attention of trained medical personnel. It is care that can be taught to a lay person who does not have any professional qualifications, skills or training.
When your doctor recommends either home health or hospice care, he or she must contact Anthem Blue Cross at 800-274-7767 for pre-authorization.
Services in Your Home
The Plan covers the following services when rendered in the patient's home, provided that the services are Medically Necessary Covered Health Services and are not considered custodial care, as determined by Anthem Blue Cross:
  • Nursing services provided by a registered nurse (R.N.), or a licensed vocational nurse (L.V.N.) or licensed practical nurse (L.P.N.) when under the supervision of an R.N.
  • Services of a home health aide.
  • Physical, occupational, speech or respiratory therapy; medical social services; and nutritional counseling.
  • For a patient formally admitted to a hospice program: homemaking services; counseling for the patient and covered family members; up to three days of respite care during a six-month period; and bereavement counseling by a certified social worker who is an employee of the hospice, for up to 12 months after the patient's death. Bereavement counseling benefits are limited to $25 per visit, four visits per family.
Hospice Facility
Medically Necessary Covered Health Services in a hospice facility are covered when a patient in the latter stages of a terminal illness is formally admitted to an inpatient hospice program and Medical Management has approved the admission.
The following inpatient hospice services are covered:
  • Bed, board and general nursing care.
  • Medical care provided by other professional providers employed by the facility.
  • Hospice facility services and supplies.
  • Family counseling related to the patient's illness.
  • Bereavement counseling for the family after the patient's death.
Eligibility for hospice benefits begins on the date on which the patient's physician certifies that the patient has a life expectancy of six months or less.
The Plan does not cover homemaking services, except as specifically provided above. Food or home-delivered meals and services by volunteers who do not regularly charge for their services are not covered.
Coverage of physician, hospital, ambulance and hemodialysis services, purchase or rental of durable medical equipment, medical supplies, drugs and medicines is provided as described elsewhere in this Handbook.