If you or your dependents require care in a nursing home, a hospice, or care in your home from a registered nurse or licensed practical nurse, the Plan will pay a percentage of covered costs while this type of care is required. These benefits must be pre-authorized in order to be covered by the Plan.
- If prior authorization is obtained, the Plan will pay:
- 80% of the allowance for covered home health care visits by a registered nurse or licensed practical nurse, after you’ve met your annual deductible
- 100% of the allowance for visits by a home health care aide
- If you (or your dependent) are required to stay in a nursing home following hospitalization, the Plan will pay for covered expenses at 100% of the allowance for up to 60 days.
- Hospice care is covered at 100% of the allowance in a pre-approved facility.
What You Need To Do
- If you are in need of home health care, contact the UHC CARE Program at 1-800-850-1418 for pre-approval.
- For care in a hospice, call the UHC CARE Program at 1-800-850-1418 to pre-approve the facility.
Home Health Care
The Plan covers expenses for home health care instead of hospitalization or beginning within 24 hours after discharge from a hospital confinement. The Plan will pay 80% of the allowance for covered home health care visits by a registered nurse or licensed practical nurse, after you’ve met your annual deductible. The Plan will pay 100% of the allowance for home health care visits by a home health care aide.
Covered home health care expenses will be paid, provided that the home health care service:
- is required for care or treatment of an injury or illness which resulted in covered medical expenses
- consists of in-home visits by a registered nurse (R.N.) or licensed practical nurse (L.P.N.) or home health care aide under supervision of a Medicare-certified home health care organization
- is approved in advance by the UHC CARE Program (800-850-1418)
For home health care visits by a home health aide, covered charges are paid up to the allowance.
Nursing Home Care
The Plan will reimburse 50% of the actual charges for convalescent nursing home expenses for a semi-private room rate charged by the discharging hospital, for up to 60 days per spell of illness. Other covered expenses are payable at 100% of the allowance up to the maximum benefit of $7,000. Charges that exceed $7,000 are payable at 80%.
! Convalescent nursing home confinement is considered “required” only if it:
is ordered by the attending physician
begins within seven days of discharge from a hospital confinement of at least two days
is due to an illness or injury resulting in covered medical expenses
Limitation on Nursing Home Care
Expenses due to required confinement in a convalescent nursing home following a hospital stay are covered in the amount of the actual charges, limited as follows:
- no more than the maximum of 60 days of confinement per spell of illness, are covered
- the maximum daily room and board charge is covered at 50% of the average semi-private room rate at the discharging hospital
- the amount payable in full under this provision, when combined with hospital expenses for the same spell of illness, may not exceed the dollar limit for covered hospital expenses shown above
The Plan pays 100% of the allowance for hospice care in a pre-approved facility. Call UHC at 1-800-850-1418 to pre-approve the facility.