N.J. Admin. Code § 11:4-14.3

Current through Register Vol. 56, No. 24, December 18, 2024

Section 11:4-14.3 - Home health care benefits required

(a) Minimum coverage rules are as follows:

1. The policy may require no more than three continuous days of hospitalization or skilled nursing facility care prior to provision of home health care benefits.

2. The home health care services listed in paragraphs 1 through 7 of the definition of home health care services must provide for at least 60 home health care visits in any calendar year or in any continuous period of 12 months.

3. Any visit by a member of a home health care team on any day shall be considered as one home health care visit.

4. If the policy contains a number of days during which home health care benefits must commence following hospital discharge, that number of days may not be less than three.

5. The services and supplies listed in paragraphs 1 through 8 of the definition of home health care services shall be furnished by a home health care provider and the charges for such services and supplies shall be made by the home health care provider.

(b) Extent of payment rules are as follows:

1. The dollar amount of payment for all home health care visits on each of the first three days of home health care services need not exceed the daily hospital room and board benefit provided by the policy during the period of prior confinement. The dollar amount of payment for all home health care visits on each subsequent day of home health care services need not exceed one half the daily hospital room and board benefit provided by the policy during the period of prior confinement. For policies which provide only benefits for skilled nursing facility care, the dollar amount of payment for each home health care visit need not exceed the daily skilled nursing facility room and board benefit.

2. Charges for home health care services may be limited to the usual and customary charges for such services.

(c) Compliance with the home health care law concerning direct reimbursement will be met if the policy includes the direct payment provisions of N.J.S.A. 17B:26-12b or N.J.S.A. 17B:27-45, or if an assignment of benefits is made available to the insured. It is not intended that the insured be denied the right to receive benefit payments which is provided by the statute.

N.J. Admin. Code § 11:4-14.3