NEW JERSEY

20 West State Street, 10th Floor

PO Box 325

Trenton, NJ 08625

Phone: 609-633-1882, ext. 50302

Fax: 609-633-2030

E-Mail: ellen.derosa@dobi.nj.gov

September 21, 2000

To: SEH Program Member Carriers

From: Ellen F. DeRosa, Deputy Executive Director

The SEH Board issued Advisory Bulletin 99-SEH–05 on June 18, 1999 addressing HMO-based coverage for home health care and private duty nursing. The purpose of this Advisory Bulletin is to address coverage for home health care and private duty nursing as provided under indemnity-based plans (Plans B, C, D, E, PPO and indemnity based-POS plans).

The standard indemnity-based plans include the following:

• A provision detailing the coverage provided for home health care; and
• A provision stating that private duty nursing is covered only if it is authorized as part of a home health care plan.

Other than stating the full-time or 24-hour care can be limited to a "short term basis," the language in the standard plans does not support the imposition of any sort of limit such as number of days, number of hours, or dollar maximum with respect to coverage under the home health care section of the plan. As with other Covered Charges under the standard plans, the carrier is only required to provide coverage for those services and supplies that are Medically Necessary and Appropriate. With respect to POS coverage, network benefits would require a referral from the Primary Care Physician.

Any carrier found to be imposing a limit on Medically Necessary and Appropriate services for home health care will be considered in knowing violation of New Jersey law, and subject to penalties as provided under New Jersey law.

Please note that this Advisory Bulletin describes the coverage provided under the standard small employer health benefits plans as they are currently set forth in the appendix exhibits to N.J.A.C. 11:21.