Home Health Policy Interpretation

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The following is the language laying out the benefit period in Manhattan' HHC plan.

HOME HEALTH CARE SERVICES BENEFIT

Daily Maximum Aggregate Benefit..................................................... $300.00

Maximum Benefit Period ................................................................... 365 Days


Maximum Benefit Period: means the maximum number of days We will pay benefits for Covered Home Health Care during Your lifetime, unless benefits are restored as provided in the policy’s Restoration of Benefits provision. Maximum Benefit Periods will vary by type of Covered Home Health Care provided. Maximum Benefit Periods are shown on the Benefits Schedule


The Maximum Benefit Period for the Home Health Care Services Benefit is set forth on the Policy Schedule. This is the maximum number of days we will pay the Home Health Care Services Benefit during a Covered Person’s lifetime, unless benefits are restored as provided in the Restoration of Benefits provision. The Maximum Benefit Period is calculated in continuous days from the first day for which the Home Health Care Services Benefit is payable, and each day you receive any services from an Approved Home Health Care Practitioner will count as one full day toward the maximum, without regard to whether the Covered Person’s Home Health Care Service is received on consecutive days.

How do you interpret this? It seems to me a benefit period begins on the first day benefits are paid and ends once benefits have been PAID for 365 days.
 
The following is the language laying out the benefit period in Manhattan' HHC plan.

HOME HEALTH CARE SERVICES BENEFIT

Daily Maximum Aggregate Benefit..................................................... $300.00

Maximum Benefit Period ................................................................... 365 Days


Maximum Benefit Period: means the maximum number of days We will pay benefits for Covered Home Health Care during Your lifetime, unless benefits are restored as provided in the policy’s Restoration of Benefits provision. Maximum Benefit Periods will vary by type of Covered Home Health Care provided. Maximum Benefit Periods are shown on the Benefits Schedule


The Maximum Benefit Period for the Home Health Care Services Benefit is set forth on the Policy Schedule. This is the maximum number of days we will pay the Home Health Care Services Benefit during a Covered Person’s lifetime, unless benefits are restored as provided in the Restoration of Benefits provision. The Maximum Benefit Period is calculated in continuous days from the first day for which the Home Health Care Services Benefit is payable, and each day you receive any services from an Approved Home Health Care Practitioner will count as one full day toward the maximum, without regard to whether the Covered Person’s Home Health Care Service is received on consecutive days.

How do you interpret this? It seems to me a benefit period begins on the first day benefits are paid and ends once benefits have been PAID for 365 days.

I agree with your comment. (I added an edit below.)

It seems to me a benefit period begins on the first day benefits are paid and ends once benefits have been PAID for 365 days [without regard to whether the Covered Person’s Home Health Care Service is received on consecutive days].

So yeah, if you are only getting care, say 3 days a week, you should have longer than a calendar year before the benefit runs out and you have to start a reset period.

However, keep in mind I am neither an agent nor an attorney, that is just my opinion about what you posted.
 
The following is the language laying out the benefit period in Manhattan' HHC plan.

HOME HEALTH CARE SERVICES BENEFIT

Daily Maximum Aggregate Benefit..................................................... $300.00

Maximum Benefit Period ................................................................... 365 Days


Maximum Benefit Period: means the maximum number of days We will pay benefits for Covered Home Health Care during Your lifetime, unless benefits are restored as provided in the policy’s Restoration of Benefits provision. Maximum Benefit Periods will vary by type of Covered Home Health Care provided. Maximum Benefit Periods are shown on the Benefits Schedule


The Maximum Benefit Period for the Home Health Care Services Benefit is set forth on the Policy Schedule. This is the maximum number of days we will pay the Home Health Care Services Benefit during a Covered Person’s lifetime, unless benefits are restored as provided in the Restoration of Benefits provision. The Maximum Benefit Period is calculated in continuous days from the first day for which the Home Health Care Services Benefit is payable, and each day you receive any services from an Approved Home Health Care Practitioner will count as one full day toward the maximum, without regard to whether the Covered Person’s Home Health Care Service is received on consecutive days.

How do you interpret this? It seems to me a benefit period begins on the first day benefits are paid and ends once benefits have been PAID for 365 days.
Yes, both GTL and Manhattan work the same way. 365 day lifetime benefit (GTL's is 360)....unless you NO LONGER REQUIRE HHC services and have gone 180 consecutive days without receiving HHC, then your 365 day benefit will be restored. The 60 day Homecare Aide benefit will also be restored.
 
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Yes, both GTL and Manhattan work the same way. 365 day lifetime benefit....unless you NO LONGER REQUIRE HHC services and have gone 180 consecutive days without receiving HHC, then your 365 day benefit will be restored. The 60 day Homecare Aide benefit will also be restored.
They are denying my June claims because my claims started in May of last year.. But, they have only paid about 120 days of care.so I should still be entitled to another 245 days..

If it is the way they say it is, you could receive treatment for one day per week in the month of May. {4 days) Again in October (4days) and again in March (4 days) Then if you have additional care in June, they would not pay because the benefit period has expired and you have not gone 6 months without treatment to restore coverage, they have paid only 12 days and then you are out of luck.
 
They are denying my June claims because my claims started in May of last year.. But, they have only paid about 120 days of care.so I should still be entitled to another 245 days..

If it is the way they say it is, you could receive treatment for one day per week in the month of May. {4 days) Again in October (4days) and again in March (4 days) Then if you have additional care in June, they would not pay because the benefit period has expired and you have not gone 6 months without treatment to restore coverage, they have paid only 12 days and then you are out of luck.
Sounds like BS to me.

Maybe the Healthcare Agency didn't file the claim properly?
 
They are denying my June claims because my claims started in May of last year.. But, they have only paid about 120 days of care.so I should still be entitled to another 245 days..

If it is the way they say it is, you could receive treatment for one day per week in the month of May. {4 days) Again in October (4days) and again in March (4 days) Then if you have additional care in June, they would not pay because the benefit period has expired and you have not gone 6 months without treatment to restore coverage, they have paid only 12 days and then you are out of luck.
Well, I got a call from Manhattan. They are going to pay the claim. The computer was programmed to stop paying the claims after 365 days from date of the first claim. They agree that it should be 365 days of PAYMENT,
 
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