Opinion ID: 777312
Heading Depth: 3
Heading Rank: 1

Heading: General Benefits

Text: 23 Three Plan provisions are crucial to resolving the Fays' claim: the Medical Care, Home Care, and exclusion provisions. Read together, these provisions demonstrate that the full-time, private duty home nursing the Fays desire is generally unavailable under the Oxford Plan. In Attachment A, the Plan lays out a detailed schedule of benefits and exclusions. Under Professional Services Performed Within Health Plan's Service Area, the Plan describes both Medical Care and Home Health Care. Because of the importance of these provisions to the outcome of the Fay's case, they are reproduced in pertinent part here. The Medical Care Provision provides that: 24 Medically Necessary medical care and services, including office visits and consultations, Hospital and Skilled Nursing Facility visits, and periodic physical examinations as described in Attachment D hereto, are covered in accordance with the terms of this Certificate when authorized in advance by Member's Primary Care Physician and/or Oxford as required under the terms of this Certificate. 25 The Fays read this provision as guaranteeing all services that are medically necessary. Thus, the Fays argue that because private duty nursing is, in their view, medically necessary for Mr. Fay, the Plan should cover his full-time, in-home service. The Fays, however, neglect the impact of the subsequent Home Health Care provision also contained under Professional Services Performed Within Health Plan's Service Area. The Home Health Care provision provides details on in-home services not specifically listed under the Medical Care provision: 26 b. Home Care. Care in the home by Physician-supervised health professionals other than Physicians, provided by a state licensed or certified Home Health Agency within the Service Area when authorized in advance by Member's Primary Care Physician and Health Plan. Such care shall be limited to two hundred (200) home care visits per contract year. For the purpose of this Certificate, a visit is defined as treatment of up to 4 hours by an eligible home health provider. Home care includes (i) parttime or intermittent home nursing care by or under the supervision of a registered professional nurse (R.N.), (ii) parttime or intermittent home health aide services which consist primarily of caring for the Member, (iii) physical, occupational, or speech therapy where provided by the home health service or agency, and (iv) medical supplies, drugs and medications prescribed by a Participating Physician, and laboratory services by or on behalf of a certified home health agency to the extent such items would have been covered or provided hereunder if the Member had been hospitalized or confined in a Skilled Nursing Facility. 27 The Fays attempt to dismiss the limitations of the Home Care Provisions (200 home care visits of up to 4 hours each per year), claiming that this provision addresses only short-term, in-home care and does not address the private duty nursing (full-time, in-home care) they desire. This provision demonstrates, however, that only short-term care, not the full-time care the Fays seek, is generally available under the Plan. The private duty nursing the Fays desire does not appear in the plain language of either the Medical Care or Home Care provisions. As discussed below, the Plan directly addresses such full-time, in-home care, only as a specific exclusion from regular coverage.