Answers to the most frequently asked questions
Home-based general nursing services were included in the GHS in December 2020, offering the possibility for certain groups of beneficiaries to receive specialised health care services at home.
Access to these services is by referral from a Personal Physician or Specialist Physician and applies to beneficiaries registered by the Personal Physician as "capped". In cases where a beneficiary, due to serious health problems, cannot move from his/her place of residence, it is possible for the health care services to be provided at home.
Once the beneficiary has obtained a referral from the Personal or Specialist Physician, he/she has the right to choose from the list of providers participating in the GHS the one he/she wishes to receive the services he/she needs at home. The beneficiary must then make an appointment with the nurse practitioner of his or her choice.
The GMS covers a specific maximum number of sessions for home-based general nursing services per beneficiary, per year.
Specifically:
All patients (children and adults) are eligible to receive up to 12 visits per year, which are covered by the System. In exceptional cases where the attending physician and nurse consider that the patient needs more visits, they may request a higher number of visits. This request is evaluated by the Agency, provided all the necessary information and documentation is provided.
Each new year, the beneficiary may receive up to 12 visits, if the conditions for which the GHS reimburses home nursing services are met.
SUPPLIES
The medical devices or consumables needed by each beneficiary for home health care are prescribed by the attending physician. Depending on the type, they may be obtained either from hospital pharmacies (or the warehouses of nursing homes) or from private pharmacies. Products supplied by private pharmacies are marked "IF" in their description.
In cases where the beneficiary or other relative is not able to obtain the necessary consumables himself and where there is an authorisation, the System shall enable the nurse to obtain them on behalf of the beneficiary. In this case, the nurse must obtain the appropriate authorization from the beneficiary. The nurse will need to provide the pharmacy with the beneficiary's personal information such as ID card number and date of birth.
FAQ
Can a beneficiary receive services outside the GHS from a nurse contracted with the System?
In cases where the beneficiary does not possess or provide a referral with services reimbursed by the GIS, then the nurse practitioner is allowed to provide the services, but they will not be reimbursed by the System. He/she must nevertheless inform the beneficiary at the outset that he/she will receive services outside the System. The same applies in cases where the beneficiary has exhausted the maximum number of visits to which the beneficiary is entitled, as defined by the Agency.
Can beneficiaries receive services during the weekend?
The Health Insurance Agency does not determine the days/hours each provider works. However, in such cases, the provider must comply with any regulations issued by the Agency with respect to the total duration of services to ensure that quality health care services are provided to beneficiaries.
A beneficiary who is hospitalized in an inpatient facility not contracted with the HHA may receive services from a nurse practitioner contracted with the HHA?
If the patient is an inpatient in a hospital not contracted with OAS and who does not have a referral for health care nursing services, then the nurse may continue to provide services outside of the GHC setting, with the cost borne by the beneficiary.
If services are provided during a beneficiary's inpatient stay in a GHC-contracted hospital, those services are reimbursed according to the DRG coding system in which they are included.
Contents of this article including associated images are owned by PIO
Views & opinions expressed are those of the author and/or PIO
Source
