1.0 BACKGROUND
1.1 The CCTP
program came into existence following the enactment of the National
Defense Authorization Act (NDAA) for Fiscal Year (FY) 2002, which
made a number of important changes to the TRICARE Program.
1.2 Congress
changed the definition of custodial care (10 USC 1072 (8) - (9).
Effective December 28, 2001, custodial care is no longer defined
by the condition of the patient but by the type of services being
rendered. Additionally, Section 701 of the NDAA for FY 2002 established
the TRICARE sub-acute care program under 10 USC 1074j adding the
TRICARE Skilled Nursing Facility (SNF) and Home Health Care (HHC)
(i.e., the Home Health Agency (HHA)) benefits, as well as the TRICARE
Extended Care Health Option (ECHO) program under 10 USC 1079(d)
- (f).
1.3 The CCTP program was developed to cover new
cases of custodial care beneficiaries entitled to expanded benefits
arising on or after the effective date of the law (December 28,
2001), because the new cases could no longer be addressed under
the repealed law authorizing the Individual Case Management Program
(ICMP), as discussed in
Chapter 1, Section 10.1. The purpose of the
CCTP program was to provide in-home medically necessary skilled
services until eligible beneficiaries could be covered under the
permanent TRICARE sub-acute care benefit and/or ECHO.
1.4 As these
new programs were being implemented, Section 713 of the NDAA for
FY 2005 authorized continued benefits under CCTP, for such time
period as determined appropriate, for those eligible beneficiaries
who were receiving CCTP benefits before establishment of the sub-acute programs
and who continued to need in-home medically necessary skilled care
exceeding the otherwise authorized TRICARE Basic Program coverage.
Once a beneficiary’s care needs can be met by the TRICARE Basic
Program HHA benefit which provides part-time or intermittent home
health care services, the beneficiary is no longer eligible for
CCTP.
1.5 This transitional policy provides TRICARE coverage
of medically necessary skilled services to those severely disabled
beneficiaries remaining in the initial CCTP population (before the
start of the TNEX contracts) that continue to receive extensive
home health care services under CCTP and will remain in effect as
indicated herein. CCTP is not open to new enrollees.
2.0 POLICY
Requirements for continued payment of CCTP
benefits:
2.1 Eligibility
The beneficiary must be TRICARE eligible. CCTP
benefits are payable for eligible beneficiaries (severely disabled
beneficiaries remaining in the initial CCTP population) who meet
the custodial care definition and who require in-home medically
necessary skilled services beyond what is provided by the HHA Prospective
Payment System (PPS) under the TRICARE Basic Program as specified
in the TRICARE Reimbursement Manual (TRM),
Chapter 12.
2.2
Authorized
Beneficiaries
Only those beneficiaries receiving
services under the CCTP prior to the implementation of the TRICARE
HHA PPS benefit in 2004 are eligible for continued coverage, specifically:
• Active
Duty Family Members (ADFMs), retirees and Non-Active Duty Family
Members (NADFMs) who were receiving medically necessary services
through the CCTP, since December 28, 2001, and remain enrolled at
the start of health care delivery under the new TRICARE Managed
Care Support (MCS) contracts.
• ADFMs who are eligible
for the CCTP program but are enrolled in and receiving benefits through
the ECHO, including ECHO Home Health Care (EHHC), remain eligible
for CCTP benefits as long as the beneficiary continues to meet the
custodial care definition and requires medically necessary skilled
services beyond what is provided by HHA PPS under the TRICARE Basic
Program.
• NADFMs
who were eligible for CCTP as ADFMs prior to their sponsor’s retirement,
including those who were enrolled in and receiving benefits through
the ECHO and/or EHHC while ADFMs, remain eligible for CCTP.
• ADFMs and NADFMs (as
described above) who become Transitional Survivors or Survivors, as
those terms are used in
Chapter 10, Section 7.1, remain eligible for
the CCTP.
Note: If a beneficiary’s
care needs can be met by the TRICARE Basic Program HHA benefit which provides
part-time or intermittent home health services, the beneficiary
is no longer eligible for CCTP.
2.3
Custodial Care
Beneficiaries must continue to meet the TRICARE
definition of custodial care in effect prior to December 28, 2001,
that is, custodial care is care rendered to a patient who:
• Is
disabled mentally or physically and such disability is expected
to continue and be prolonged; and
• Requires a protected,
monitored, or controlled environment whether in an institution or
in the home; and
• Requires
assistance to support the activities of daily living; and
• Is not under active
and specific medical, surgical, or psychiatric treatment that will
reduce the disability to the extent necessary that would improve
function to enable the patient to function outside the protected,
monitored, or controlled environment.
2.4 Authorized
Services
2.4.1 The care authorized under this policy is specifically
limited to medically necessary skilled services provided in the
home and coded with the CT designation. Claims for
other services shall be processed under normal TRICARE rules.
2.4.2 The approved
services are based on medical needs and medical needs should not
change significantly from day to day or week to week without a reassessment
of those medical needs. Additionally authorized but not used care
periods or portions thereof, cannot be saved or accumulated for
future use.
2.5 Annual Eligibility Reviews
Continuation of receipt of services requires
reassessment on a regular basis. The contractor shall submit a “custodial
care reassessment letter” annually to the Director, Defense Health
Agency (DHA), or designee.
2.5.1 The custodial care reassessment
review shall demonstrate that the beneficiary:
• Is disabled mentally
or physically and that such disability(ies) is (are) expected to continue
and be prolonged;
• Requires
a protected, monitored or controlled environment;
• Requires assistance
to support the Activities Of Daily Living (ADL) as defined in
32 CFR 199.2, which consists of providing
food (including special diets), clothing, and shelter; personal
hygiene services; observation and general monitoring; bowel training
or management (unless abnormalities in bowel function are of a severity
to result in a need for medical or surgical intervention in the
absence of skilled services); safety precautions; general preventive
procedures (such as turning to prevent bedsores); passive exercise;
companionship; recreation; transportation; and such other elements of
personal care that reasonably can be performed by an untrained adult
with minimal instruction or supervision. Activities of daily living
may also be referred to as “essentials of daily living”; and
• Is not undergoing
a plan of care which includes specific medical, surgical or psychiatric treatment
that will reduce the disability to the extent necessary to enable
the patient to function outside the protected, monitored or controlled
environment.
Note: A program of
physical and mental rehabilitation which is designed to reduce a
disability is not custodial care as long as the objective of the
program is a reduced level of care.
2.5.2 The contractor shall provide
supporting clinical documentation of all authorized participant’s
medically necessary skilled services, to include a plan of care
signed by the attending physician. The contractor shall provide
a complete clinical documentation update and recommendation for
continuation of coverage at the same level or indicate if either
an increase or decrease in services is indicated by the beneficiary’s
current needs. The recommendation shall also include cost-effective
strategies to meet the beneficiary’s needs and to ensure the appropriate
level of care is delivered to include projected costs based on the
number of skilled nursing hours and the rate obtained for those
hours. Once DHA reviews the reassessment and updated recommendations
of the contractor, the TRICARE Clinical Support Division (CSD) will
indicate concurrence or non-concurrence with the contractor’s determination
that the beneficiary meets the custodial care definition under
paragraph 2.3,
and a revised or updated authorization for continued coverage will
be issued to the contractor.
• Communication related
to annual assessment or condition changes should be made through
secure modalities, which can include email, fax, scanned document,
and/or electronic storage devices.
• Contractor shall administer
oversight of authorized medically necessary in-home skilled services
in accordance with current MCSC contract. This includes review of
CCTP program claims for quality of care and appropriate utilization
as required for all TRICARE health care claims. In addition, reviews
by both the DHA and the contractor shall be periodically conducted
to ensure that skilled services are provided in accordance with
established program requirements for medically necessary and appropriate
care and that hours of skilled services are being utilized in accordance
with the plan of care as approved. Approved hours are designed to
meet the medically necessary in-home skilled service needs of CCTP-eligible
beneficiaries. There is no authority under CCTP to provide respite
or custodial care. Consequently, “banking” or “saving” hours under
the program, by foregoing authorized hours of medically necessary
in-home skilled services, in order to provide continuous coverage
(in excess of the hours of medically necessary skilled services)
while family caretakers are out of town or otherwise unavailable
is not permitted. Authorized but unused hours may not be saved or
accumulated for any future use that is inconsistent with CCTP authorized services.
2.5.3 For ADFMs
who remain in the CCTP and whose in-home medically necessary skilled services
are provided under CCTP instead of ECHO EHHC, the contractor’s annual
assessment shall include a determination that the fiscal year financial
cap established in accordance with
Chapter 9, Section 15.1 will not support the
level of care required. CCTP beneficiaries are eligible to utilize
ECHO and ECHO EHHC during the sponsor’s active duty status, if these
programs meet the medical needs of the beneficiary. Beneficiaries
maintain their enrollment in CCTP for life as long as they continue
to meet the eligibility requirements stated under
paragraph 2.2.
2.5.4 When the
Director, DHA, or designee does not concur with the custodial care determination,
the beneficiary is disenrolled from CCTP and the contractor shall
process subsequent claims for medically necessary in-home skilled
services under the TRICARE Basic Program HHA in accordance with
the current MCS contract.
2.6 Portability
The
Director, DHA or designee’s decision regarding the custodial care
determination is transferable between TRICARE Regions, that is,
the “receiving” contractor shall accept the current decision of
the Director, DHA or designee and proceed to process claims accordingly.
ADFMs who relocate between annual assessments will be assessed by
the receiving contractor for determination of whether the EHHC rather
than the CCTP benefit can meet the beneficiary’s needs
2.7 Revisions
If at any time a contractor determines a need
for a change in authorized services for a beneficiary (e.g., due
to a change in CMAC rates, a change in patient condition, such as
a need for more or fewer covered hours, a change in HHA, etc.) the
contractor shall submit a written request for such change to the
Director, DHA CSD, or designee, that includes a detailed explanation
of why the change is required. The DHA CSD, or designee, will evaluate
each request and provide a written decision to the contractor.
2.8 Cost-Shares
Cost-shares shall not be applied to services
authorized under this policy.
2.9 Appeals
2.9.1 Appeals should be made directly
to the DHA, Office of General Counsel (OGC), Appeals and Hearings
Division. There are two appealable issues related to CCTP:
• A
custodial care determination under
paragraph 2.3; and
• Types and extent
of skilled services authorized for a CCTP eligible beneficiary.
2.9.2 The following
language is to be included by the contractors in the annual determination
of custodial care and notification of benefits related to CCTP letters
that are sent to beneficiaries:
“You
may appeal the custodial care determination as well as the denial
of in-home skilled services authorized under CCTP. Appealable issues
include the types and extent of services and supplies authorized
under CCTP and the determination that the care is custodial. The
request must be in writing, be signed, and must be postmarked or
received by the DHA, OGC, Appeals and Hearings Division, 16401 East
Centretech Parkway, Aurora, Colorado 80011-9066, within 90 days
from the date of this determination. For the purposes of TRICARE,
a postmark is a cancellation mark issued by the United States Postal Service.”
2.9.3 The contractor
is required to issue a letter of custodial care determination to
each CCTP beneficiary annually outlining the hours of skilled in
home care approved for the upcoming year.
2.10 Claims Processing
CCTP claims are to be paid as non-underwritten
health care and should be reported as such. TED records for these
claims must reflect both special processing codes CT and W.
Claims for services that are provided outside of this policy must
be processed in accordance with the TOM, the TRM, and the TRICARE
Systems Manual (TSM), and without the use of the special processing
codes CT and W.
2.11 The contractor
shall notify the Director, DHA CSD, or designee upon any of the
following changes to any beneficiary who is covered under this policy:
• Death;
• Eligibility status,
including becoming a Transitional Survivor or a Survivor as those
terms are used in
Chapter 10, Section 7.1;
• Residential relocation
(pending or completed);
• Custodial care status
(as defined in
paragraph 2.3);
• Inpatient admission;
• Requests for disengagement.
3.0 EXCLUSIONS
3.1 Custodial
care, as defined in
32 CFR 199.2,
is not a TRICARE benefit. The term “custodial care” means treatment
or services, regardless of who recommends such treatment or services
or where such treatment or services are provided, that:
• Can
be rendered safely and reasonably by a person who is not medically
skilled; or
• Are
designed mainly to help the patient with the Activities of Daily
Living (ADL).
3.2 CCTP benefits may not be extended
for or credited towards institutional care, including assisted living
facilities.
3.3 Beneficiaries who were receiving benefits under
the Individual Case Management Program For Persons With Extraordinary
Conditions (ICMP-PEC) as of December 27, 2001, and those grandfathered under
the former HHC/Case Management (CM) demonstration project will continue
to receive those services as grandfathered members of those programs,
and will not be considered for the CCTP.