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the repealed law authorizing the Individual Case Management Program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.