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no longer be addressed under the repealed law authorizing the Individual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.
