TRICARE Manuals - Display Chap 8 Sect 15.1 (Change 120, Nov 8, 2023)

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Chapter 8

Section 15.1

Custodial Care Transitional Policy (CCTP)

Issue Date: June 11, 2002

Authority: 10 USC 1074 j(b)(4), 10 USC 1072 (8) and (9); 32 CFR 199.2

Revision: C-107, January 6, 2023

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after the effective date of the law (December 28, 2001), because the new cases could no longer be addressed under the repealed law authorizing the Individual Case Management Program (ICMP), as discussed in Chapter 1, Section 9.1. The CCTP program provides in-home medically necessary skilled services until eligible beneficiaries are covered under the permanent TRICARE sub-acute care benefit 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 are 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 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 are 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 reduces the disability to the extent necessary to improve function enabling 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 are processed under normal TRICARE rules.

2.4.2 The approved services are based upon medical needs and medical needs normally do 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, are not 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 demonstrates 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 (see the TRICARE Operations Manual (TOM), Appendix A); and

• Is not undergoing a plan of care that includes specific medical, surgical or psychiatric treatment that reduces 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 that 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 also includes cost-effective strategies to meet the beneficiary’s needs and to ensure the appropriate level of care is delivered to include projected costs based upon 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) indicates concurrence or non-concurrence with the contractor’s determination that the beneficiary meets the custodial care definition under paragraph 2.3, and issues a revised or updated authorization for continued coverage to the contractor.

• Use of secure modalities for communication related to annual assessment or condition changes (e.g., email, fax, scanned document, and electronic storage devices).

• The contractor shall administer oversight of authorized medically necessary in-home skilled services in accordance with current MCS 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, both the DHA and the contractor conduct periodic reviews 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, 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 are not 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 FY 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 The beneficiary disenrolled from CCTP when the Director, DHA, or designee does not concur with the custodial care determination. 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 Managed Care Support Program Sections (MCSPSs), that is, the “receiving” contractor shall accept the current decision of the Director, DHA or designee and proceed to process claims accordingly. The receiving contractor shall assess ADFMs who relocate between annual assessments to determine 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 CHAMPUS Maximum Allowable Charge (CMAC) rates, a change in patient condition, such as a need for more or fewer covered hours, a change in HHA) 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 are not applied to services authorized under this policy.

2.9 Appeals

2.9.1 Appeals are 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 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 shall 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 paid as non-underwritten health care and reported as such. TRICARE Encounter Data (TED) records for these claims reflect both special processing codes CT and W. Claims for services that are provided outside of this policy are 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 (see the TOM, Appendix A), is not a TRICARE benefit.

3.2 CCTP benefits are not 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.

4.0 EFFECTIVE DATE

December 28, 2001.

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DHA Address: 7700 Arlington Boulevard | Suite 5101 | Falls Church, VA | 22042-5101

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