Aetna Commercial Clinical Policy

Aetna Home Behavioral Healthcare Services Form

Effective Date

11/17/2006

Last Reviewed

10/18/2023

Original Document

  Reference



Background for this Policy

Skilled home behavioral health care is the provision of intermittent skilled services for treatment of behavioral disorders in the home. These services are rendered in lieu of hospitalization, confinement in an extended care facility, or going outside of the home for the service.

Scope of Policy

This Clinical Policy Bulletin addresses home behavioral healthcare services.

Medical Necessity

Subject to applicable benefit plan terms and limitations, Aetna considers provision of skilled behavioral health services in the home medically necessary when

all

of the following criteria are met:

  • The services are ordered by a physician or independently licensed behavioral health professional (BHP) (e.g., psychiatrist, psychologist, and social worker or professional counselor licensed to practice without supervison in their State) and are directly related to an active treatment plan of care established by the physician or licensed BHP;
    • and
  • The skilled behavioral health care is appropriate for the active treatment of a condition, illness or disease;
    • and
  • The skilled behavioral health care is intermittent or hourly in nature
    • Footnotes for Intermittent or part-time skilled home behavioral health care *
  • ;
    • and
  • The skilled behavioral health care is provided under the supervision of an independently licensed BHP;
    • and
  • The services are provided in lieu of a continued hospitalization, confinement in a residential treatment facility (RTF), or receiving outpatient services outside of the home;
    • and
  • The treatment provided is appropriate for the member's condition including the amount of time spent providing the service as well as the frequency, type and duration of the services;
    • and
  • The behavioral health services provided are not primarily for the comfort or convenience of the member or family or custodial in nature
    • Footnotes for Custodial care **
  • .
    • Footnotes for Intermittent or part-time skilled home behavioral health care

    * Intermittent or part-time skilled home behavioral health care is defined as a visit of up to 1 hour in duration.

    Footnotes for Custodial care

    ** Custodial care is defined as services and supplies furnished to a person mainly to help him or her with activities of daily living. Custodial care includes services and supplies:

  • Furnished mainly to train or assist the insured family member in personal hygiene and other activities of daily living rather than to provide therapeutic treatment;
    • or
  • That can be safely and adequately provided by persons without the technical skills of a health care provider (e.g., nurse).

    • Policy Limitations and Exclusions

    Note:

    Skilled home behavioral healthcare services are covered under the member’s behavioral healthcare benefit. Please check benefit plan descriptions.