Clinical Policy: Long Term Care Placement Form

CENTENE
Corporation

Clinical Policy: Long Term Care Placement
Reference Number: CP.MP.71
Date of Last Review: 01/25

Coding Implications
Revision Log

See Important Reminder at the end of this policy for important regulatory and legal information.

Description
Nursing home care includes both long term residential care and short-term post-acute or rehabilitative care. This policy addresses long term care (LTC) placement ranging from basic custodial care to more intense care needed due to dementia or other complex medical needs. Skilled services require the skills of qualified technical or professional health personnel such as registered nurses, licensed vocational nurses, physical therapists, occupational therapists, speech pathologists, or audiologists.

Policy/Criteria
I. It is the policy of health plans affiliated with Centene Corporation® that long term care placement is medically necessary for the following indications:

A. Custodial/Non-Skilled Care .................................................................................................................1
B. Dementia/Wandering Care .................................................................................................................2
C. Dementia with Behaviors Care ...........................................................................................................3
D. Dialysis Care ...................................................................................................................................4
E. Respiratory Care ................................................................................................................................5
F. Ventilator Care ..................................................................................................................................5
G. Bariatric Care ...................................................................................................................................6

A. Custodial/Non-Skilled Care
Care that does not meet the criteria for skilled nursing, skilled rehabilitation, or the specialized care services included later in this policy is considered custodial care, or non-skilled care. Custodial care can be maintenance care provided by family members, health aides or other unlicensed individuals when an individual has reached the maximum level of physical or mental function and still requires assistance.

Custodial care is primarily for those who need hands on help and/or supervision with activities of daily living (ADLs) or supervision for safety or behavior management. Areas of ADLs include bathing, dressing, toileting, transferring, and eating. These are generally personal needs rather than medical and are not specific to an illness or injury. Other factors that should be considered when determining need for custodial care include ability to communicate, cognitive status, behavior, and ability to self-administer medications.

B. Dementia/Wandering Care
Service Goal: To ensure the provision of residential care for demented member/enrollee in need of a protective environment for wandering behavior.

2. Intensity of Service: the member/enrollee must be provided with all of the following:
   a. Secure living area indoors and outdoors by means of locks and/or electronically controlled access;
   b. Activities appropriate for persons with dementia;
   c. All services, medications, supplies and equipment necessary to manage the needs of the member/enrollee.

3. Discharge Criteria
   a. Member/enrollee no longer meets placement criteria, and b or c;
   b. Member/enrollee is able to be safely managed in a lower level of care, or
   c. Member/enrollee requires higher level of care than what is able to be provided.

C. Dementia with Behaviors Care
Service Goal: To ensure the provision of residential care for members/enrollees with cognitive impairments in need of a protective environment for significant behaviors.

2. Intensity of Service: the member/enrollee must be provided with all of the following:
   a. Secure living area indoors and outdoors by means of locks and/or electronically controlled access that is separate from the areas of other facility residents, and
   b. Staff ability to directly observe and supervise the member/enrollee at all times, and
   c. Psychiatric nursing care services with observation and assessment of member’s/enrollee’s changing condition, and
   d. Activities appropriate for persons with dementia, and
   e. All services, medications, supplies and equipment necessary to manage the needs of the member/enrollee.

3. Discharge Criteria
   a. Member/enrollee no longer meets placement criteria, and b or c;
   b. Member/enrollee is able to be safely managed in a lower level of care, or
   c. Member/enrollee requires higher level of care than what is able to be provided.

D. Dialysis Care
Service Goal: To provide skilled nursing, residential care, and supervision for members/enrollees with high acuity and specialized dialysis needs.

2. Intensity of Service: the member/enrollee must be provided with:
   a. Dialysis treatment as prescribed by a nephrologist, and
   b. Evaluation and monitoring of member’s/enrollee’s condition on an on-going basis, and
   c. Relevant diagnostic studies and reporting of results to ordering physician on a timely basis, and
   d. All services, medications, supplies and equipment necessary to manage the needs of the member/enrollee.

3. Discharge Criteria
   a. Member/enrollee no longer meets placement criteria, and b or c;
   b. Member/enrollee is able to be safely managed in a lower level of care, or
   c. Member/enrollee requires higher level of care than what is able to be provided.

E. Respiratory Care
Service Goal: To provide skilled nursing, residential care, and supervision for members/enrollees requiring respiratory care who need nursing services on a 24-hour basis, but who do not require hospital care under the daily direction of a physician.

2. Intensity of Service: the member/enrollee must be provided with:
   a. Respiratory therapy needs as prescribed by member’s/enrollee’s physician, and
   b. Evaluation and monitoring of member’s/enrollee’s condition on an ongoing basis, and
   c. Relevant diagnostic studies and reporting of results to ordering physician on a timely basis, and
   d. All services, medications, supplies and equipment necessary to manage the needs of the member/enrollee.

3. Discharge Criteria
   a. Member/enrollee no longer meets placement criteria, and b or c;
   b. Member/enrollee is able to be safely managed in a lower level of care, or
   c. Member/enrollee requires higher level of care than what is able to be provided.

F. Ventilator Care
Service Goal: To provide skilled nursing care, residential care, and supervision for members/enrollees who are dependent on mechanical ventilation to sustain life and who need nursing services on a 24-hour basis, but do not require hospital care under the daily direction of a physician.

2. Intensity of Service: the member/enrollee must be provided with:
   a. Mechanical ventilation needs as prescribed by member’s/enrollee’s physician, and
   b. Evaluation and monitoring of member’s/enrollee’s condition on an on-going basis, and
   c. Relevant diagnostic studies and reporting of results to ordering physician on a timely basis, and
   d. All services, medications, supplies and equipment necessary to manage the needs of the member/enrollee.

3. Discharge Criteria
   a. Member/enrollee no longer meets placement criteria, and b or c;
   b. Member/enrollee is able to be safely managed in a lower level of care, or
   c. Member/enrollee requires higher level of care than what is able to be provided.

G. Bariatric Care
Service Goal: To provide skilled nursing care, residential care, and supervision for member/enrollee with high acuity and specialized care due to extreme obesity.

1. Placement Criteria: the member/enrollee must meet both of the following:
   a. BMI ≥ 50 kg/m², and
   b. Member/enrollee is unable to change position, ambulate, or transfer without hands-on assistance from three or more caregivers.

2. Intensity of Service: the member/enrollee must be provided with all of the following:
   a. Nutritional counseling to assist with appropriate caloric needs
   b. Physical, occupational or restorative therapies tailored to the member/enrollee
   c. An ongoing, multidisciplinary approach to weight loss
   d. All services, medications, supplies and bariatric equipment necessary to manage the needs of the member/enrollee.

3. Discharge Criteria
   a. Member/enrollee no longer meets placement criteria, and b or c;
   b. Member/enrollee is able to be safely managed in a lower level of care, or
   c. Member/enrollee requires higher level of care than what is able to be provided.

Background
Nursing home care accounts for a substantial portion of health care costs for older individuals. For individuals who reside in these facilities, room and board costs are generally paid by by Medicaid, long term care insurance, or out-of-pocket by individuals and their families. Short stay nursing home care, such as after an acute inpatient admit for rehabilitation, is generally paid by the skilled nursing facility benefit, most often through Medicare.

Per Medicare, a patient whose inpatient stay is based solely on the need for skilled rehabilitation services would meet the daily basis requirement when they need and receive those services, even if these therapy services are offered just five or six days a week, as long as they need and get the therapy services each day they’re offered.

The need for basic custodial care is not based on the medical need of an individual, rather the need for assistance with ADLs, or supervision for safety or behavior management. However, when there are complex medical needs or the need for more intense supervision, different levels of care within a nursing home facility exist.

Many states have obtained waivers from the Center for Medicare and Medicaid Services to provide community-based long term custodial care to consumers who are eligible for nursing facility care but chose to and can be safely managed in community settings.

A comprehensive geriatric assessment evaluates the individual’s functional, physical, cognitive, emotional, and psychosocial status. The Omnibus Reconciliation Act of 1987 (OBRA) requires that nursing homes complete a comprehensive assessment at the time of admission in order to develop a comprehensive treatment plan. Information from this assessment and treatment plan will help determine the level of care that the individual requires upon admission.

Ongoing assessment of an individual’s status is required to ensure the appropriate level of care is maintained to ensure patient needs are met. An individual’s status changes can be observed by both facility staff and the family/friends of the individual. Family meetings are an important component of care to serve as a means of learning and sharing information. Medical decision making and advanced care planning should be shared by the facility and medical staff as well as the family. Changes in an individual’s status should also be shared with the Health Plan Case Manager to ensure proper placement.

Definitions
Custodial care provides services that assist a member/enrollee with ADLs such as assistance with walking, bathing, dressing, feeding, toileting, and supervision of medication that can normally be self-administered. Services can be provided by someone who is not a trained medical or paramedical personnel.

Coding Implications
This clinical policy references Current Procedural Terminology (CPT®). CPT® is a registered trademark of the American Medical Association. All CPT codes and descriptions are copyrighted 2024, American Medical Association. All rights reserved. CPT codes and CPT descriptions are from the current manuals and those included herein are not intended to be all inclusive and are included for informational purposes only. Codes referenced in this clinical policy are for informational purposes only. Inclusion or exclusion of any codes does not guarantee coverage. Providers should reference the most up to date sources of professional coding guidance prior to the submission of claims for reimbursement of covered services.

https://www.tn.gov/content/dam/tn/tenncare/documents/PAEManual.pdf

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