Hospice Care Long Term Care Hospitals (LTCH)

PURPOSE
Administrative Policies are intended to provide further information about the administration of standard Cigna benefit plans. In the event of a conflict, a customer’s benefit plan document always supersedes the information in an Administrative Policy. Coverage determinations require consideration of 1) the terms of the applicable benefit plan document; 2) any applicable laws/regulations; 3) any relevant collateral source materials including Administrative Policies and; 4) the specific facts of the particular situation.

Administrative Policies relate exclusively to the administration of health benefit plans. Administrative Policies are not recommendations for treatment and should never be used as treatment guidelines.

Custodial and/or non-skilled services are specifically excluded under most benefit plans. Please refer to the applicable benefit plan document to determine benefit availability and the terms and conditions of coverage.

Coverage for custodial and/or non-skilled services provided in the home are subject to the terms, conditions and limitations of the applicable benefit plan’s Home Health Services benefit.

Cigna does not cover EITHER of the following because the service is either considered not medically necessary or because it is excluded from many benefit plans:

• Custodial services
• Non-Skilled services with the exception of limited coverage under some benefit plans for home health aides when in direct support of skilled services

General Background

Custodial services are services that are of a sheltering, protective, or safeguarding nature, primarily to help the person in activities of daily living. These services may be provided in an institutional setting or at-home care, and may include services to care for someone because of age or mental or physical condition. Custodial care may also include clinical services provided mainly to maintain the person’s current state of health. Custodial services generally do not greatly improve a medical condition; they are intended to provide care while the patient cannot care for himself or herself.

Custodial services include, but are not limited to:

• Services related to watching or protecting a person;
• Services related to performing or assisting a person in performing any activities of daily living, such as walking, grooming, bathing, dressing, getting in or out of bed, toileting, eating, preparing foods, or taking medications that can be self-administered, and
• Services not required to be performed by trained or skilled medical or paramedical personnel.

An individual’s diagnosis, prognosis and medical condition as well as the services required should all be considered in determining whether services are skilled, non-skilled or custodial. While these should be considered, they are not the sole factors in determining whether the service is skilled, non-skilled or custodial.

The fact that a skilled professional is performing a particular service does not render it a skilled service. The fact that there is an absence of caregiver assistance in the home to assist with activities of daily living (ADLs) or other non-skilled services, does not cause an otherwise custodial service to be considered skilled. These services may still be considered non-skilled or custodial.

Skilled care is the provision of services and supplies that can be given only by or under the supervision of trained or licensed medical personnel. A skilled service is a service that requires the skills of a licensed medical professional to be administered safely and effectively. Services that can reasonably be taught and safely provided by a non-skilled caregiver are considered non-skilled or custodial.

An example of this is the care and maintenance of a long-term indwelling urinary catheter or gastric tube or uncomplicated tracheostomy care.

However, a service which ordinarily is not performed by trained non-skilled caregivers may continue to be a skilled service even if it is taught to the individual, family member or another non-skilled caregiver. Home nursing visits are covered only when they are determined to be skilled. For example, services for an individual while on a ventilator, or for an individual with unpredictable intermittent ventilator needs, are considered skilled services. Home nursing visits made solely for the purpose of providing non-skilled services are considered non-skilled and generally not covered. Under almost all health benefit plans, home health services must be skilled to be covered.

The services at issue in a given case may be non-skilled, but not meet the plan definition of custodial services. In evaluating coverage, services may be viewed along a continuum from skilled services, to non-skilled services, to custodial services. Non-skilled services are usually not excluded in the same manner as custodial services, but non-skilled home health services are also not a covered benefit.

A limited number of home nursing visits provided for the teaching/training of an individual and/or caregiver to perform a skilled or semi-skilled procedure may be considered skilled and covered. The reason why the teaching was not completed in the prior treatment setting (e.g., in the acute care hospital prior to discharge) should be noted. Appropriate teaching visit frequency and number of visits depends on the complexity of the procedure being taught and the learning ability of the caregiver and/or individual. Once a procedure is mastered by the individual and/or caregiver, further periodic visits to reinforce previous teaching may be considered skilled and covered.

In rare cases, an individual may be considered to have skilled care needs even though none of the services provided to the individual when examined separately would constitute skilled care. This can occur if an individual has a significant number of non-skilled or custodial care needs such that the management of those care needs taken together require the skills of a licensed medical professional to be managed safely and effectively.

Services that may be considered to be non-skilled and/or custodial, include but are not limited to:

• Preparation and administration of routine oral medications, eye drops, ointment, topical and suppository medications and medications that are typically self-administered
• Filling drug boxes with medications
• Preparation and administration of routine self-injectable medications or maintenance subcutaneous injectable medications
• General maintenance care of a stable colostomy or ileostomy (Care of a colostomy or ileostomy in the immediate postoperative period or in the presence of associated complications may be considered skilled care.)
• 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
• Routine care of the incontinent individual (bowel and/or bladder)

A012

• Routine services to maintain satisfactory functioning of an indwelling bladder catheter (including emptying contents, containers and cleaning containers)
• Intermittent straight catheterization for chronic conditions (e.g., neurogenic bladder, spinal cord injury, multiple sclerosis)
• Uncomplicated long-term, routine care of a stable tracheostomy
• Chronic uncomplicated oral, nasopharyngeal and tracheal suctioning.

(Frequency of suctioning may be relevant to determine proper classification as skilled or non-skilled)

• Routine administration of long-term oxygen therapy by nasal cannula or mask in a stable individual.
• Routine administration of nebulizer and intermittent positive pressure breathing (IPPB) treatments in a stable individual
• Changes of non-sterile dressings
• Changes of non-infected postoperative dressings; uncomplicated changes of dressings for a chronic condition that do not involve prescription medication, packing or aseptic techniques, irrigation
• Uncomplicated stage I or stage II decubitus ulcer care
• Providing food, feeding, including preparation of special diets
• Stable/routine uncomplicated (e.g., without aspiration risks, residuals) feeding by gastric, PEG, jejunostomy feeding (Note: skilled care, supervision or observation may be required if feedings are not stable)
• Services associated with continuous positive airway pressure (CPAP) or bi-level positive airway pressure (BiPAP) unless used as a substitute for a ventilator for individuals with neuromuscular disorders
• Use of heat or cold as a palliative or comfort measure, such as whirlpool, hot or cold packs, heat lamps. Routine foot and nail care
• General preventive measures such as turning and positioning, prophylactic and palliative skin care, bathing and application of creams or treatment of minor skin problems
• General maintenance care of plaster or other cast; routine care in connection with braces and similar devices
• General supervision of exercises which have been taught to the individual, carrying out repetitive exercises to improve gait, maintain strength, flexibility or endurance
• Assistance with ambulation
• Assistance with bathing, dressing and/or toileting
• Assistance with transfers, getting in and out of bed
• Transportation
• Recreation
• Geriatric daycare

Objective documentation that may be requested to determine if the services are skilled or custodial in nature include:

• Home health care plan
• Nursing notes
• Physician care plan
• Facility progress notes
• Facility discharge plan

Definitions:

Skilled Nursing Service: A service that must be provided by a Nurse to be safe and effective.