1. Skilled nursing care consists of those services that must be performed by a registered nurse or licensed practical (vocational) nurse, and meet all of the following criteria for skilled nursing services:
   
   
   1. Pursuant to physician orders, the service(s) is so inherently complex that it can be safely and effectively performed only by, or under the supervision of, a licensed nurse to achieve the medically desired result; and
   2. The skilled nursing care must be provided on an intermittent* or hourly** basis; and
   3. The skilled nursing service is not custodial*** in nature; and
   4. The skilled nursing service(s) must be reasonable and necessary for the treatment of the illness or injury, that is, the services must be consistent with the unique nature and severity of the member's illness or injury, his or her particular medical needs, and accepted standards of medical and nursing practice, without regard to whether the illness or injury is acute, chronic, terminal, or expected to last a long time.
2. Skilled home health nursing care is the provision of intermittent skilled services to a member in the home for the purpose of restoring and maintaining his or her maximal level of function and health.  These services are rendered in lieu of hospitalization, confinement in an extended care facility, or going outside of the home for the service.

Subject to applicable benefit plan terms and limitations, Aetna considers skilled home health nursing services medically necessary when all of the following criteria are met:

1. The member is homebound because of illness or injury (i.e., the member leaves home only with considerable and taxing effort and absences from home are infrequent, or of short duration, or to receive medical care); and
2. The nursing services provided are not primarily for the comfort or convenience of the member or custodial in nature; and
3. The services are ordered by a physician and are directly related to an active treatment plan of care established by the physician; and
4. The services are provided in lieu of a continued hospitalization, confinement in a skilled nursing facility (SNF), or receiving outpatient services outside of the home; and
5. The skilled nursing care is appropriate for the active treatment of a condition, illness, disease, or injury to avoid placing the member at risk for serious medical complications; and
6. The skilled nursing care is intermittent or hourly in nature*; and
7. The treatment provided is appropriate for the member's condition including the amount of time spent providing the service as well as the frequency and duration of the services.

* Intermittent or part time skilled home care nursing is defined as a visit of up to 4 hours in duration.

** Home health skilled nursing care is defined as a consecutive 4-hour period of time (i.e., an 8-hour shift equals 2 visits).

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

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

Note: Benefit plan documents may include a more specific definition of custodial care that would supersede the general definition of custodial care provided in this CPB.  Please check benefit plan descriptions for details.

Notes:

This CPB does not pertain to home infusion services.  Home infusion services, including the related nursing service, are not considered to be part of the Home Health Care or Skilled Home Health Care Nursing Services benefit and do not accumulate toward any associated Home or Skilled Nursing benefit limits.

Under traditional (e.g., Managed Choice POS, PPO, and indemnity) plans and out-of-network care in QPOS plans, additional benefits for nursing services beyond those that are provided for under the home health care benefit (outlined above) may be available through the visiting or private duty nursing benefit.  Please check benefit plans for details.  See CPB 0136 - Skilled Home Private Duty Nursing Care for information on criteria and limitations for the visiting or private duty nursing benefit.

Skilled nursing care is health care given when a person needs skilled nursing staff (registered nurse (RN) or licensed practical nurse (LPN)) to manage, observe, and evaluate care.  Skilled nursing care requires the involvement of skilled nursing staff in order to be given safely and effectively.  Care that can be given by non-professional staff is not considered skilled nursing care.  The goal of skilled nursing care is to help improve the patient's condition or to maintain the patient's condition and prevent it from getting worse.

Custodial care is care that helps persons with usual daily activities like walking, eating, or bathing.  It may also include care that most people do themselves, like using eye drops, oxygen, and taking care of colostomy or bladder catheters.