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 and are directly related to an active treatment plan of care established by the physician; and 
• The skilled behavioral health care is appropriate for the active treatment of a condition, illness or disease to avoid placing the member at risk for serious complications; and 
• The skilled behavioral health care is intermittent or hourly in nature*; 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 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
• The behavioral health services provided are not primarily for the comfort or convenience of the member or custodial in nature**. 

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

** 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).

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

See also CPB 0201 - Skilled Home Health Care Nursing Services.

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.