CurrentBaylor Scott & White Health PlanPolicy 042

Custodial Care (Coverage Criteria)

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Defines custodial (non-skilled) care, explains coverage stance across lines of business, and provides guidance for Texas Medicaid use of TMPPM criteria. Affects providers seeking reimbursement from Baylor Scott & White Health Plan.

Policy Summary

PayerBaylor Scott & White Health Plan

PolicyCustodial Care (Coverage Criteria)

Policy CodePolicy 042

Change TypeNo material changes

Effective DateApr 1, 2026

Last ReviewMar 26, 2026

Next Review DateMar 26, 2027

Key ActionVerify member benefit applicability in the Evidence of Coverage (EOC) or Summary Plan Description (SPD) before seeking reimbursement.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Not coveredCommercial/Self-funded/Medicare

Follow TMPPMTexas Medicaid

Not applicable

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CurrentBaylor Scott & White Health PlanPolicy 042

Custodial Care (Coverage Criteria)

Customize your policy alerts

Sign up for Baylor Scott & White Health Plan Policy 042 alerts

Get alerted when Policy 042 changes without checking for updates manually.

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Policy Summary

PayerBaylor Scott & White Health Plan

PolicyCustodial Care (Coverage Criteria)

Policy CodePolicy 042

Change TypeNo material changes

Effective DateApr 1, 2026

Last ReviewMar 26, 2026

Next Review DateMar 26, 2027

Key ActionVerify member benefit applicability in the Evidence of Coverage (EOC) or Summary Plan Description (SPD) before seeking reimbursement.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Not coveredCommercial/Self-funded/Medicare

Follow TMPPMTexas Medicaid

Not applicable

Coverage Criteria

Coverage by line of business

Coverage determinations by line of business:

Medicaid (Texas): Texas Medicaid: 'Domiciliary, rest home, or custodial care services' are benefits; confirm coverage per Texas Medicaid Provider Procedures Manual (TMPPM). If TMPPM lacks criteria, use the criteria set forth in this policy.

Follow TMPPM when applicable.

Commercial/Self-funded/Medicare: BSWHP does NOT consider custodial care to be a skilled health care service and it is not a covered benefit; custodial services are defined and specifically excluded in member EOC and SPD.

Coverage exclusion — see member plan documents.

Custodial services are excluded from coverage for Commercial, Self-funded, and Medicare lines of business as specified in the member Evidence of Coverage (EOC) and Summary Plan Description (SPD). Review the member plan documents for the definitive statement of benefits and any applicable exclusions, as the plan document supersedes this policy.

Services that constitute nonskilled personal care (custodial) — for example, assistance with activities of daily living that do not require skilled clinical intervention — are considered not medically necessary for coverage under the Commercial, Self-funded, and Medicare lines of business per this policy. Providers should confirm benefit applicability against the member's EOC or SPD before billing.

Coding

CPT Not CoveredCPTNot Covered

99509

Home visit for assistance with activities of daily living and personal care.

Inclusive diagnosis list disclaimer

DisclaimerDue to the wide range of applicable diagnosis codes and potential changes to codes, an inclusive list of diagnosis codes may not be presented; inclusion of a code does not guarantee reimbursement and the patient must meet the policy criteria.

Coverage governed by plan documentsMedical necessity as defined by this policy does not ensure the benefit is covered; benefits are determined by the member's Evidence of Coverage (EOC) or Summary Plan Description (SPD).

State/federal rulesThis policy does not replace existing federal or state rules and regulations; in the event of a discrepancy, the plan document supersedes this policy.

Code applicability noteCodes listed are examples that may apply; inclusion in the policy does not guarantee reimbursement and applicable criteria must be met.

Reference for exceptionsFor Texas Medicaid, follow the Texas Medicaid Provider Procedures Manual (TMPPM); if TMPPM lacks criteria, use this policy's criteria.

Provider Actions & Billing

Note

Prior Authorization

Prior authorization — Not applicable.

Note

Benefit Verification

Benefit verification — Providers should reference the member Evidence of Coverage (EOC) or Summary Plan Description (SPD) to determine benefit applicability. Medical necessity determinations in this policy do not guarantee coverage; the plan document governs benefits and may exclude custodial care.

Denial Risk

Denial Risk — Custodial Care Excluded

Denial risk for excluded benefit — Custodial services are not a covered benefit for Commercial, Self-funded, and Medicare lines of business; claims for custodial care may be denied per the member's plan exclusions.

Background

Custodial care is defined as nonskilled, personal care that assists with activities of daily living (ADLs) such as bathing, dressing, eating, transferring in or out of a bed or chair, ambulation, and toileting. It may include routine tasks people commonly perform for themselves (for example, applying eye drops) and other non–health-related services (e.g., domiciliary care, room and board) that do not require the continuous services of skilled, trained medical personnel.

Definitions

Custodial Care

DefinitionNonskilled, personal care such as help with activities of daily living (bathing, dressing, eating, toileting, ambulation) and non-health-related services (domiciliary care, room and board); also includes services that can be performed by non-skilled personnel after training and services that do not seek to cure.

Examples of ADL assistanceHelp in walking or getting in or out of bed; assistance with bathing, dressing, feeding, and using toilet facilities.

Non-health-related servicesPreparation of diets and nutritional supplements, provision of socially necessary services such as room and board.

When providedServices provided when the patient's medical condition is stable or not changing, and services that do not require continuous skilled personnel.

Trainable tasksServices that skilled personnel can train non-skilled personnel to perform (e.g., medication preparation and self-administered treatments).