CurrentKaiser PermanentePolicy N/A

Advanced Care at Home (ACAH) — Coverage Criteria

Defines Kaiser Permanente coverage, eligibility, and services for the Advanced Care at Home program for members receiving acute-episode care at home or another appropriate location within the service area.

Policy Summary

PayerKaiser Permanente

PolicyAdvanced Care at Home (ACAH) — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateAug 6, 2024

Key ActionObtain preauthorization and document that the member meets all ACAH criteria, including referral by the managing provider and care location requirements.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

30 daysepisode duration

30 minmax travel time to ED

24/7command center availability

cell serviceconnectivity req

Coverage and Eligibility for Advanced Care at Home (ACAH)

Advanced Care at Home eligibility and coverage criteria

Covered when ALL of the following are met

ACAH Eligibility: Member meets ALL of the following: referral into the advanced care program by the managing provider; preauthorization obtained based on the member's health status, treatment plan, and home setting; clinical condition meets inpatient medical necessity per MCG inpatient hospitalization guidelines; care location is within 30 minutes ground travel time of an emergency department; member consents to receiving advanced care described in the treatment plan; care location has cell service.

Services are provided through Medically Home and availability may depend on geography and plan design.

Services covered under ACAH

Covered services when prescribed as part of the ACAH treatment plan

Covered services: Communication devices to allow 24/7 contact with the medical command center (including required communication technology and a personal emergency response system); home visits by RNs, physical therapists, occupational therapists, speech therapists, respiratory therapists, nutritionists, health aides, and other healthcare professionals within scope of practice; monitoring equipment (blood pressure monitor, pulse oximeter, scale, thermometer); safety items when medically necessary (e.g., shower stools, raised toilet seats, grabbers, long-handled shoehorns, sock aids); mobile imaging and tests (X-ray, ultrasound, EKG); meals when medically necessary; medical supplies; durable medical equipment; member transportation when medically necessary; Emergency Department visits associated with the benefit; and Physician Assistant and Nurse Practitioner house calls.

Policy Summary

PayerKaiser Permanente

PolicyAdvanced Care at Home (ACAH) — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateAug 6, 2024

Key ActionObtain preauthorization and document that the member meets all ACAH criteria, including referral by the managing provider and care location requirements.

SourceLink

On This Page

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Codes, Durations, and Time-Based Limits

Applicable Codesmixed

No codes listed

inv-05: Episode duration — combined acute + restorative limited to 30 days

Episode durationCombined acute and restorative phases limited to a total of 30 days.

ScopeEpisode includes acute episode care plus any restorative care associated with that episode.

Limit applicationDuration limit applies to the Advanced Care at Home treatment episode as defined in the program.

inv-06: Maximum travel time to ED — 30 minutes ground travel time

Maximum travel time to EDCare location must be within 30 minutes ground travel time of an emergency department.

ApplicabilityRequirement applies to the member's residence or other appropriate care location within the service area.

Relation to authorizationPreauthorization requires documentation that the care location meets this travel-time requirement.

Authorization, Documentation, and Provider Responsibilities

Prior Authorization

Prior Authorization Required

Preauthorization is required for Advanced Care at Home (ACAH). Authorization decisions are based on the member's health status, treatment plan, and home setting or other appropriate care location within the service area. The member must be referred into the ACAH program by the managing provider (for example, from an emergency department) and must meet inpatient-level medical necessity criteria per applicable MCG inpatient hospitalization guidelines.

Care location must be within 30 minutes ground travel time of an emergency department
Care location must have cell service
Member must consent to the advanced care treatment plan

Step Therapy

Step therapy is not applicable to Advanced Care at Home. There are no step therapy rules specified for this benefit.

Documentation Required

Required Documentation for Authorization

Verify member benefits and document that the member meets ALL ACAH criteria prior to authorization. Documentation should include referral source (managing provider), evidence that the clinical condition meets inpatient medical necessity (per MCG guidelines), confirmation that the care location meets operational requirements (within 30 minutes of an ED, has cell service), and documented member consent. Retain records of the treatment plan and any orders for covered services, equipment, or home visits.

Document referral into ACAH by managing provider
Document inpatient-level medical necessity per MCG guidelines
Document travel time eligibility and cell service at care location
Document member consent and the ACAH treatment plan

Denial Risk

Authorization and Referral Requirements

Failure to obtain preauthorization may result in denial of coverage. The member must meet all ACAH eligibility criteria and obtain any required referrals or authorizations before services are rendered. ACAH is provided through Medically Home (Kaiser Permanente's network provider); ensure referrals and authorizations specify use of the network provider as applicable.

Services must be part of the documented ACAH treatment plan to be covered
Exclusions include private duty nursing, non-plan housekeeping or meal services, care provided by family members, and any home services not specified in the ACAH treatment plan
Medically necessary transportation, emergency department visits related to ACAH, and covered home visits/equipment require authorization as part of the ACAH plan

Program Overview

Advanced Care at Home (ACAH) is a personalized, patient-centered program that delivers acute-episode and related restorative care in the home or another appropriate location. The program is intended to provide hospital-level services through a coordinated model (delivered through Medically Home within the Kaiser Permanente network) so eligible members can receive necessary acute care and follow-up restorative services outside the traditional inpatient setting.

Services provided under ACAH must be associated with an acute episode and are time-limited; the combined acute and restorative episode of care is limited to 30 days. Availability of the ACAH model may depend on geography and plan design, and members must meet program eligibility requirements (including referral by the managing provider, preauthorization, inpatient-level medical necessity per MCG guidelines, care location within 30 minutes ground travel time of an emergency department, consent to the treatment plan, and cell service at the care location) to participate.

Key Definitions

inv-12: Episode of care — The combined acute and restorative phases limited to a total of 30 days.

DefinitionEpisode of care = combined acute and restorative phases of Advanced Care at Home treatment, limited to a total of 30 days.

Associated servicesServices must be associated with an acute episode; restorative care included in same episode count toward the 30-day total.

Program deliveryProvided through Medically Home as Kaiser Permanente's network provider; availability may depend on geography and plan design.

inv-13: Care location requirements — within 30 minutes ground travel time of an ED and cell service to support 24/7 communication.

Proximity to EDCare location must be within 30 minutes ground travel time of an emergency department.

Communication requirementCare location must have cell service to support 24/7 communication with the medical command center.

Examples of care locationMember's residence or another appropriate care location within the service area.

Operational noteCommunication devices and personal emergency response system alerts are provided to enable 24/7 contact with the medical command center.