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    v1.0.31
    OpenPayerPolicy Updatesmagellan_healthcareMagellan Healthcare Respite Care Coverage | OpenPa…
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    CurrentMagellan HealthcarePolicy N/A

    Connect Nevada Medical Necessity Criteria for Planned and Emergency Respite Care

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    This policy establishes medical necessity criteria for planned and emergency respite services for youth in the Connect Nevada program. It governs respite provided in home or out of home to support caregivers, prevent out-of-home placement or child welfare involvement, and address behavioral health or other circumstances placing youth at risk.

    Policy Summary
    PayerMagellan Healthcare
    PolicyConnect Nevada Medical Necessity Criteria for Planned and Emergency Respite Care
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateN/A
    Next Review DateN/A
    Key ActionDocument that respite is recommended on the youth's plan of care and that the youth demonstrates one or more needs identified through a comprehensive assessment.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    8 hours/monthMaximum respite service limit per youth
    2 typesPlanned and emergency respite
    CME enrollmentYouth eligibility requirement
    Not allowedConcurrent inpatient or residential care

    Coverage Criteria

    Admission Criteria

    Covered when ALL of the following admission criteria are met:

    Admission criteria

    • Plan of care recommendation: Respite must be recommended on the plan of care.
    • CME eligibility: The youth must qualify for enrollment in the Care Management Entity (CME) model.
    • Comprehensive assessment need: The youth must demonstrate one or more needs on a comprehensive assessment.one or more needs
    Policy Summary
    PayerMagellan Healthcare
    PolicyConnect Nevada Medical Necessity Criteria for Planned and Emergency Respite Care
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateN/A
    Next Review DateN/A
    Key ActionDocument that respite is recommended on the youth's plan of care and that the youth demonstrates one or more needs identified through a comprehensive assessment.
    SourceLink
    On This Page
    Coverage CriteriaService LimitsDocumentation and Operational RequirementsPolicy BackgroundRespite Service DefinitionsRespite Care CriteriaPer-Youth Respite Limit

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    Treatment participation:
    The youth must be willing to participate in outpatient treatment and/or community-based services.
  1. Service limit: Respite is limited to eight (8) hours per month for each youth.8 hours per month

    2. Continued Services Criteria

    Continued services require ALL of the following:

    Continued services criteria

    • Service utilization: The family or caregivers are utilizing respite service.
    • Ongoing plan of care recommendation: Respite care is recommended on the plan of care.

    Respite services may not be provided simultaneously with any inpatient or residential level of care.

    Service Limits

    Respite service duration
    Maximum durationLimited to eight (8) hours per month for each youth

    Documentation and Operational Requirements

    Documentation Required

    Document plan-of-care recommendation and assessed needs

    Document that respite is recommended on the youth’s plan of care and that the youth demonstrates one or more needs on a comprehensive assessment.

    Documentation Required

    Document CME eligibility and treatment participation

    Document the youth’s eligibility for enrollment in the Care Management Entity (CME) model and willingness to participate in outpatient treatment and/or community-based services.

    Documentation Required

    Support continued respite services

    For continued services, document that the family or caregivers are utilizing respite service and that respite care remains recommended on the plan of care.

    Denial Risk

    Avoid concurrent inpatient or residential care

    Do not provide respite simultaneously with any inpatient or residential levels of care.

    Denial Risk

    Stay within the monthly respite limit

    Keep respite requests within the stated service limit of eight (8) hours per month for each youth. Requests exceeding eight hours per month do not meet the service limit.

    Policy Background

    Planned respite provides scheduled, temporary relief for caregivers supporting youth with behavioral health needs or other circumstances that may place the youth at risk of out-of-home placement or child welfare involvement. It is intended to reduce caregiver stress, help prevent crises, and connect families with longer-term community-based services and supports.

    Respite Service Definitions

    Planned respite
    DefinitionOne or more respite sessions scheduled ahead of time.
    Emergency respite
    DefinitionImmediate temporary or short-term care for youth when families or caregivers are facing a crisis and no other safe childcare options are available.
    Self-directed model
    DefinitionA model that allows families to select their provider using existing and/or new community-based providers.

    Respite Care Criteria

    Per-Youth Respite Limit

    Respite care per youth
    Maximum allowance8 hours per month per youth