CurrentmhnPolicy N/A

Recuperative (Medical Respite) Care — Coverage Criteria

Policy governing authorization, eligibility, allowable services, limits, and documentation requirements for recuperative care (medical respite) for members experiencing or at risk of homelessness. Affects network providers and plan reviewers responsible for arranging short-term residential recovery services.

Policy Summary

Payermhn

PolicyRecuperative (Medical Respite) Care — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit Recuperative Care Referral Form with required supporting documentation (history & physical and discharge summary for physical recovery; history & physical and discharge summary for behavioral health) to initiate presumptive authorization.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

6 monthsglobal cap (rolling 12 mo)

Up to 90dinitial auth

7 dayspresumptive auth

Per diembilling unit

T2033 U6billing code

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Coverage Criteria — Eligibility, Authorization, and Service Limits

inv-01: Eligibility Criteria

Covered when ALL of the following are met

Eligibility: Member requires a period of recovery to heal from an injury or illness

From Eligibility section

Housing status: Member is experiencing or at risk of homelessness (meets HUD definition with listed modifications)

From Eligibility section and HUD modification details

inv-02: Authorization & Duration

Authorization and duration conditions

Presumptive authorization: Seven-day presumptive authorization upon submission while Plan reviews eligibility and required documentation; contingent on Plan approval and confirmation member has not reached six-month global cap7 days

If authorization is denied, the presumptive period is not reimbursed

Initial authorization duration: Initial authorization up to 90 days based on individual needs<=90 days

Service limit: Total recuperative care cannot exceed six months per rolling 12-month period (global cap on Room & Board services)6 months

May be authorized for a shorter period based on individual needs

Extension requirement: Extensions require reassessment of the member's needs by a licensed professional and submission with the authorization request

Extension may be approved up to remaining days within six-month service limit

inv-03: Service Restrictions

Service delivery restrictions

ADL/IADL assistance limitation: Facility operators not licensed as Community Care Facilities may not directly assist members with Activities of Daily Living (ADLs) or Instrumental Activities of Daily Living (IADLs); for members requiring such support, managed care plans may coordinate concurrent Personal Care/Homemaker Services or contract licensed third-party providers to furnish these services

From Restrictions section

Facility operators and staff who provide recuperative care but are not licensed as Community Care Facilities are not permitted to directly assist members with ADLs or IADLs. If a member requires assistance with activities of daily living or instrumental activities of daily living while in a recuperative care setting, the managed care plan must arrange those supports separately — either by coordinating concurrent Personal Care and Homemaker Services or by contracting a licensed third-party provider to deliver the ADL/IADL assistance.

A seven-day presumptive authorization is allowed while the Plan reviews eligibility and documentation, but if the Plan ultimately denies authorization, the presumptive period is ineligible for reimbursement. The member is not held financially responsible for services provided during a denied presumptive authorization period.

Admission Criteria for Recuperative (Medical Respite) Care

inv-17: recuperative care / medical respite

Admission eligibility: Member requires recovery period for injury or illness AND is experiencing or at risk of homelessness (meets modified HUD definition)

Admission contingent on submission of required documentation and Plan approval

Continued Stay / Extension Requirements

inv-18: Continued stay criteria

Continued stay requires reassessment by a licensed professional submitted with the authorization extension request and demonstration of ongoing need

Extensions approved up to remaining days within six-month cap

Discharge Criteria

Discharge criteria are not defined as separate top-level medical necessity nodes in this policy. However, discharge-related documentation requirements are part of the authorization process: for recovery from physical illness or injury include a history and physical and a discharge summary from the treating medical facility; for behavioral health recovery include a history and physical that documents diagnoses, medications, comorbidities and psychosocial risks, and a discharge summary from the behavioral health facility. The discharge summary must be submitted with the authorization materials and is used to support eligibility and ongoing care planning.

Billing Codes and Limits

Covered HCPCS CodesHCPCSCovered

T2033 U6

Residential care, not otherwise specified, waiver

inv-07: Global cap on Room and Board services — 6 months per rolling 12-month period

Global cap6 months per rolling 12-month period for combined Room & Board services (Short-Term Post-Hospitalization Housing, Recuperative Care, Transitional Rent)

ScopeApplies as a combined limit across Short-Term Post-Hospitalization Housing, Recuperative Care and Transitional Rent

Measurement periodRolling 12-month period

Effect of cap on eligibilityMember may not receive more than a combined six months of these Room & Board services within any rolling 12-month period

Time Limits and Global Caps

inv-20: SNF / community recuperative settings — 6 months per rolling 12-month period (global cap)

Service limit (SNF/community recuperative)6 months per rolling 12-month period (global cap across Room & Board services)

Applies toSNF and community recuperative settings when billed as Room & Board services combined with other waiver services

Rolling period definitionLimit calculated over any rolling 12-month period

Plan review requirementPresumptive authorization and ongoing authorizations subject to confirmation member has not reached the six-month cap

inv-21: Recuperative care — Up to 90 days

Maximum initial authorizationUp to 90 days, based on individual needs

Provider Actions — Authorization, Documentation, and Appeals

Denial Risk

Presumptive authorization and denial consequence

Recuperative care has a seven-day presumptive authorization period, contingent upon the Plan's approval of eligibility, submission of required documentation and confirmation that the member has not reached the six-month global cap. If authorization is denied, the presumptive authorization period is ineligible for reimbursement. The member does not assume financial responsibility.

Seven-day presumptive authorization period; reimbursement ineligible if final authorization denied
Plan approval of eligibility required
Member not financially responsible for presumptive period

Prior Authorization

Authorization timeframe and extension process

Initial authorization may be approved for up to 90 days based on individual needs. If an extension is needed, submit an authorization request with a reassessment of the member's needs completed by a licensed professional. Extensions may be approved based on individual needs, up to the remaining days in the six-month service limit.

Definitions and Eligibility Modifiers

inv-15: Recuperative care / medical respite definition — short-term residential setting providing interim housing, meals, monitoring, and supportive services

DefinitionShort-term residential setting providing interim housing, meals, ongoing medical or behavioral monitoring, and access to supportive services for individuals experiencing or at risk of homelessness who need recovery from injury, illness, or behavioral health conditions.

Core services includedInterim housing with a bed and meals; ongoing monitoring of medical/behavioral condition (vital signs, assessments, wound care, medication monitoring)

Additional supportive servicesConnection to primary care, behavioral health, case management, transportation, housing supports and assistance accessing benefits

ADL/IADL assistanceLimited or short-term assistance with ADLs/IADLs may be provided to the extent permitted by licensure; otherwise must be coordinated through licensed providers or personal care services

inv-16: HUD homelessness definition (modified) — HUD criteria with modifications for institutional exit and prior homeless status

Background

Recuperative care (medical respite) provides a short-term residential setting for individuals who are experiencing or at risk of homelessness and require a period of recovery from injury, illness, or a behavioral health condition. Services include interim housing with a bed and meals, ongoing monitoring of medical or behavioral conditions (for example, vital signs, wound care, and medication monitoring), and connections to primary care, behavioral health, case management, transportation, and housing supports.

Policy Summary

Payermhn

PolicyRecuperative (Medical Respite) Care — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

Presumptive authorizationSeven-day presumptive authorization upon submission while Plan reviews eligibility and documentation

Extension processExtensions require reassessment by a licensed professional and may be approved up to remaining days within the six-month service limit

Documentation for initial authRequired supportive documents (history & physical and discharge summary for physical recovery; history & physical and behavioral health discharge summary for behavioral recovery)

Initial authorization: up to 90 days
Extension requires reassessment by a licensed professional
Extension limited to remaining days within six-month rolling service limit

Step Therapy

Step therapy

No step therapy applies to recuperative care.

Step therapy: Not applicable

Documentation Required

Required documentation for authorization

Required documentation for initial authorization and extensions: submit the Recuperative Care Referral Form plus supporting clinical documentation. For individuals recovering from physical illness or injury, include a history and physical and a discharge summary from the medical facility. For individuals recovering from a behavioral health condition, include a history and physical (detailing diagnoses, high-risk diagnoses, medications, comorbid medical and substance use issues, and relevant psychosocial risk factors) and a discharge summary from the behavioral health facility. Discharge summaries must be dated within 30 days of submission.

Recuperative Care Referral Form (required)
History and physical (physical-illness/injury cases)
Discharge summary from medical facility (physical cases) — dated within 30 days of submission
History and physical including diagnoses, medications, comorbidities, psychosocial risk factors (behavioral health cases)
Discharge summary from behavioral health facility (behavioral health cases) — dated within 30 days of submission

Documentation Required

Extension documentation

For authorization extensions, a reassessment by a licensed professional documenting the member's current needs must accompany the authorization request. The reassessment should demonstrate continued medical necessity for recuperative care and specify the additional time requested within the remaining allowable service period.

Reassessment by a licensed professional required for extension requests
Reassessment must document ongoing medical necessity and requested extension length
Extensions limited to remaining days within the six-month global cap

Note

Presumptive authorization contingencies

Presumptive authorization is contingent on plan approval, submission of all required documentation, and confirmation that the member has not exceeded the six-month global cap on Room and Board services. If these contingencies are not met, final authorization may be denied and the presumptive period will not be reimbursed.

Contingencies: plan approval, required documentation submission, confirmation member under six-month cap
Failure to meet contingencies may result in denial and loss of reimbursement for presumptive period

Base definition referencedHUD definition in 24 CFR §91.5 (members must meet HUD homeless or at-risk definition)

Modification — institutional exitIf exiting an institution, individuals are considered homeless if they were homeless immediately prior to entering the institution or become homeless during the institutional stay, regardless of length of institutionalization

Modification — imminent loss timeframeTimeframe for imminent loss of housing extended to 30 days (from 14/21 days in standard HUD definition)

Modification — income requirementFor at-risk definition, the HUD annual income below 30% of area median family income requirement is waived