Proposition 56 Home Health Pediatric Day Health Center Rate Update
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Overview
This program provides rates increases for Home Health (HH) and Pediatric Day Health Center (PDHC) services provided to Medi-Cal beneficiaries. The fee-for-service reimbursement rates were increased by 50 percent, effective July 1, 2018. Additionally, an exemption from the AB 97 one percent payment reduction is provided for these same services.
Providers who are eligible to provide and bill for the following procedure codes will receive an increased payment, in order to bring their payment total to the amount identified in the table below.
State Plan/EPSDT Rate Update
| Procedure Code | Procedure Code Description |
Medi-Cal Fee-For-Service Rate |
|---|---|---|
| G0156 | SVCS HH/HSPC AIDE,HH/HSPC PER 15MINS | $7.09 |
| G0162 | SKILLED SVC RN MGT EVAL/PLAN PER 15MIN | $17.04 |
| G0299 | SKILLED NURS RN HH/HSPC EACH 15MINS | $15.21 |
| G0300 | SKILLED NURS LPN, HH/HSPC PER 15MIN | $11.03 |
| S9123 | NURSING CARE HOME;RN PER HR | $47.91 |
| S9124 | NURSING CARE HOME;LPN PER HR | $36.63 |
| T1002 | RN SERVICE UP TO 15MINS | $16.74 |
| T1003 | LPN/LVN SVCS UP TO 15MINS | $12.13 |
| T1016 | CASE MNGMNT, EACH 15MINS | $13.41 |
| T1026 | PED COMPR CARE PKG. PER HOUR | $44.12 |
| Z5805 | EPSDT SHARED NURSING(RN),INDVL NRS PROV | $52.70 |
| Z5807 | EPSDT SHARED NURSING(LVN)INDVL NRS PROV | $40.29 |
The Centers for Medicare & Medicaid Services (CMS) approved SPA 18-037 which provides authority to provide the rate increase for eligible services, as well as the exemption from the payment reduction, effective July 1, 2018.
PDHC is not an approved service/provider type under Home and Community Based Services (HCBS) 1915(c) waivers. PDHC are only a state plan service/provider type.
1915(c) HCBA Waiver Rate Update
CMS approved the 1915(c) Home and Community-Based Services (HCBS) waiver to authorize this rate update. These services are only available through the Home and Community-Based Alternatives (HCBA) Waiver and payments became effective July 1, 2018. It is expected to continue until June 2021.
Procedure Code/Description HCBS Usage
S9122 Home health aide or certified nurse assistant, providing care in the home; per hour. Individual private duty services provided by a certified home health aide (CHHA) who is employed by a Home Health Agency and supervised by a registered nurse. Per hour.
| Provider Type | Additional Required Codes | Rates |
|---|---|---|
| HHA (14) | None |
28.35 |
| HHA (14) | TT | 31.19 |
S9123 Nursing care, in the home; by registered nurse, per hour (use of general nursing care only, not to be used when CPT® codes 99500 – 99602 can be used). Individual private duty nursing services provided by a registered nurse for individual and shared nursing care.
| Provider Type | Additional Required Codes | Rates |
|---|---|---|
| HHA (14) | None | 60.86 |
| HCBS RN (67) |
None |
47.91 |
| HHA (14) | TT | 66.95 |
| HCBS RN (67) | TT | 52.70 |
S9124 Nursing care, in the home; by licensed practical nurse, per hour. Individual private duty nursing services provided by a licensed vocational nurse (LVN) for individual and shared nursing care.
| Provider Type | Additional Required Codes | Rates |
|---|---|---|
| HHA (14) | None | 44.12 |
| HCBS LVN (67) | None | 36.63 |
| HHA (14) | TT | 48.53 |
| HCBS LVN (67) | TT |
40.29 |