Long-Term Care Reimbursement
The Long Term Care (LTC) Reimbursement Unit conducts the annual study to develop the Medi-Cal rates for a variety of long-term care providers. This study serves as the basis for Medi-Cal reimbursements of Nursing Facilities, including Nursing Facility - Level A (NF-A), Distinct Part Skilled Nursing Facilities of General Acute Care Hospitals (DP/NF-Bs), Distinct Part Adult Subacute Units of General Acute Care Hospitals (DP/ASA), Hospice Care, Rural Swing Beds, Acute and Transitional Inpatient Care Administrative Days (Administrative Days Level 1), and Intermediate Care Facilities for the Developmentally Disabled (ICF-DD), ICF/DD-Habilitative (ICF/DD-H), and ICF/DD-Nursing (ICF/DD-N). This unit also conducts the necessary research to develop new or revised reimbursement methodologies necessary to meet changing policy or program needs.
The Medi-Cal LTC reimbursement rates are established under the authority of Title XIX of the federal Social Security Act. The specific methodology is described in the State Plan, a document prepared by the Department staff which requires approval by the Centers for Medicare and Medicaid Services (CMS).
Latest News - Updated 12/28/2021
2021-22 Facility Rates Now Available
All rates are effective August 1, 2021, except for Hospice rates which are effective October 1, 2021.
Intermediate Care Facilities Rate Methodology Update
Effective August 1, 2021, in accordance with Assembly Bill 133 (Chapter 143, Statutes of 2021) the reimbursement rates for ICF/DD, ICF/DD-H, and ICF/DD-N facilities will be determined without applying any reduction, limitation, or increase, including the 3.7-percent increase, imposed by Welfare and Institutions Code sections 14105.191 and 14105.192. The reimbursement rates for these facilities will be established at the 65th percentile of the group's projected costs, including the projected cost of complying with new state or federal mandates and the quality assurance fee. The reimbursement rate will be inclusive of the Proposition 56 supplemental payment per diem amount received.
Additionally, for dates of service August 1, 2021 through July 31, 2022, the reimbursement rates shall be the greater of the facility's new rate established as described above inclusive of Proposition 56 supplemental payments, or the approved Medi-Cal State Plan reimbursement rate temporarily increased during the COVID-19 Public Health Emergency, plus the Proposition 56 supplemental payment, in effect for the facility on July 31, 2021.
There are no changes to the billing process. For claims billed with dates of service between August 1, 2021 and July 31, 2022, providers should continue to bill the rate year (RY) 2021-22 temporary increased COVID-19 rate, until the COVID-19 Public Health Emergency ends as described below. Proposition 56 supplemental payments will continue automatically for eligible claims. Retroactive payment adjustments will automatically be made as necessary by the fiscal intermediary through an Erroneous Payment Correction (EPC). No additional action will be necessary on the providers' part.
COVID-19 Public Health Emergency
Due to the Coronavirus disease (COVID-19) outbreak, a Public Health Emergency (PHE) was declared for the United States on January 31, 2020, and a national emergency was declared under the Stafford Act on March 13, 2020. In response to the COVID-19 outbreak, the Department will temporarily provide an additional 10% reimbursement for LTC per diem rates. The Department received federal approval of State Plan Amendment (SPA) 20-0024, effective March 1, 2020, which authorizes temporary additional reimbursement for eligible LTC facilities during the emergency period related to the COVID-19 outbreak. Effective August 1, 2021, the COVID-19 increased amounts will remain unchanged and will be added to the per diem rates that are effective August 1, 2021.
In order for providers to receive the additional reimbursement they should bill the temporarily increased rates established by the Department. The temporary increased rates can be found in the Rates and Policy Information section of this webpage. Once the updated rates have been implemented in the system, the Department will process an EPC retroactive to dates of service on or after March 1, 2020 for the 2019-20 RY COVID-19 increases; August 1, 2020 for the RY 2020-21 COVID-19 increases; and August 1, 2021 for the RY 2021-22 COVID-19 increases, as applicable. Retroactive payment adjustments will be made automatically by the fiscal intermediary. No additional action will be necessary on the providers' part.
Upon expiration of the PHE or national emergency, whichever occurs first, LTC reimbursements will revert to RY 2021-22 per diem rates. The Department will post an update on this webpage to inform providers of the expiration of the emergency period and the corresponding expiration of the additional reimbursement.
Additional Medi-Cal information and updates related to the COVID-19 outbreak may be found on the DHCS COVID-19 Response website and at the Facility Rates and Policy links below.
Providers Impacted by AB 97
The following classes of providers are impacted by the rate freeze and the 10 percent payment reduction:
Nursing Facilities - Level A (NF-A)
The following are impacted by the rate freeze ONLY:
Rural Swing Bed rates for Hospitals without a DP/NF-B
Adult Day Health Care has moved to the
Community Based Adult Services (CBAS) program.
Please send your questions regarding any topic on this webpage to: LTCReimbursement@dhcs.ca.gov
Facility Rates and Policy Information