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 for General Acute Care Hospitals (DP/SA), 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) (including ICF/DD-Habilitative and ICF/DD-Nursing). 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 8/28/2020

EPC for Retroactive ICF/DD Temporary COVID-19 Increase & Erroneous Rate Correction.
2019-20 and 2020-21 Temporary COVID-19 Increased Comprehensive Rate Lists.
2020-21 ICF/DD Temporary COVID-19 Increased Rates
Corrected 2019-20 ICF/DD Temporary COVID-19 Increased Rates

Due to the Coronavirus disease (COVID-19) outbreak, a public health emergency 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. For rate year (RY) 2020-21, the COVID-19 increased amounts will remain unchanged and will be added to the per diem rates that became effective August 1, 2020.

In order for providers to receive the additional reimbursement they should begin to bill at the temporarily increased rates established by the Department. The temporary increased rates for each facility by NPI number can be found in the Facilities' Rate and Policy Information section of this webpage. Once the updated rates have been implemented in the system to pay prospectively, the Department will run a subsequent Erroneous Payment Correction, retroactive to dates of service on or after March 1, 2020, for the 2019-20 RY COVID-19 increases and August 1, 2020 for the RY 2020-21 COVID-19 increases, as applicable. Retroactive payment adjustments to will be made automatically by the fiscal intermediary, so no additional action will be necessary on the providers' part.

Upon expiration of the public health emergency or national emergency, whichever occurs first, LTC reimbursements will revert to their RY 2020-21 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.

Correction to Previously Posted Temporary COVID-19 Increased Rates for ICF/DDs

The previously posted rates for the 2019-20 temporary COVID-19 increased rates for Developmentally Disabled (ICF/DD), Habilitative (ICF/DD-H), Nursing (ICF/DD-N) facilities included erroneous rates for some providers that resulted in underpayments for the period of March 1, 2020 through June 22, 2020 and overpayments for the period of June 23, 2020 through July 31, 2020.

As of August 19, 2020, corrected COVID-19 increased rates were installed in the payment system with a March 1, 2020 effective date. Retroactive payment adjustments will be made as necessary by the fiscal intermediary through an erroneous payment correction (EPC). The EPC to retroactively adjust the claims for the temporary COVID-19 increased rates will reflect the following adjustments:

The March 1, 2020 through June 22, 2020 Underpayment Period: The EPC will adjust eligible claims paid at the regular 2019-20 rates up to the corrected temporary COVID-19 increased rates.

The June 23, 2020 through July 31, 2020 Overpayment Period: The EPC will adjust overpaid claims to the corrected temporary COVID-19 rates. The negative adjustment will reduce any amount due to the provider for the underpayment outlined in item 1.

Retroactive payment adjustments will be made automatically by the fiscal intermediary, and no additional action will be necessary on the providers' part.

Additional Reimbursement for Fee-For-Service Hospice Room and Board Services Provided in ICF/DD Facilities

Effective for dates of service on or after August 1, 2018, the Department of Health Care Services (DHCS) will reimburse hospice providers for fee-for-service room and board services at 95 percent of the total per diem reimbursement, which will include the 2018 – 2019 facility per diem rate plus the supplemental payment per diem amount authorized by SPA 18-0029, for patients residing in an ICF/DD facility.

The additional reimbursement will be paid on a quarterly basis, beginning on December 2018, for hospice room and board service bed days rendered in the immediately preceding quarter, beginning with the quarter spanning August 1, 2018, through October 31, 2018.
The additional quarterly reimbursements will be paid through warrants issued by the State Controller’s Office and will be paid separately and in addition to the usual hospice room and board reimbursements paid through the California Medicaid Management Information System (CA-MMIS) Fiscal Intermediary.
The additional reimbursement is subject to the availability of funds.

Claims submitted with Revenue Code 0658 for fee-for-service room and board services for patients residing in ICF/DDs will receive the additional reimbursement. Hospice providers should continue to bill as usual. No additional action is required of providers. DHCS may contact affected providers for additional information if needed to process reimbursements.

The Hospice Room and Board Additional Reimbursement per diem amounts are as follows. Note that facilities in peer groups in which the unfrozen 2017-18 65th percentile rate is lower than the current reimbursement rate will not receive the additional reimbursement.

Facility Peer Group	ICF/DD Accommodation Codes (Regular Services)	Behold Accommodation Codes	Hospice Additional Reimbursement Per Diem (95% of ICF/DD Supplemental Payment Per Diem)
ICF/DD	41 (1-59 beds)	43	$14.70
ICF/DD	41 (60+ beds)	43	$0.00
ICF/DD-H	61 (4-6 beds)	63	$10.21
ICF/DD-H	65 (7-15 beds)	68	$0.00
ICF/DD-N	62 (4-6 beds)	64	$11.85
ICF/DD-N	66 (7-15 beds)	69	$21.19

2018-19 ICF/DD Prop 56 Supplemental Payment News

On August 7, 2018, the Department of Health Care Services (DHCS) received approval from the Center for Medicare & Medicaid Services to extend the Proposition 56 supplemental payment for Intermediate Care Facilities for the Developmentally Disabled, including Habilitative and Nursing facilities, effective for dates of service August 1, 2018, through July 31, 2019. Providers will continue to receive a single reimbursement payment that includes the current per diem rate in addition to the supplemental payment amount shown below.

The supplemental payment amounts are automatically added to reimbursement payments for claims meeting the supplemental payment criteria. Conduent State Healthcare LLC will prepare an Erroneous Payment Correction to reprocess claims to retroactively pay the supplemental payment.

ICF/DD Supplemental Payment Per Diem Amounts

Note that facilities in peer groups in which the unfrozen 2017-18 65th percentile rate is lower than the current reimbursement rate will not receive the supplemental payment.

Facility Peer Group	ICF/DD Accommodation Codes (Regular Services)	Behold Accommodation Codes	Supplemental Payment Per Diem
ICF/DD	41 (1-59 beds)	43	$15.47
ICF/DD	41 (60+ beds)	43	$0.00
ICF/DD-H	61 (4-6 beds)	63	$10.75
ICF/DD-H	65 (7-15 beds)	68	$0.00
ICF/DD-N	62 (4-6 beds)	64	$12.47
ICF/DD-N	66 (7-15 beds)	69	$22.30

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

Please Note

Adult Day Health Care has moved to the Community Based Adult Services (CBAS) program.
Beginning with the 2013.14 rate year, the Freestanding and Distinct Part Pediatric Subacute facility rates are established by the Long Term Care Systems Development Unit, Fee For Services Rates Development Division. For information and rates, see the LTC AB1629 page.