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Long-Term Care

Provider Type

  • Participating Physician Groups (PPG)
  • Hospitals
  • Ancillary

Health Net must authorize long-term care (LTC) services when a member has a medical condition that requires LTC. LTC includes both skilled nursing care and non-skilled custodial care, specific to out of-home protective living arrangements with 24-hour supervised or observation care on an ongoing intermittent basis to abate deterioration.

LTC is care provided in a skilled nursing facility (SNF), intermediate care facility or subacute care facility. Additionally, it is an inpatient care level for members who meet medical necessity at the following care levels as defined in the Manual of Criteria for Medi-Cal Authorization:

  1. A skilled nursing facility admission for members accessing Medi-Cal nursing facility Level A or B benefit level.
  2. An intermediate care facility admission for members accessing Medi-Cal nursing facility Level A benefits.
  3. A subacute care facility admission for members accessing Medi-Cal covered subacute care services.

Members in need of LTC services are placed in facilities providing the level of care commensurate with their medical needs.

Coordination of Care

The PCP continues to provide care during the transition to LTC, and coordinates with the LTC attending physician to ensure continuity of care. This includes forwarding all pertinent records to the new PCP when identified and available to consult. For coordination of benefit questions, providers may contact the Health Net Public Programs Department.

Additional communication requirements for appropriate and timely concurrent review, claims submission and claims adjudication include:

  1. Hand-off communications - Upon authorizing LTC services, Health Net and the participating physician group (PPG), communicate about the member's LTC admission
  2. Level of care communications - Health Net and the PPG communicate regarding the member's level of care or transition from Medicare-based skilled nursing services to Medi-Cal-based LTC benefits.

Referrals and Authorizations

Providers must supply both the completed Health Net Long-Term Care Authorization Notification Form as well as any supporting clinical information, such as the Pre-Admission Screening and Resident Review (PASRR), Minimum Data Set (MDS) or approved Treatment Authorization Request (TAR), as applicable, to the Health Net Long-Term Care Intake Line by fax. Health Net continues to honor any currently active TAR approved authorizations.

For new admission authorization/notification requests, once a decision is made, Health Net notifies the provider by telephone or fax. Other ancillary services may require prior authorization and are not included in the nursing facility room rate. Providers must obtain prior authorization prior to providing such services.

Providers may contact the Health Net Long-Term Care Intake Line with all questions regarding LTC referrals and authorizations, or to check the status of a request.

Claims and Payment

The Coordinated Care Initiative (CCI) integrates care and services for long term care services. Cal MediConnect members are provided long-term support and services benefits including LTC nursing facility services. Providers can refer to the Cal Duals website at www.calduals.org for enrollment charts and timelines, including enrollment data by county to confirm transition dates. Additionally, providers must verify eligibility to be certain claims are appropriately directed. Providers may submit claims directly to the Health Net Cal MediConnect Claims Department.

The two primary methods of identifying hospitalized Cal MediConnect or Medi-Cal members who may require long-term care (LTC) are:

  • Physician identification - The member's primary care physician (PCP) or specialist makes a diagnosis that requires services in an LTC facility. The physician then contacts the Health Net's Utilization Management (UM) Department (or participating physician group (PPG), if UM responsibilities have been delegated to the PPG) to request prior authorization for admission
  • Care management concurrent review - Health Net or the subcontractor's concurrent review nurses review daily census reports that identify members who may need LTC services following discharge

Other means of identifying a candidate for LTC services are reviewing retroactive claims for LTC services or through social workers, discharge planners and other health care providers involved in the member's care. Refer to disenrollment request requirements regarding Medi-Cal members accessing LTC, specific to non-Coordinated Care Initiative (CCI) counties.

Additional communication requirements for appropriate and timely concurrent review, claims submission and claims adjudication include:

  • Hand-off communications - Upon authorizing LTC services, Health Net and the PPG communicate about the member's LTC admission
  • Level of care communications - Health Net and the PPG communicate regarding changes in the member's level of care or transition from Medicare-based skilled nursing services to Medi-Cal-based LTC benefits¬†

To qualify for long-term care (LTC), which includes nursing facility and custodial care, a member must have a medical condition that requires an out-of-home protective living arrangements with 24-hour supervision and skilled nursing care or observation on an ongoing intermittent basis to abate deterioration. LTC services emphasize care aimed at preventing or delaying acute episodes of physical or mental illness and encourage each member's independence to the extent of the member's ability. The following factors are considered in determining appropriate placement for LTC:

  • The complexity of the member's medical problem is such that the member requires skilled nursing care or observation on an ongoing intermittent basis and 24-hour supervision to meet the member's health needs
  • Medications may be mainly supportive or stabilizing, but still require professional nurse observation for response and effect on an intermittent basis. Members on daily, injectable medications or frequent doses of pro re nata (PRN) narcotics may not qualify
  • Diet may be special, but the member needs little or no feeding assistance
  • The member may require minor assistance or supervision in personal care, such as in bathing or dressing
  • The member may need encouragement in restorative measures for increasing and strengthening functional capacity to work toward greater independence
  • The member may have some degree of vision, hearing or sensory loss
  • The member may have some limitation in movement, but must be ambulatory with or without an assistive device, such as a cane, walker, crutches, prosthesis, or wheelchair
  • The member may need some supervision or assistance in transferring to a wheelchair, but must be able to ambulate the chair independently
  • The member may have occasional urine incontinence; however, a member who has bowel incontinence or complete urine incontinence may qualify for intermediate care service when the member has been taught and is capable of self-care
  • The member may exhibit some mild confusion or depression; however, the member's behavior must be stabilized to such an extent that it poses no threat to self or others

One of the criteria Health Net uses to determine medical necessity is the Department of Health Care Services (DHCS) Manual of Criteria for Medi-Cal Authorization, available at www.dhcs.ca.gov/formsandpubs/publications/Documents/Medi-Cal_PDFs/Manual_of_Criteria.pdf.

Last Updated: 10/29/2019