Long-Term Care
Provider Type
- Physicians
- Participating Physician Groups (PPG)
- Hospitals
- Ancillary
This section contains general member benefit information on long-term care services and problem resolution. Unless specified in title, information provided applies to all counties listed above.
Identification
The two primary methods of identifying hospitalized 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 or the physician's representative 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.
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
Long-Term Care
Medi-Cal members in need of long-term care (LTC) facility services should be placed in facilities providing the level of care commensurate with their medical needs.
- Skilled nursing facility (SNF) for short and long-term care
- Intermediate care facility (ICF):
- Adult subacute care facility
- Pediatric subacute care facility
Hospice services are not considered LTC services. When hospice services are provided in an LTC facility, the member's eligibility under the Medi-Cal managed care is not affected regardless of the member's expected or actual length of stay in the nursing facility.
Special Treatment Program Services
Special treatment program services in nursing facilities are covered under Medi-Cal and rendered to members who:
- Have chronic psychiatric impairment and whose adaptive functioning is moderately impaired
- Have conditions that are responsive to special treatment program services and prohibitive to placement in a skilled nursing facility
- Require a therapeutic program of services designed, staffed and implemented by a special treatment program unit for the purpose of meeting the special needs of this identified population group
- Are disabled mentally or physically and such disability is expected to be prolonged
Coordination of Care
The primary care physician (PCP) continues to provide care during the transition to long-term chronic care, 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.
Long-Term Care for Permanently Institutionalized
Medi-Cal members who reside in a long-term care (LTC) facility beyond the month of admission plus one month, are deemed permanently institutionalized. These members are reassigned from their participating physician groups (PPGs) to Health Net for utilization management upon Health Net's evaluation that the member is deemed permanently institutionalized and qualifies for reassignment. PPGs are responsible for LTC members until they are no longer listed on their monthly eligibility reports.
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:
- A skilled nursing facility admission for members accessing Medi-Cal nursing facility Level A or B benefit level.
- An intermediate care facility admission for members accessing Medi-Cal nursing facility Level A benefits.
- 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.
Criteria for Long-Term Care
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 (PDF).
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:
- Hand-off communications - Upon authorizing LTC services, Health Net and the participating physician group (PPG) communicate about the member's LTC admission.
- 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 Medi-Cal (PDF), Long-Term Care Authorization Notification Form - Community Health Plan of Imperial Valley (PDF), Long-Term Care Authorization Notification Form - CalViva Health (PDF), 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 phone 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
Most non-dual and dual LTC members in all counties (including those with a Share of Cost) are required to enroll in a Medi-Cal Managed Care Plan, including Fresno, Kings and Madera counties. Providers may refer to the Cal Duals for enrollment charts and timelines, including enrollment data by county to confirm transitioned dates. Additionally, providers must verify eligibility to ensure claims are appropriately directed and may submit claims directly to the Health Net Medi-Cal Claims Department, as outlined in the Division of Financial Responsibility (DOFR).
Member Selection Criteria - Los Angeles County Only
Long-term care (LTC) coverage eligibility is based on intensity of medical services required and severity of illness. Each member is evaluated based on primary care physician (PCP) diagnosis and treatment recommendations, facility heath care team assessments, Medi-Cal regulations, including the Department of Health Care Services (DHCS) Manual of Criteria for Medi-Cal Authorization, and the Minimum Data Set (MDS). The MDS is a standardized, primary health status screening and assessment tool that forms the foundation of the comprehensive assessment of all nursing facility residents in LTC facilities.
If the provider's Medi-Cal contract is through Molina Healthcare, providers should contact Molina for a copy of its LTC member selection criteria. Specific policies can be accessed by contacting the participating physician group (PPG) administrator. Where there are conflicts between established Health Net medical policy and DHCS policies and guidelines, Health Net defers to DHCS requirements.
Member Selection Criteria - All other counties
Long-term care (LTC) coverage eligibility is based on intensity of member services required and severity of illness. Each member is evaluated based on primary care physician (PCP) diagnosis and treatment recommendations, facility health care team assessments, Medi-Cal regulations, including the Department of Health Care Services (DHCS) Manual of Criteria for Medi-Cal Authorization, and the Minimum Data Set (MDS).
The MDS is a standardized, primary screening and assessment tool of health status that forms the foundation of the comprehensive assessment of all nursing facility residents in long term care facilities.
Criteria for Adult Subacute Care Program
Adult subacute level of care refers to very intensive, licensed, skilled nursing care provided to members who have fragile medical condition. To qualify for the adult subacute program, the member must require at least four hours of direct skilled nursing care per day and at least one of the following:
- Tracheostomy care with continuous mechanical ventilation for at least 50 percent of the day
- Tracheostomy care with suctioning and room air mist or oxygen as needed, and one of the six treatment procedures listed below; or
- Administration of any three of the six following treatment procedures:
- total parenteral nutrition
- inpatient physical, occupational or speech therapy at least two hours per day, five days per week
- tube feeding (nasogastric or gastrostomy)
- inhalation therapy treatments every shift and a minimum of four times per 24-hour period
- intravenous (IV) therapy involving one of the following:
- continuous administration of a therapeutic agent
- hydration
- frequent intermittent IV medication administration via a peripheral or central line (heparin lock)
- wound debridement, packing and medicated irrigation with or without whirlpool treatment
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 (PDF).
Criteria for Coverage of Skilled Nursing Facility Care
To qualify for coverage of skilled nursing facility (SNF) care, the member must no longer need acute hospital care, but requires skilled nursing or skilled rehabilitation services daily. The member's overall condition must be evaluated for purposes of admission to a SNF.
Criteria for coverage of skilled nursing services are as follows:
- Intravenous, intramuscular or subcutaneous injections and intravenous feeding.
- Administration of new medications requiring initial observations by skilled staff.
- Levin tube and gastrostomy feedings.
- Nasopharyngeal and tracheostomy aspiration.
- Insertion, sterile irrigation and replacement of catheters.
- Application of dressings involving prescription medications and aseptic techniques.
- Treatment of extensive decubitus ulcers or other widespread skin disorder.
- Heat treatments that have been specifically ordered by a physician as part of active treatment and require observation by skilled staff to evaluate the member's response.
- Initial phases of a regimen involving administration of medical gases.
- Rehabilitation nursing procedures, including related teaching and adaptive aspects of nursing, that are part of active treatment (for example, institution and supervision of bowel and bladder training programs).
- Colostomy and ileostomy care for new colostomies and ileostomies or for debilitated members.
Criteria for coverage of skilled rehabilitation services are as follows:
- Services concurrent with management of a member care plan, including tests and measurements of range of motion, strength, balance, coordination, endurance, functional ability, activities of daily living, perceptual deficits, speech and language, or hearing disorders.
- Therapeutic exercises or activities that, because of the type of exercises employed or the condition of the member, must be performed by or under the supervision of a qualified physical therapist or occupational therapist to ensure the safety of the member and the effectiveness of the treatment.
- Gait evaluation and training furnished to restore function to a member whose ability to walk has been impaired by neurological, muscular or skeletal abnormality.
- Range of motion exercises that are part of active treatment of a disease that has resulted in a loss of, or restriction of, mobility.
- Maintenance therapy, when the specialized knowledge and judgment of a physical therapist is required to design and establish a maintenance program based on an initial evaluation and periodic reassessment of the member's needs.
- Ultrasound, short-wave and microwave therapy treatment by a physical therapist.
- Hot packs, hydrocollator, infrared treatments, paraffin baths, and whirlpool in cases where the member's condition is complicated by circulatory deficiency, areas of desensitization, open wounds, fractures, or other complications and the skills, knowledge and judgment of a physical therapist are required.
- Services of a speech pathologist or audiologist when necessary for the restoration of speech or hearing.
Additional requirements for skilled nursing services and/or skilled rehabilitation services:
- The service must be so inherently complex that it can only be safely and effectively performed by, or under the supervision of, professional or technical staff.
- A condition that does not ordinarily require skilled services may require them because of special medical complications.
- The restoration potential of a member is not the deciding factor in determining whether skilled services are needed. Even if full recovery or medical improvement is not possible, a member may need skilled services to prevent further deterioration or preserve current capabilities.
- Criteria for "daily" means with the following frequency:
- Skilled nursing services or skilled rehabilitation services must be needed and provided seven days a week.
- As an exception, if skilled rehabilitation services are not available seven days a week, those services must be needed and provided at least five days a week.
- A break of one or two days in the furnishing of rehabilitation services does not preclude coverage if discharge would not be practical for the one or two days during which therapy is suspended (for example, the physician has postponed therapy sessions because the member exhibited extreme fatigue).
- The primary care physician (PCP) and hospital discharge planner determine that the member requires short-term nursing facility care for post-surgical, rehabilitative, or therapy services designed to cure the member's condition rather than just relieve the condition. In making a practical matter determination, consideration must be given to the member's condition and to the availability of more economical, alternative facilities and services:
- Member's condition - Inpatient care would be required as a practical matter if transporting the member to and from the nearest facility that furnishes the required daily skilled services would be an excessive physical hardship.
- Economy and efficiency - Even if the member's condition does not preclude transportation, inpatient care might be more efficient and less costly if, for instance, the only alternative is daily transportation by ambulance.
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 (PDF).
Criteria for Pediatric Subacute Care Program
To qualify for the pediatric subacute care program, the member must be under age 21 and need one of the following:
- Tracheostomy care with dependence on mechanical ventilation for a minimum of six hours each day
- Tracheostomy care requiring suctioning at least every six hours, room air mist or oxygen as needed, and dependence on one of the four (2-5) treatment procedures listed below
- Total parenteral nutrition or other intravenous nutritional support and one of the five treatment procedures listed below
- Skilled nursing care in the administration of any three of the five treatment procedures listed below
Treatment Criteria for Pediatric Subacute Care
- Intermittent suctioning at least every eight hours and room air mist or oxygen as need.
- Continuous intravenous therapy, including administration of therapeutic agents necessary for hydration or of intravenous pharmaceuticals, or intravenous pharmaceutical administration of more than one agent via a peripheral or central line without continuous infusion.
- Peritoneal dialysis treatment requiring at least four exchanges every 24 hours.
- Tube feeding via nasogastric or gastrostomy tube.
- Other medical technologies required continuously, which, in the opinion of the attending physician and Medi-Cal consultant, require the services of a professional nurse.
Additional Criteria
- The intensity of medical/skilled nursing care required by the member is such that the continuous availability of a registered nurse in the pediatric subacute unit is medically necessary to meet the member's health care needs and not be any less than the nursing staff ratios required.
- The member's medical condition must have stabilized so that the immediate services of an acute care hospital, including daily physician visits, are not medically necessary.
- The intensity of medical/skilled nursing care required by the member is such that, in the absence of a facility providing pediatric subacute care services, the only other medically necessary inpatient care appropriate to meet the member's health care needs under the Medi-Cal program is in an acute care licensed hospital bed.
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 (PDF).