Long-Term Care
Provider Type
- Physicians and Practitioners
- Participating Physician Groups (PPG)
- Hospitals
- Ancillary
This section provides general member benefit information on long-term care services and problem resolution. Unless specified in title, the information provided applies to all Health Net participating counties.
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 requiring services in an LTC facility. The physician or the physician's representative then contacts Health Net's Utilization Management (UM) Department (or the participating physician group (PPG), if UM responsibilities have been delegated to the PPG) to request prior authorization for admission
- Concurrent review – During an acute inpatient stay, the concurrent review nurse identifies discharge needs, including LTC placement.
Additional communication requirements for appropriate and timely concurrent review, claims submission and claims adjudication include:
- Hand-off and level of care communications - Health Net and the Skilled Nursing Facility (SNF)/PPG communicate regarding the members LTC admission, 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 who require long-term care (LTC) facility services should be placed in facilities that provide a 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
Turnaround times for authorizations:
Request Type | Turnaround Time (TAT) |
|---|---|
Authorization for members transitioning from an acute care hospital to a skilled nursing facility (SNF) | 72 hours |
Initial admission (from a non-acute stay) | Seven calendar days |
Concurrent requests | Three calendar days |
Day 0= receipt of request |
Placement requirements: Member must be placed in SNFs within five working days, seven working days, or 14 calendar days of a request, depending on the county of residence, as outlined in W&I section 14197.
Note: Hospice services are not a benefit of LTC. For outpatient hospice services, send documentation via encrypted email to CTIforms@centene.com. For inpatient hospice services, prior authorization is required.
For more information on hospice care, access the Provider Library at providerlibrary.healthnetcalifornia.com > select line of business > Provider Manual > Benefits > Hospice Care.
Special Treatment Program Services
Special Treatment Program (STP) services are covered under Medi-Cal Fee-For-Service (FFS), with the County Mental Health Department responsible for authorizing mental health services.
STP’s are licensed skilled nursing facilities with an approved mental health program serving individuals with chronic psychiatric impairment and moderately impaired adaptive functioning. STP objectives are aimed at improving and stabilizing adaptive functioning through short‑term, intensive mental health treatment to support transition to a less restrictive environment when possible and to prevent regression to a lower level of functioning when discharge is not immediately feasible.
Coordination of Care
The primary care physician (PCP) continues to provide care during the transition to long-term care and coordinates with the LTC attending physician or Medical Director to ensure the member’s care continues without delay.
This includes forwarding all pertinent records to the new PCP (attending in the SNF), when identified, and ensuring availability for consultation.
Long-Term Care for Permanently Institutionalized
Medi-Cal members residing in LTC facilities with institutional status, as indicated by long-term aid codes, are considered permanently institutionalized if their inpatient stay continues beyond the initial month of admission and the expected subsequent month. PPGs remain responsible for LTC members until those members are removed from their monthly eligibility reports.
Health Net must authorize (LTC services when a member has a medical condition that requires LTC. LTC includes both skilled nursing care and non-skilled custodial care.
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:
- Intermediate care facility admission for members accessing the Medi-Cal nursing facility Level A benefit.
- Skilled nursing facility admission for members accessing the Medi-Cal nursing facility Level B benefit
- Subacute facility admission for members accessing Medi-Cal covered subacute care services.
Members in need of LTC services are placed in facilities that provide a the level of care commensurate with their medical needs.
Criteria for Long-Term Care-NF level B
LTC nursing facility Level B services are for members who require ongoing nursing care due to medical, physical, or functional limitations, including members who demonstrate moderate to total dependency in activities of daily living.
The criteria Health Net uses to determine medical necessity for LTC services is Title 22 Chapter 7 of the,DHCS Manual of Criteria for Medi-Cal Authorization.
Referrals and Authorizations
Providers must submit one of the following completed forms as applicable: 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), along with 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 an active TAR for up to 12 months following enrollment, or for the duration of the TAR, whichever is shorter.
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 before providing such services.
Providers may contact the Health Net Long-Term Care Intake Line and/or the Healthnet provider porta with any 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 in Imperial, Fresno, Kings, and Madera counties.
Providers may refer to the Integrated Care for Dual Eligible Beneficiaries website for enrollment information, policy resources, workgroups, and other materials.
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 the intensity of medical services required and the severity of illness. Each member is evaluated based on primary care physician (PCP) diagnosis and treatment recommendations, facility heath care team assessments, and 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 the 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 Coverage of Skilled Nursing Facility Care
To qualify for coverage of skilled nursing facility (SNF) care, the member must no longer require acute hospital care but must require daily skilled nursing or skilled rehabilitation services.
The member's overall condition must be evaluated for purposes of admission to a SNF.
The need must require a level of service that includes the continuous availability of procedures, including, but not limited to, the following:
Procedure | Explanation |
|---|---|
Skilled nursing procedures | Intravenous, intramuscular, or subcutaneous injections and intravenous or enteral feeding. Administration of new medications requiring initial observation by skilled nursing staff. Nasopharyngeal or 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 disorders. Heat treatments ordered by a physician requiring observation to evaluate the member’s response. Initial phases of a regimen involving administration of medical gases. Rehabilitation nursing procedures, including teaching and adaptive nursing as part of active treatment. e.g., the institution and supervision of bowel and bladder training programs. Colostomy and ileostomy care for new or debilitated members. |
Skilled rehabilitation services | Ongoing assessment of rehabilitation needs and potential. Therapeutic exercises or activities requiring the supervision of a qualified physical or occupational therapist. Gait evaluation and training. Range of motion exercises as part of active treatment. Maintenance therapy designed by qualified therapist based on an initial evaluation and periodic reassessment of members needs, capacity and tolerance. Physical therapy modalities including ultrasound, short-wave, and microwave therapy. Hot packs, hydrocollator, infrared treatments, paraffin baths, and whirlpool when clinically indicated. Speech pathology or audiology services for restoration of speech or hearing. |
Health Net uses to determine medical necessity for LTC services is Title 22 Chapter 7 of the Department of Health Care Services (DHCS) Manual of Criteria for Medi-Cal Authorization (PDF)
Criteria for Adult and Pediatric Subacute Care Program
See Subacute Care Facilities section for applicable criteria and benefit details.