22-916 Long-Term Care Benefit for Medi-Cal
Date: 10/26/22
Effective January 1, 2023, long-term care members to enroll in a managed care plan
Per All Plan Letter 22-0181, the Department of Health Care Services (DHCS) will require the following to enroll in a managed care plan:
- By January 1, 2023, most non-dual and dual long-term care (LTC) members residing in skilled nursing facilities (SNFs).
- By July 1, 2023, the remaining LTC residents receiving services from adult and pediatric Subacute Facility and Intermediate Care Facility for the Developmentally Disabled (ICD-DD).
Starting January 1, 2023, Health Net, on behalf of CalViva Health, will authorize and cover medically necessary long-term care services provided in SNFs. Members who are admitted into a SNF and who would otherwise have been disenrolled from the Plan will remain enrolled.
Bed hold and leave of absence
Members may return to the same SNF where they previously resided under the bed hold and leave of absence policies per Medi-Cal requirements for bed hold and leave of absence.2 The Plan will ensure that SNFs notify our members or their authorized representative in writing of the right to exercise the bed hold and leave of absence provisions.
Continuity of care
The Plan will automatically provide 12 months of continuity of care for the SNF placement of any member residing in a SNF who undergoes a mandatory transition to the Plan on January 1, 2023, and before July 1, 2023. If the member is currently residing in a SNF, they do not have to request continuity of care.
Members may stay in the same SNF under continuity of care only in the following scenarios:
- The SNF is enrolled and licensed by the California Department of Public Health (CDPH).
- The SNF meets the Plan’s applicable professional standards and has no disqualifying quality of care issues.
- The SNF and the Plan agree to payment rates that meet state statutory requirements.
Following the initial 12-month continuity of care period, members may request an additional 12 months of continuity of care, following the process established by All Plan Letter (APL) 18-008.
Primary care physicians continue to provide care prior to the transition to LTC, and coordinate with the LTC attending physician to ensure continuity of care. For coordination of benefit questions, physicians and physicians and other providers may contact the Plan’s Public Programs Department at 800-526-1898.
Prior authorization and referral
Physicians and other providers must supply both the completed 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 Long-Term Care Intake Line by fax at 855-851-4563. The Plan continues to honor any currently active TAR approved authorizations.
For new admission authorization/notification requests, once a decision is made, the Plan notifies the physician and other provider by telephone or fax. Other ancillary services may require prior authorization and are not included in the nursing facility room rate. Physicians and other providers must obtain prior authorization before providing such services.
Physicians and other providers may contact the Long-Term Care Intake Line at 800-453-3033 with all questions regarding LTC referrals and authorizations, or to check the status of a request.
The Plan is responsible for all other approved services in a SNF exclusive of the LTC per diem rate for a period of 90 days after enrollment in the Plan or for the duration of the treatment authorization (whichever is shorter) and until the Plan is able to reassess the member and authorize and connect the member to medically necessary services. For current prior authorization requirements, go to pre-log in, select Working with Health Net > Additional Resources > Services Requiring Prior Authorization.
Claims and payment
Physicians and other providers must verify eligibility monthly to ensure claims are appropriately directed. Once the transition of all impacted members occurs by enrollment type from Medi-Cal fee-for-service (FFS) to the Managed Care Plan, if the member is in an LTC facility receiving long-term skilled or custodial Medi-Cal-type benefits, physicians and other providers may submit claims directly to the Plan Medi-Cal Claims Department. A prior authorization number from the Plan is required on the claim form.
Additional information
Relevant sections of the provider operations manuals have been revised to reflect the information contained in this update as applicable. Provider operations manuals are available electronically in the Provider Library after logging in to the provider website > Provider Library under Quick Links, or go directly to provider library.
Physicians and other providers are encouraged to access the provider portal for real-time information, including eligibility verification, claims status, prior authorization status, plan summaries, and more.
If you have questions regarding the information contained in this update, contact CalViva Health at 888-893-1569.
1https://www.dhcs.ca.gov/formsandpubs/Documents/MMCDAPLsandPolicyLetters/APL2022/APL22-018.pdf.
2Detailed in Title 22 California Code of Regulations (CCR) Sections 51535 and 51535.1.
This information applies to Physicians, Participating Physician Groups (PPGs), Hospitals, and Ancillary providers.
This information applies to Medi-Cal in Fresno, Kings and Madera counties.