23-1252 New Medi-Cal Benefit: Intermediate Care Facility for the Developmentally Disabled (ICF/DD)
Date: 10/24/23
Starting January 1, 2024, beneficiaries residing in an ICF/DD home must enroll in a managed care plan
Per All Plan Letter (APL) 23-023, the Department of Health Care Services (DHCS) will require beneficiaries residing in an intermediate care facility for the developmentally disabled (ICF/DD) home to enroll in a managed care plan starting January 1, 2024. Enrollment in a managed care plan does not change a member’s relationship with their Regional Center. Access to the Regional Center services and the current Individual Program Plan (IPP) process will remain the same.
Health Net will ensure members in need of ICF/DD home services, as determined by the individual program plan (IPP) and the Regional Center, are authorized using the Certification for Special Treatment Program Services Form HS 231. Health Net will receive a copy of the HS 231 as a prerequisite to providing coverage of ICF/DD home services.
Register to attend an upcoming webinar
We highly encourage you and your office staff to attend one of the webinars listed in the table below to learn more about ICF/DD home services. The training includes information on claims submissions and payments, disputes, prior authorization, transportation, continuity of care and more.
Date | Time | Registration |
|---|---|---|
December 6, 2023 | 1 p.m. | |
December 13, 2023 | 1 p.m. |
Covered services
Effective January 1, 2024, Health Net will authorize and cover all medically necessary services for members residing in an ICF/DD home, including professional, ancillary and transportation services. Health Net will cover:
- Long-term care benefits at the following facility types and homes:
- Intermediate care facility for the developmentally disabled (ICF/DD)
- Intermediate care facility for the developmentally disabled-habilitative (ICF/DD-H)
- Intermediate care facility for the developmentally disabled -nursing (ICF/DD-N)
- Leave of absence (LOA) and bed hold that an ICF/DD home provides:
- For LOA, Health Net will authorize up to 73 days per calendar year.
- For a bed hold, Health Net will authorize up to a total of seven days per hospitalization.
- Non-emergency medical transportation (NEMT) and non-medical transportation (NMT) services. Transportation services will be coordinated between the ICF/DD home and Health Net.
Note: ICF/DD – Continuous nursing is excluded from coverage under Health Net and remains a carve-out benefit.
Continuity of care
Health Net will automatically provide 12 months of continuity of care for the ICF/DD home placement of any member residing in an ICF/DD home who undergoes a mandatory transition to Health Net after January 1, 2024. Health Net provides continuity of care for all medically necessary ICF/DD home services, including professional services, ancillary services, and transportation services not already provided in the ICF/DD home. Health Net will also provide the appropriate level of care coordination.
Members may continue to see their out-of-network Medi-Cal provider if the member, authorized representative or the provider contacts Health Net to make the request. For coordination of benefit questions, physicians and providers may contact the Public Programs Department at 800‐526‐1898.
Prior authorization
Health Net will continue to honor any currently active Treatment Authorization Requests (TARs) approved by DHCS for the duration of the treatment authorization and up to two years for any new ICF/DD home services requests.
Health Net is responsible for all other approved authorization requests for services in an ICF/DD home, exclusive of the ICF/DD home per diem rate for a period of 90 days after enrollment in Health Net, or until Health Net is able to reassess the member and authorize and connect the member to medically necessary services.
Benefit coordination
As the payer of last resort, Health Net’s Medi-Cal plan coordinates benefits for members who are dually Medicare and Medi-Cal covered, or who have other health care coverage (OHC). Medicare does not cover ICF/DD home benefits. ICF/DD home benefits are exclusively covered by Medi-Cal. Members may, however, receive other benefits from Medicare in addition to the ICF/DD home benefits that fall to Health Net to coordinate.
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 on the provider portal > Provider Library under Quick Links, or go directly to provider library.
If you have questions regarding the information contained in this update, contact the Health Net Provider Services Center at 800-675-6110.
This information applies to Physicians, Participating Physician Groups (PPGs), Hospitals, Ancillary providers, Community Supports (CS) Providers, and Enhanced Care Management (ECM) Providers.
For Medi-Cal, this information applies to Kern, Los Angeles, Riverside, Sacramento, San Bernardino, San Diego, San Joaquin, Stanislaus, and Tulare counties.