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Subdivision 1. California Medical Assistance Program, Chapter 5. Adult Day Health Care. Article 6. Payment of Services (Refs & Annos). Adult Day Health Care Services.   

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(a) Department reimbursement for adult day health care services shall be the usual charges made to the general public by the center not to exceed the maximum reimbursement rates listed in this section.

(b) The maximum all-inclusive rate per day of attendance for each approved Medi-Cal participant shall be the amount specified in the chart below.

All-Inclusive Max. Daily Rate

Effective Rate Year

Ƞ

2004-05

2005-06

2006-07

$69.58

$73.56

$76.22

(c) Payments shall be made only for days of attendance in the time period approved by the Medi-Cal consultant.

(d) The comprehensive daily rate shall be reduced by the Department for any component of the required basic services which is funded in part or in whole from any other source, as indicated in fiscal reports submitted in accordance with Section 54413 or as determined by a Department fiscal audit. Failure to report other income sources may, at the discretion of the Department, result in suspension of certification.

(e) The comprehensive daily rate shall be payment in full for all adult day health care services provided to the Medi-Cal participant. Physical therapy, occupational therapy and speech therapy provided or arranged by the center beyond the requirements stated in Section 54423 (a) may be reimbursed according to Sections 51507, 51507.1 and 51507.2 if a separate prior authorization request is approved for physical therapy in accordance with Section 51309 (b) or for rehabilitation center outpatient services in accordance with Section 51314. A written statement, signed by the adult day health care provider, certifying that they are meeting the requirements of Section 54423 (a) for the time period of the treatment authorization request and that the therapeutic needs of this participant are in excess of Section 54423 requirements, shall be attached to the claim and prior authorization request.

(f) A provider of adult day health care shall not submit claims to or demands or otherwise collect reimbursement from a Medi-Cal participant, or from other persons on behalf of the participant, for any service included in the daily rate for adult day health care services unless the exceptions of Section 51002, Division 3, Chapter 3, Title 22, California Administrative Code, apply.

(g) The daily rate includes costs for purchase of meals and transportation. Utilization of existing community resources for meals and transportation is mandated unless the adult day health care provider can justify to the satisfaction of the Department the need to provide meals or transportation directly.

(h) The maximum number of payments for days of attendance for any 24-hour period shall not exceed the licensed capacity.

(i) A provider of adult day health care shall make reasonable efforts to recover the value of services rendered to participants whenever said participants are covered for the same services, either fully or partially, under any other state or federal program or under other contractual or legal entitlement, including but not limited to, a private group or indemnification program. Such recoveries are returned to the Department. A provider shall notify the Department if efforts to recover payment are unsuccessful.

(j) A provider of adult day health care shall not attempt to recover the value of services rendered when such recovery shall result from an action involving third-party tort liability. The provider shall notify the Department of any situation in which it appears that a participant will benefit from a third-party liability.

Authority cited:

Health and Safety Code 20

Welfare and Institutions Code 10725

Welfare and Institutions Code 14105

Welfare and Institutions Code 14124.5

Welfare and Institutions Code 14570

Reference:

Welfare and Institutions Code 14571

Statutes of 2004, Chapter 208, Items 4260-101-0001 and 4260-101-0890

Statutes of 2005, Chapter 38, Items 4260-101-0001 and 4260-101-0890

Statutes of 2006, Chapter 48, Items 4260-101-0001 and 4260-101-0890

Settlement Agreement in California Association for Adult Day Services v. Department of Health Services, January 12, 1994, San Francisco County Superior Court (Case Number 944047)

(Amended by Register 2013, No. 52.)