Legal Resources | | T22 51510.3
Subdivision 1. California Medical Assistance Program. Chapter 3. Health Care Services. Article 7. Payment for Services and Supplies (Refs & Annos). Intermediate Care Services for the Developmentally Disabled-Nursing
(a) Daily Reimbursement Rate -Intermediate care facilities meeting licensing and Medi-Cal standards and criteria for providing services to the developmentally disabled-nursing as contained or referred to in Sections 51164.2 through 51343.2, Division 3, and Sections 73800 through 73956, Division 5, Title 22, California Code of Regulations, shall be entitled to payment according to the following daily rates. Payment for service includes the Quality Assurance Fee pursuant to Health and Safety Code Section 1324.2.
Total Licensed Beds
Effective
4-6
7-15
Rate Year
Ƞ
2004-05
$200.28
$177.60
2005-06
$203.18
$202.61
2006-07
$212.55
$217.66
(1) Each provider of intermediate care, developmentally disabled-nursing services shall furnish:
(A) Services of the facility's direct care staff in accordance with Section 73873, Title 22, California Code of Regulations.
(B) Services of the facility's interdisciplinary professional staff/team and qualified mental retardation professional as follows:
1. Case conference review of beneficiary's medical/nursing and developmental needs.
2. Joint development of individual service plans.
3. In-service training of direct care staff and follow-up to ensure proper implementation of individual service plans.
4. Advising on the need for provision of various types of intervention beyond the capabilities of the direct care staff and specialized equipment beyond the resources of the facility.
(C) Administrative services in accordance with Sections 73908 through 73932, Title 22, California Code of Regulations.
(D) Health support, food and nutritional, and pharmaceutical services as required in Sections 73875 through 73907, Title 22, California Code of Regulations.
(E) Transportation services when necessary for round trips to attending physicians in accordance with Section 51343.2(i), (j) and (o), Title 22, California Code of Regulations.
(F) Social services required in Section 73856(c), Title 22, California Code of Regulations.
(G) All services, drugs, equipment and supplies required to provide intermediate care, developmentally disabled-nursing services except as provided in subsection (b). Such equipment, drugs, supplies, and services are, at a minimum, those which are required by law, including those required by federal Medicaid regulations and state licensing regulations.
(2) The daily reimbursement rate shall be adjusted for purposes of leave of absence or acute hospitalization in accordance with Sections 51535 and 51535.1, Title 22, California Code of Regulations.
(b) Services and supplies not covered by the payment rate but which are recommended by the interdisciplinary staff and ordered by the authorized health practitioners and which the facility's direct care staff are not qualified to provide may be billed separately, subject to the utilization controls and limitations of Medi-Cal regulations covering such services and supplies. These include:
(1) Medical and dental services.
(A) Costs of medical or dental services.
(B) Cost of a physician's medical evaluation for purposes of Section 51343.2(i), Title 22, California Code of Regulations. If a physician's evaluation has been completed for purposes of that section, the costs of an additional evaluation will not be reimbursed until 12 months thereafter.
(2) Psychological services provided by a licensed psychologist. These services shall be reimbursed in accordance with Title 22, California Code of Regulations, Section 51505.3.
(3) Cost of incontinence medical supplies for beneficiaries five years of age or more whose developmental deficits are such that bowel and bladder control cannot be attained. Prior authorization is required in accordance with Section 51003, Title 22, California Code of Regulations.
(4) The following services, items and supplies:
(A) Allied health services ordered by the attending physician.
(B) Alternating pressure mattresses/pads with motor.
(C) Atmospheric oxygen concentrators and enrichers and accessories.
(D) Blood, plasma and substitutes.
(E) Dental services.
(F) Durable medical equipment as specified in Section 51321(g).
(G) Insulin.
(H) Intermittent positive pressure breathing equipment.
(I) Intravenous trays, tubing and blood infusion sets.
(J) Laboratory services.
(K) Legend drugs.
(L) Liquid oxygen system.
(M) MacLaren or Pogon Buggy.
(N) Medical supplies as specified in the list established by the Department.
(O) Nasal cannula.
(P) Osteogenesis stimulator device.
(Q) Oxygen (except emergency).
(R) Parts and labor for repairs of durable medical equipment if originally separately payable or owned by the beneficiary.
(S) Physician services.
(T) Portable aspirator.
(U) Portable gas oxygen system and accessories.
(V) Precontoured structures (VASCO-PASS, cut out foam).
(W) Prescribed prosthetic and orthotic devices for exclusive use of patient.
(X) Reagent testing sets.
(Y) Therapeutic air/fluid support systems/beds.
(Z) Traction equipment and accessories.
(AA) Variable height beds.
(BB) X-rays.
(c) All services and supplies billed separately are subject to the general provisions and billing limitations set forth in Sections 51303 and 51304, Title 22, California Code of Regulations.
(d) Payment shall not be provided for purposes of respite care except for beneficiaries who are enrolled in a federally approved home and community-based care program under Section 1915(c) of the Social Security Act. Whenever respite care is provided to Medi-Cal beneficiaries through other funding sources, all Medi-Cal admission requirements shall be met.
(e) Not included in the payment rate nor in the Medi-Cal schedule of benefits are costs of beneficiaries' personal items such as cosmetics, tobacco products and accessories, dry cleaning, beauty shop services (other than shaves or shampoos performed by the facility staff as part of patient care and periodic hair trims), television rental, and costs associated with recreational activities not otherwise provided for in the daily reimbursement rate.
Authority cited:
Health and Safety Code 20
Health and Safety Code 1267.7
Health and Safety Code 1275.3
Welfare and Institutions Code 10725
Welfare and Institutions Code 14105
Welfare and Institutions Code 14108
Welfare and Institutions Code 14108.2
Welfare and Institutions Code 14110.6
Welfare and Institutions Code 14110.7
Welfare and Institutions Code 14124.5,
Reference:
Health and Safety Code 1250
Health and Safety Code 1267.7
Health and Safety Code 1324
Health and Safety Code 1324.2
Health and Safety Code 1324.4
Health and Safety Code 1324.6
Health and Safety Code 1324.8
Health and Safety Code 1324.10
Health and Safety Code 1324.12
Health and Safety Code 1324.14
Welfare and Institutions Code 14108
Welfare and Institutions Code 14108.2
Welfare and Institutions Code 14109.5
Welfare and Institutions Code 14110.4
Welfare and Institutions Code 14110.6
Welfare and Institutions Code 14123
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
(Amended by Register 2013, No. 52.)