Skilled nursing facility services necessary for the
treatment of illness or injury, are covered subject to the following:
(a) Skilled nursing facility services are
covered only after prior authorization has been obtained from the designated
Medi-Cal consultant for the district where the skilled nursing facility is
located. The authorization request shall be initiated by the facility and shall
be signed by the attending physician.
(b) An initial Treatment Authorization
Request shall be required for each admission.
(1) An initial authorization may be granted
for periods up to one year from the date of admission.
(2) An approved initial Treatment
Authorization Request shall be required prior to the transfer of a beneficiary
between skilled nursing facilities.
(3) For Medicare/Medi-Cal covered services
(crossover services) a request for authorization shall be received by the
Medi-Cal consultant's office on or before the 20th calendar day of skilled
nursing facility care. Medi-Cal shall not pay coinsurance for skilled nursing
facility care unless an authorization request has been approved covering the
21st and subsequent days of skilled nursing facility care. When the
authorization request is received by the Medi-Cal consultant's office after the
20th day of skilled nursing facility care, one day of coinsurance authorization
shall be denied for each day the request is late.
(c) A request for reauthorization must be
received by the appropriate Medi-Cal consultant on or before the first working
day following the expiration of a current authorization. When the request is
received by the Medi-Cal consultant later than the first working day after the
previously authorized period, one day of authorization shall be denied for each
day the request is late.
(1) Reauthorizations
may be granted for periods up to one year.
(d) The Medi-Cal consultant shall deny an
authorization request or reauthorization request or shall cancel any
authorization or reauthorization in effect when services or placement are not
appropriate to the needs of the patient (beneficiary).
(1) Where the reauthorization request is
denied or an existing authorization is cancelled, the beneficiary shall be
notified in writing of the Department's decision to deny ongoing services; the
provider will be notified simultaneously. If the beneficiary does not agree
with the Department's decision, the beneficiary has the right to request a fair
hearing pursuant to section
51014.1 herein. If the beneficiary
requests a fair hearing within ten days of the date of the notice, the
Department will institute aid paid pending the hearing decision pursuant to
section
51014.2 herein.
(2) Medi-Cal consultants shall deny any
initial authorization request if the skilled nursing facility is not
participating in Medicare as a skilled nursing facility and the patient is
qualified for skilled nursing facility care. Medicare benefits shall be
utilized to their fullest extent; failure to utilize such benefits shall result
in denial of Medi-Cal benefits under this section for the same period of time
Medicare benefits would have been available. Exception to this rule may be
made:
(A) When skilled nursing facility
benefits are known to have been exhausted.
(B) When Medicare rejects skilled nursing
facility level of care and the Medi-Cal consultant determines the medical
necessity for skilled nursing facility care.
(C) When it can be determined that there are
no skilled nursing facility care beds available in or near the
community.
(e)
The attending physician must recertify, at least every 60 days, the patient's
need for continued care in accordance with the procedures specified by the
Director. The attending physician must comply with this requirement prior to
the start of the 60-day period of stay for which the patient is being
recertified. The facility must present proof of this recertification at the
time of billing for services rendered.
(f) Medi-Cal beneficiaries in the facility
shall be visited by their attending physician no less often than once every 30
days for the first 90 days following admission. Subsequent to the 90th day, an
alternative schedule of visits may be proposed, subject to approval by the
Medi-Cal consultant. At no time, however, shall an alternative schedule of
visits result in more than 60 days elapsing between physician visits.
(g) Services are not covered unless provided
on the signed order of the physician responsible for the care of the
patient.
(h) There shall be a
periodic medical review, not less often than annually, of all beneficiaries
receiving skilled nursing facility services by a medical review team as defined
in section
50028.2.
(i) Leave of absence from skilled nursing
facilities is reimbursed in accordance with section
51535 and is covered for the
maximum number of days per calendar year as indicated below:
(1) Developmentally disabled patients: 73
days.
(2) Patients in a certified
special treatment program for mentally disordered persons, or patients in a
mental health therapeutic program approved and certified by a local mental
health director: 30 days.
(3) All
other patients: 18 days. Up to 12 additional days of leave per year may be
approved in increments of no more than two consecutive days when the following
conditions are met:
(A) The request for
additional days of leave shall be in accordance with the individual patient
care plan and appropriate to the physical and mental well-being of the
patient.
(B) At least five days
inpatient care must be provided between each approved leave of
absence.
(j) In
order to qualify for skilled nursing facility services, a patient shall have a
medical condition which needs visits by a physician at least every 60 days and
constantly available skilled nursing services. The following criteria together
with the provisions of section
51124, will assist in determining
appropriate placement:
(1) Need for patient
observation, evaluation of treatment plans, and updating of medical orders by
the responsible physician;
(2) Need
for constantly available skilled nursing services. A patient may qualify for
nursing home services if the patient has one or more of the following
conditions:
(A) A condition which needs
therapeutic procedures. A condition such as the following may weigh in favor of
nursing home placement.
1. Dressing of
postsurgical wounds, decubiti, leg ulcers, etc. The severity of the lesions and
the frequency of dressings will be determining factors in evaluating whether
they require nursing home care.
2.
Tracheostomy care, nasal catheter maintenance.
3. Indwelling catheter in conjunction with
other conditions. Its presence without a requirement for other skilled nursing
care is not a sufficient criterion for nursing home placement.
4. Gastrostomy feeding or other tube
feeding.
5. Colostomy care for
initial or debilitated patients. Facilities shall be required to instruct in
self-care, where such is feasible for the patient. Colostomy care alone should
not be a reason for continuing nursing home placement.
6. Bladder and bowel training for incontinent
patients.
(B) A condition
which needs patient skilled nursing observation. Patients whose medical
condition requires continuous skilled nursing observation of the following may
be in a nursing home dependent on the severity of the condition. Observation
must, however, be needed at frequent intervals throughout the 24 hours to
warrant care in a nursing home:
1. Regular
observation of blood pressure, pulse, and respiration is indicated by the
diagnosis or medication and ordered by the attending physician.
2. Regular observation of skin for conditions
such as decubiti, edema, color, and turgor.
3. Careful measurement of intake and output
is indicated by the diagnosis or medication and ordered by the attending
physician.
(C) The
patient needs medications which cannot be self-administered and requires
skilled nursing services for administration of the medications. Nursing home
placement may be necessary for reasons such as the following:
1. Injections administered during more than
one nursing shift. If this is the only reason for nursing home placement,
consideration should be given to other therapeutic approaches, or the
possibility of teaching the patient or a family member to give the
injections.
2. Medications
prescribed on an as needed basis. This will depend on the nature of the drug
and the condition being treated and frequency of need as documented. Many
medications are now self-administered on an PRN basis in residential care
facilities.
3. Use of restricted or
dangerous drugs, if required more than during the daytime, requiring close
nursing supervision.
4. Use of new
medications requiring close observation during initial stabilization for
selected patients. Depending upon the circumstances, such patients may also be
candidates for intermediate care facilities.
(D) A physical or mental functional
limitation.
1. Physical limitations. The
physical functional incapacity of certain patients may exceed the patient care
capability of intermediate care facilities.
a.
Bedfast patients.
b. Quadriplegics,
or other severe paralysis cases. Severe quadriplegics may require such
demanding attention (skin care, personal assistance, respiratory embarrassment)
as to justify placement in nursing homes.
c. Patients who are unable to feed
themselves.
2. Mental
limitations. Persons with a primary diagnosis of mental illness (including
mental retardation), when such patients are severely incapacitated by mental
illness or mental retardation.
The following criteria are used when considering the type
of facility most suitable for the mentally ill and mentally retarded person
where care is related to his mental condition.
a. The severity of unpredictability of the
patient's behavior or emotional state.
b. The intensity of the care, treatment,
services, or skilled observation that his condition requires and,
c. The physical environment of the facility,
its equipment, and the qualifications of staff and,
d. The impact of the particular patient on
other patients under care in the
facility.
(3) The general criteria identified above are
not intended to be either all-inclusive or mutually exclusive. In practice,
they should be applied as a total package in evaluation of an approved
admission.
(k) Special
program services for the mentally disordered (as defined in chapter 3, division
5, title 22) provided in skilled nursing facilities are covered when prior
authorization has been granted by the Department for such services. Payment for
these services will be made in accordance with Section
51511.1.
(l) A need for a special services program for
the mentally disordered is not sufficient justification for a beneficiary to be
placed in a skilled nursing facility. All beneficiaries admitted to skilled
nursing facilities must meet the criteria found in paragraph (i) of this
section.
(m) A need for a special
services program for the developmentally disabled or mentally disordered is not
sufficient justification for a beneficiary to be placed in a skilled nursing
facility. All beneficiaries admitted to skilled nursing facilities must meet
the criteria found in paragraph (j) of this section.
(n) The placement criteria established in
Section
14091.21
of the Welfare and Institutions Code must be met except in either of the
following circumstances:
(1) The beneficiary's
physician and the discharge planner determine that the beneficiary requires
short-term nursing facility care for postsurgical, rehabilitation, or therapy
services which are curative rather than palliative in nature; or
(2) The beneficiary's attending physician
certifies in the medical record that transfer to a freestanding nursing
facility would cause specific physical or psychological harm to the
beneficiary.
Notes
Cal. Code Regs. Tit. 22, §
51335
1.
Amendment filed 11-19-76 as an emergency; effective upon filing (Register 76,
No. 47). For prior history, see Register 75, No. 46.
2. Certificate
of Compliance filed 3-8-77 (Register 77, No. 11).
3. Amendment of
subsections (k) and (l) filed 3-2-79; effective thirtieth day thereafter
(Register 79, No. 9).
4. Amendment of subsection (i) filed 9-20-79
as an emergency; designated effective 9-20-79 (Register 79, No. 38). A
Certificate of Compliance must be filed within 120 days or emergency language
will be repealed on 1-18-80.
5. Certificate of Compliance filed
11-29-79 (Register 79, No. 48).
6. Amendment of subsection (i) filed
4-7-83; effective thirtieth day thereafter (Register 83, No. 15).
7.
Amendment of subsection (i)(3) filed 2-9-84; designated effective 3-1-84
(Register 84, No. 6).
8. Amendment of subsection (d)(1) filed
10-26-90 as an emergency; operative 10-26-90 (Register 90, No. 50). A
Certificate of Compliance must be transmitted to OAL by 2-25-91 or emergency
language will be repealed by operation of law on the following
day.
9. Amendment of subsection (a) and (b) filed 11-26-90 as an
emergency; operative 11-26-90 (Register 91, No. 3). A Certificate of Compliance
must be transmitted to OAL by 3-26-91 or emergency language will be repealed by
operation of law on the following day.
10. Certificate of Compliance
as to 10-26-90 order transmitted to OAL 2-22-91 and filed 3-25-91 (Register 91,
No. 15).
11. Amendment filed 4-2-91 as an emergency; operative
4-2-91 (Register 91, No. 18). A Certificate of Compliance must be transmitted
to OAL by 7-31-91 or emergency language will be repealed by operation of law on
the following day.
12. Amendment refiled 8-8-91 as an emergency;
operative 8-8-91 (Register 92, No. 6). A Certificate of Compliance must be
transmitted to OAL 12-6-91 or emergency language will be repealed by operation
of law on the following day.
13. Amendment refiled 12-2-91 as an
emergency; operative 12-6-91 (Register 92, No. 10). A Certificate of Compliance
must be transmitted to OAL 4-6-92 or emergency language will be repealed by
operation of law on the following day.
14. Amendment refiled 4-13-92
as an emergency; operative 4-13-92 (Register 92, No. 21). A Certificate of
Compliance must be transmitted to OAL 8-12-92 or emergency language will be
repealed by operation of law on the following day.
15. Editorial
correction of printing error restoring inadvertently omitted subsection (a)(2)
(Register 92, No. 28).
16. Amendments, including additional
amendments to subsections (a)(3)(C)(2) and (a)(5), refiled 7-2-92 as an
emergency; operative 8-11-92 (Register 92, No. 28). A Certificate of Compliance
must be transmitted to OAL by 10-30-92 or emergency language will be repealed
by operation of law on the following day.
17. Reinstatement of
section as it existed prior to emergency amendment filed 4-2-91 by operation of
Government Code section
11346.1(g)
(Register 93, No. 4).
18. Editorial correction of printing error
restoring inadvertently omitted NOTE (Register 93, No. 33).
19.
Amendment of subsection (d) and NOTE and new subsections (n)-(n)(2) filed
6-9-94 as an emergency; operative 6-9-94. Exempt from OAL review, approval and
repeal and shall remain in effect until revised or replaced per Statutes of
1992, Chapter 722, Section
147 (Register 94, No.
23).
Note: Authority cited: Sections
10725,
14105,
14108,
14108.1
and
14124.5,
Welfare and Institutions Code. Reference: Sections
10725,
14091.21,
14105,
14108,
14108.1,
14108.2,
14124.5
and
14132,
Welfare and Institutions Code; Hudman v Kizer, Sacramento County Superior Court
Case No. 362172, and Laguna Honda Hospital and Rehabilitation Center of the
City and County of San Francisco v Kizer, U.S. District Court, EDCA, No.
CIV-S90-1239 MLS EM.
1. Amendment filed
11-19-76 as an emergency; effective upon filing (Register 76, No. 47). For
prior history, see Register 75, No. 46.
2. Certificate of
Compliance filed 3-8-77 (Register 77, No. 11).
3. Amendment of
subsections (k) and ( l) filed 3-2-79; effective thirtieth day thereafter
(Register 79, No. 9).
4. Amendment of subsection (i) filed 9-20-79
as an emergency; designated effective 9-20-79 (Register 79, No. 38). A
Certificate of Compliance must be filed within 120 days or emergency language
will be repealed on 1-18-80.
5. Certificate of Compliance filed
11-29-79 (Register 79, No. 48).
6. Amendment of subsection (i)
filed 4-7-83; effective thirtieth day thereafter (Register 83, No.
15).
7. Amendment of subsection (i)(3) filed 2-9-84; designated
effective 3-1-84 (Register 84, No. 6).
8. Amendment of subsection
(d)(1) filed 10-26-90 as an emergency; operative 10-26-90 (Register 90, No.
50). A Certificate of Compliance must be transmitted to OAL by 2-25-91 or
emergency language will be repealed by operation of law on the following
day.
9. Amendment of subsection (a) and (b) filed 11-26-90 as an
emergency; operative 11-26-90 (Register 91, No. 3). A Certificate of Compliance
must be transmitted to OAL by 3-26-91 or emergency language will be repealed by
operation of law on the following day.
10. Certificate of
Compliance as to 10-26-90 order transmitted to OAL 2-22-91 and filed 3-25-91
(Register 91, No. 15).
11. Amendment filed 4-2-91 as an emergency;
operative 4-2-91 (Register 91, No. 18). A Certificate of Compliance must be
transmitted to OAL by 7-31-91 or emergency language will be repealed by
operation of law on the following day.
12. Amendment refiled 8-8-91
as an emergency; operative 8-8-91 (Register 92, No. 6). A Certificate of
Compliance must be transmitted to OAL 12-6-91 or emergency language will be
repealed by operation of law on the following day.
13. Amendment
refiled 12-2-91 as an emergency; operative 12-6-91 (Register 92, No. 10). A
Certificate of Compliance must be transmitted to OAL 4-6-92 or emergency
language will be repealed by operation of law on the following day.
14. Amendment refiled 4-13-92 as an emergency; operative 4-13-92 (Register 92,
No. 21). A Certificate of Compliance must be transmitted to OAL 8-12-92 or
emergency language will be repealed by operation of law on the following
day.
15. Editorial correction of printing error restoring
inadvertently omitted subsection (a)(2) (Register 92, No. 28).
16.
Amendments, including additional amendments to subsections (a)(3)(C)(2) and
(a)(5), refiled 7-2-92 as an emergency; operative 8-11-92 (Register 92, No.
28). A Certificate of Compliance must be transmitted to OAL by 10-30-92 or
emergency language will be repealed by operation of law on the following
day.
17. Reinstatement of section as it existed prior to emergency
amendment filed 4-2-91 by operation of Government Code section
11346.1(g)
(Register 93, No. 4).
18. Editorial correction of printing error
restoring inadvertently omitted Note (Register 93, No. 33).
19.
Amendment of subsection (d) and Note and new subsections (n)-(n)(2) filed
6-9-94 as an emergency; operative 6-9-94. Exempt from OAL review, approval and
repeal and shall remain in effect until revised or replaced per Statutes of
1992, Chapter 722, Section 147 (Register 94, No.
23).