California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 7 - Payment for Services and Supplies › Section 51511 - Nursing Facility Level B Services

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) Payment to nursing facilities, hospitals,
					 or public institutions providing Level B services in accordance with Section
					 51123 shall be as set forth in
					 this section. As used in this section, the term "nursing facility Level B
					 services" is defined as nursing facility services provided in accordance with
					 Section 51123. Payment for service
					 includes the Quality Assurance Fee pursuant to Health and Safety Code Section
					 1324.21.
					 Payment shall be as follows:
(1) For
					 facilities with licensed bed capacities and located by county, for the 2004-05
					 rate year are as follows:
Alameda, Contra Costa, Marin, Napa, San
								Francisco, San Mateo
Bedsize
Los
								Angeles County
Santa Clara & Sonoma
								Counties
All Other Counties
1-59
$112.79
$137.95
$122.90
60+
$112.92
$146.81
$126.80
(2) For nursing facilities that are distinct
					 parts of acute care hospitals, if such facilities are not state operated, the
					 per diem reimbursement rate shall be the lesser of the facility's costs, as
					 projected by the Department, or as listed in the chart below:
Distinct Part Nursing
								Facilities Effective Rate Year
2004-05
2005-06
2006-07
$236.82
$299.80
$310.68
(A) For
					 purposes of this section, the rate year is August 1st through July
					 31st.
(B) The facility's projected
					 costs shall be based on the audit report findings of cost reports with fiscal
					 periods ending January 1 through December 31, two calendar years prior to the
					 beginning of the effective rate year. In the event the provider appeals the
					 audit, pursuant to Welfare and Institutions Code Section
					 14171,
					 and the provider notifies the Department by June 1 of the effective rate year
					 that the audit report findings have been modified by an appeal decision or an
					 agreement between the hospital and the Department, the facility's projected
					 costs shall be based on the modified audit findings.
(C) If the audit of a cost report is not
					 issued by July 1 of the effective rate year, the Department shall establish an
					 interim projected reimbursement rate based on the cost report with a fiscal
					 period ending January 1 through December 31, two calendar years prior to the
					 effective rate year, adjusted by an audit disallowance factor as listed in the
					 chart below:
Audit Disallowance Factor Per
								Rate Year
2004-05
2005-06
2006-07
.95566
.95211
.95211
(D) The Department will use the facility's
					 interim projected reimbursement rate in the computation of the prospective
					 class median rate. Facilities that did not provide Nursing Facility Level B
					 services to Medi-Cal patients during the cost report period and/or facilities
					 with less than a full year's reported cost shall not be used to establish the
					 prospective class median rate. In addition, facilities with Medi-Cal patient
					 days representing less than 20 percent of their total patient days will be
					 excluded from the median determination.
(E) If the facility has an interim
					 reimbursement rate as specified in (C), when the audit report is issued or when
					 the cost report is deemed true and correct under Welfare and Institutions Code
					 Section
					 14170(a)(1),
					 the Department shall adjust the facility's projected reimbursement rate
					 retroactively to August 1 of the effective rate year, to reflect the cost
					 determined pursuant to such audit, or to reflect the cost in the cost report in
					 the event that cost report is deemed true and correct. The Department shall
					 notify the provider of the revised rates within 45 days of issuance of the
					 audit report.
(F) Interest will
					 accrue from August 1 of the effective rate year, and be payable on any such
					 underpayment or overpayment at a rate equal to the monthly average received on
					 investment in the Surplus Money Investment Fund (as referenced in Welfare and
					 Institutions Code Section
					 14171)
					 during the month the audit report is issued.
(G) If a provider appeals an audit pursuant
					 to Welfare & Institutions Code Section
					 14171, and there is a
					 determination that the audit findings inaccurately reflect the audited
					 facility's projected costs, the provider shall be entitled to seek a
					 retroactive adjustment in its reimbursement rate, but the resulting
					 reimbursement rate shall not exceed the prospective median rate as provided in
					 subsection (a)(2).
(H) Payment
					 under subsection (a)(2) shall only be made for services authorized pursuant to
					 conditions set forth in Section
					 51335 for patients determined to
					 need Level B services for other than post-surgical rehabilitation or therapy
					 services.
(3)
					 Reimbursement to any state-operated facility shall be based on its actual
					 allowable costs.
(4) For facilities
					 that are designated as swing bed facilities, the rates are listed in the chart
					 below:
Swing Bed Facilities Effective
								Rate Year
2004-05
2005-06
2006-07
$229.96
$250.04
$269.26
(5) Reduced for leave of absence provided
					 pursuant to Section
					 51535.
(6) Reduced for bed hold provided pursuant to
					 Section 51535.1.