California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 5 - ADULT DAY HEALTH CARE › Article 6 - PAYMENT OF SERVICES › Section 54501 - Adult Day Health Care Services

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(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
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.
1.
						Amendment filed 8-7-89 as an emergency; operative 8-7-89 (Register 89, No. 32).
						A Certificate of Compliance must be transmitted to OAL within 120 days or
						emergency language will be repealed on 12-5-89. For prior history, see Register
						87, No. 33.
2. Certificate of Compliance transmitted to OAL 12-1-89
						and filed 1-2-90 (Register 90, No. 2).
3. Amendment of subsection
						(b) and NOTE filed 11-7-94 as an emergency; operative 11-7-94 (Register 94, No.
						45). A Certificate of Compliance must be transmitted to OAL by 3-7-95 or
						emergency language will be repealed by operation of law on the following
						day.
4. Certificate of Compliance as to 11-7-94 order transmitted to
						OAL 3-1-95 and filed 4-12-95 (Register 95, No. 15).
5. Amendment of
						subsection (b) and NOTE filed 12-31-97 as an emergency; operative 12-31-97
						(Register 98, No. 1). A Certificate of Compliance must be transmitted to OAL by
						4-30-98 or emergency language will be repealed by operation of law on the
						following day.
6. Editorial correction of HISTORY 5 (Register 98,
						No. 24).
7. Certificate of Compliance as to 12-31-97 order
						transmitted to OAL 4-27-98 and filed 6-9-98 (Register 98, No.
						24).
8. Amendment of subsection (b) and NOTE filed 10-29-98 as an
						emergency; operative 10-29-98 (Register 98, No. 44). A Certificate of
						Compliance must be transmitted to OAL by 2-26-99 or emergency language will be
						repealed by operation of law on the following day.
9. Certificate of
						Compliance as to 10-29-98 order transmitted to OAL 2-26-99 and filed 4-8-99
						(Register 99, No. 15).
10. Amendment of subsection (b) and amendment
						of NOTE filed 11-3-99 as an emergency; operative 11-3-99 (Register 99, No. 45).
						A Certificate of Compliance must be transmitted to OAL by 3-2-2000 or emergency
						language will be repealed by operation of law on the following
						day.
11. Certificate of Compliance as to 11-3-99 order transmitted
						to OAL 3-1-2000 and filed 4-6-2000 (Register 2000, No. 14).
12.
						Amendment of subsection (b) and amendment of NOTE filed 11-17-2000 as an
						emergency; operative 11-17-2000 (Register 2000, No. 46). A Certificate of
						Compliance must be transmitted to OAL by 3-19-2001 or emergency language will
						be repealed by operation of law on the following day.
13.
						Certificate of Compliance as to 11-17-2000 order transmitted to OAL 3-8-2001
						and filed 4-19-2001 (Register 2001, No. 16).
14. Amendment of
						subsection (b) and amendment of NOTE filed 1-27-2003 as an emergency; operative
						8-1-2001 pursuant to Statutes of 2002, Chapter 16, Items 4260-101-0001 and
						4260-101-0890 (Register 2003, No. 5). A Certificate of Compliance must be
						transmitted to OAL by 5-27-2003 or emergency language will be repealed by
						operation of law on the following day.
15. Amendment of subsection
						(b) and amendment of NOTE refiled 5-22-2003 as an emergency; operative
						5-22-2003 (Register 2003, No. 21). A Certificate of Compliance must be
						transmitted to OAL by 9-19-2003 or emergency language will be repealed by
						operation of law on the following day.
16. Certificate of Compliance
						as to 5-22-2003 order transmitted to OAL 9-18-2003 and filed 10-16-2003
						(Register 2003, No. 42).
17. Amendment of subsection (d) and
						amendment of NOTE filed 8-24-2005 as a deemed emergency pursuant to Welfare and
						Institutions Code section
						14105(a);
						operative 8-24-2005 for dates of service 8-1-2002 through 7-31-2003 pursuant to
						Statutes of
						2002,
						Chapter 379, Items 4260-101-0001 and 4260-101-0890 (Register 2005, No. 34). A
						Certificate of Compliance must be transmitted to OAL by 12-23-2005 or emergency
						language will be repealed by operation of law on the following
						day.
18. Certificate of Compliance as to 8-24-2005 order transmitted
						to OAL 12-22-2005 and filed 1-23-2006 (Register 2006, No. 4).
19.
						Amendment of subsection (b) and NOTE filed 6-24-2010 as an emergency; operative
						6-24-2010 (Register 2010, No. 26). A Certificate of Compliance must be
						transmitted to OAL by 12-21-2010 or emergency language will be repealed by
						operation of law on the following day.
20. Certificate of Compliance
						as to 6-24-2010 order transmitted to OAL 11-29-2010 and filed 1-10-2011
						(Register 2011, No. 2).
21. Amendment of subsection (b) and NOTE
						filed 12-24-2013 as an emergency; operative 12-24-2013 (Register 2013, No. 52).
						A Certificate of Compliance must be transmitted to OAL by 6-23-2014 or
						emergency language will be repealed by operation of law on the following
						day.
22. Certificate of Compliance as to 12-24-2013 order
						transmitted to OAL 4-15-2014 and filed 5-22-2014 (Register 2014, No.
						21).
Note: Authority cited: Section
						  20, Health and Safety Code; and
						  Sections
						  10725,
						  14105,
						  14124.5
						  and
						  14570,
						  Welfare and Institutions Code. Reference: Section
						  14571,
						  Welfare and Institutions Code; 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; and Statutes of 2006, Chapter 48, Items
						  4260-101-0001 and 4260-101-0890; and the 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).