1. (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.

   1. (1) Each provider of intermediate care, developmentally disabled-nursing services shall furnish:

      1. (A) Services of the facility's direct care staff in accordance with Section 73873, Title 22, California Code of Regulations.

      2. (B) Services of the facility's interdisciplinary professional staff/team and qualified mental retardation professional as follows:

         1. 1. Case conference review of beneficiary's medical/nursing and developmental needs.
         2. 2. Joint development of individual service plans.
         3. 3. In-service training of direct care staff and follow-up to ensure proper implementation of individual service plans.
         4. 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.
      3. (C) Administrative services in accordance with Sections 73908 through 73932, Title 22, California Code of Regulations.
      4. (D) Health support, food and nutritional, and pharmaceutical services as required in Sections 73875 through 73907, Title 22, California Code of Regulations.
      5. (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.
      6. (F) Social services required in Section 73856(c), Title 22, California Code of Regulations.
      7. (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. (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.

   Total Licensed Beds

   Effective Rate Year

   4-6

   7-15

   2004-05

   $200.28

   $177.60

   2005-06

   $203.18

   $202.61

   2006-07

   $212.55

   $217.66

2. (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. (1) Medical and dental services.

      1. (A) Costs of medical or dental services.
      2. (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. (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. (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. (4) The following services, items and supplies:

      1. (A) Allied health services ordered by the attending physician.
      2. (B) Alternating pressure mattresses/pads with motor.
      3. (C) Atmospheric oxygen concentrators and enrichers and accessories.
      4. (D) Blood, plasma and substitutes.
      5. (E) Dental services.
      6. (F) Durable medical equipment as specified in Section 51321(g).
      7. (G) Insulin.
      8. (H) Intermittent positive pressure breathing equipment.
      9. (I) Intravenous trays, tubing and blood infusion sets.
      10. (J) Laboratory services.
      11. (K) Legend drugs.
      12. (L) Liquid oxygen system.
      13. (M) MacLaren or Pogon Buggy.
      14. (N) Medical supplies as specified in the list established by the Department.
      15. (O) Nasal cannula.
      16. (P) Osteogenesis stimulator device.
      17. (Q) Oxygen (except emergency).
      18. (R) Parts and labor for repairs of durable medical equipment if originally separately payable or owned by the beneficiary.
      19. (S) Physician services.
      20. (T) Portable aspirator.
      21. (U) Portable gas oxygen system and accessories.
      22. (V) Precontoured structures (VASCO-PASS, cut out foam).
      23. (W) Prescribed prosthetic and orthotic devices for exclusive use of patient.
      24. (X) Reagent testing sets.
      25. (Y) Therapeutic air/fluid support systems/beds.
      26. (Z) Traction equipment and accessories.
      27. (AA) Variable height beds.
      28. (BB) X-rays.
3. (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.
4. (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.
5. (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.

Note: Authority cited: Sections 20, 1267.7 and 1275.3, Health and Safety Code; and Sections 10725, 14105, 14108, 14108.2, 14110.6, 14110.7 and 14124.5, Welfare and Institutions Code. Reference: Sections 1250, 1267.7, 1324, 1324.2, 1324.4, 1324.6, 1324.8, 1324.10, 1324.12 and 1324.14, Health and Safety Code; Sections 14108, 14108.2, 14109.5, 14110.4, 14110.6 and 14123, 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.

History

1. New section refiled by the Department of Health Services with the Secretary of State on 5-30-89 as an emergency pursuant to Health and Safety Code section 1275.3; operative 5-30-89. Submitted to OAL for printing only pursuant to Government Code section 11343.8 (Register 89, No. 23). For prior history, see Register 89, No. 1.

2. 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.

3. Certificate of Compliance as to 5-30-89 order including amendment transmitted to OAL 9-27-89 and filed 10-26-89 (Register 89, No. 44).

4. Certificate of Compliance as to 8-7-89 order transmitted to OAL 12-1-89 and filed 1-2-90 (Register 90, No. 2).

5. Amendment filed 12-10-90 as an emergency; operative 12-10-90 (Register 91, No. 6). A Certificate of Compliance must be transmitted to OAL by 4-9-91 or emergency language will be repealed by operation of law on the following day.

6. Certificate of Compliance as to 12-10-90 order including amendment of subsection (a) transmitted to OAL 4-8-91 and filed 5-8-91 (Register 91, No. 24).

7. Amendment of subsection (a) and Note filed 8-12-91 as an emergency; operative 8-12-91 (Register 92, No. 6). A Certificate of Compliance must be transmitted to OAL 12-10-91 or emergency language will be repealed by operation of law on the following day.

8. Certificate of Compliance as to 8-12-91 order transmitted to OAL 12-9-91 and filed 1-2-92 (Register 92, No. 18).

9. Amendment of subsection (a) and Note filed 12-3-92 as an emergency; operative 12-3-92 (Register 92, No. 49). A Certificate of Compliance must be transmitted to OAL 4-2-93 or emergency language will be repealed by operation of law on the following day.

10. Certificate of Compliance as to 12-3-92 order transmitted to OAL 4-2-93 and filed 5-14-93 (Register 93, No. 20).

11. Amendment of subsection (a) and Note filed 8-24-93 as an emergency; operative 8-24-93 (Register 93, No. 35). A Certificate of Compliance must be transmitted to OAL by 12-22-93 or emergency language will be repealed by operation of law on the following day.

12. Amendment of subsection (a) and Note refiled 12-20-93 as an emergency; operative 12-20-93 (Register 93, No. 52). A Certificate of Compliance must be transmitted to OAL by 4-21-94 or emergency language will be repealed by operation of law on the following day.

13. Certificate of Compliance as to 12-20-93 order transmitted with amendments to OAL 3-22-94 and filed 4-28-94 (Register 94, No. 17).

14. Amendment of subsection (a) and Note filed 8-31-94 as an emergency; operative 8-31-94 (Register 94, No. 35). A Certificate of Compliance must be transmitted to OAL by 12-29-94 or emergency language will be repealed by operation of law on the following day.

15. Amendment of subsection (a) and Note refiled 1-3-95 as an emergency; operative 1-3-95 (Register 95, No. 1). A Certificate of Compliance must be transmitted to OAL 5-3-95 or emergency language will be repealed by operation of law on the following day.

16. Certificate of Compliance as to 1-3-95 order transmitted to OAL 4-27-95 and filed 6-9-95 (Register 95, No. 23).

17. Amendment of subsection (a) and Note filed 10-16-95 as an emergency; operative 10-16-95 (Register 95, No. 42). A Certificate of Compliance must be transmitted to OAL by 2-13-96 or emergency language will be repealed by operation of law on the following day.

18. Amendment of subsection (b)(3) filed 12-21-95; operative 1-20-96 (Register 95, No. 51).

19. Amendment of subsection (a) and Note refiled 2-5-96 as an emergency; operative 2-5-96 (Register 96, No. 6). A Certificate of Compliance must be transmitted to OAL by 6-6-96 or emergency language will be repealed by operation of law on the following day.

20. Certificate of Compliance as to 2-5-96 order transmitted to OAL 6-4-96 and filed 7-12-96 (Register 96, No. 28).

21. Amendment of subsection (a) and Note filed 9-19-96 as an emergency; operative 9-19-96 (Register 96, No. 38). A Certificate of Compliance must be transmitted to OAL by 1-17-97 or emergency language will be repealed by operation of law on the following day.

22. Certificate of Compliance as to 9-19-96 order transmitted to OAL 1-17-97 and filed 3-3-97 (Register 97, No. 10).

23. Amendment of subsection (a) filed 5-15-97 as an emergency; operative 5-15-97 (Register 97, No. 20). A Certificate of Compliance must be transmitted to OAL by 9-12-97 or emergency language will be repealed by operation of law on the following day.

24. Certificate of Compliance as to 5-15-97 order transmitted to OAL 9-10-97 and filed 9-30-97 (Register 97, No. 40).

25. Amendment of subsection (a) 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.

26. Editorial correction of History 25 (Register 98, No. 24).

27. Certificate of Compliance as to 12-31-97 order transmitted to OAL 4-27-98 and filed 6-9-98 (Register 98, No. 24).

28. Amendment of subsection (a) 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.

29. Certificate of Compliance as to 10-29-98 order transmitted to OAL 2-26-99 and filed 4-8-99 (Register 99, No. 15).

30. Amendment of subsection (a) and 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.

31. Certificate of Compliance as to 11-3-99 order transmitted to OAL 3-1-2000 and filed 4-6-2000 (Register 2000, No. 14).

32. Amendment of subsection (a) filed 6-29-2000 as an emergency; operative 7-1-2000 (Register 2000, No. 26). A Certificate of Compliance must be transmitted to OAL by 10-30-2000 or emergency language will be repealed by operation of law on the following day.

33. Certificate of Compliance as to 6-29-2000 order transmitted to OAL 9-29-2000 and filed 11-1-2000 (Register 2000, No. 44).

34. Amendment of subsection (a) and 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.

35. Certificate of Compliance as to 11-17-2000 order transmitted to OAL 3-8-2001 and filed 4-19-2001 (Register 2001, No. 16).

36. Amendment of subsection (a) 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.

37. Amendment of subsection (a) 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.

38. Certificate of Compliance as to 5-22-2003 order transmitted to OAL 9-18-2003 and filed 10-16-2003 (Register 2003, No. 42).

39. Change without regulatory effect amending subsections (a)(1)(A), (a)(1)(C)-(F), (a)(2), (b)(1)(B), (b)(2), (b)(4)(F), b)(4)(N), (c) and (d) and amending Note filed 1-26-2009 pursuant to section 100, title 1, California Code of Regulations (Register 2009, No. 5).

40. Amendment of subsection (a) 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.

41. Certificate of Compliance as to 6-24-2010 order transmitted to OAL 11-29-2010 and filed 1-10-2011 (Register 2011, No. 2).

42. Amendment of subsection (a) 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.

43. Certificate of Compliance as to 12-24-2013 order transmitted to OAL 4-15-2014 and filed 5-22-2014 (Register 2014, No. 21).