1. (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.

2. (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

3. (c) Payments shall be made only for days of attendance in the time period approved by the Medi-Cal consultant.
4. (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.
5. (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.
6. (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.
7. (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.
8. (h) The maximum number of payments for days of attendance for any 24-hour period shall not exceed the licensed capacity.
9. (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.
10. (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.

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).

History

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).