2005 California Welfare and Institutions Code Sections 14091.21 Article 2.92. Health Benefits Study

14091.21.  (a) Nursing facility services necessary for the treatment
of illness or injury are covered subject to the provisions of this
section:
   (b) Nursing facility services are covered only after prior
authorization has been obtained from the designated Medi-Cal
consultant for the field office area in which the nursing facility is
located.  The authorization request shall be initiated by the
facility and shall be signed by the attending physician.  Nursing
facility services may be authorized either for a distinct-part
nursing facility (a facility that is a distinct part of an acute care
hospital), or for a freestanding nursing facility (a facility that
is not part of an acute care hospital).
   (1) Distinct-part nursing facility care at the distinct-part
nursing facility reimbursement rate for any Medi-Cal patient
determined to need long-term nursing care shall be authorized when
any one of the following conditions is met:
   (A) There is no freestanding nursing facility within 15 miles,
which shall be defined as 30 minutes at 30 miles per hour, from the
established residential address of that patient prior to admission to
nursing care and the distinct-part nursing facility is within a
shorter actual travel time than the closest freestanding nursing
facility able and willing to admit the patient.
   (B) There is a freestanding nursing facility within 15 miles, as
defined in subparagraph (A) from the established residential address
of the patient before admission to nursing care, but after reasonable
placement efforts, no such facility is able and willing to accept
the patient, and the distinct-part nursing facility is within a
shorter travel time than the closest freestanding nursing facility
able and willing to admit the patient, within the 25-day placement
period.
   (C) There is no freestanding nursing facility within 30 minutes
actual travel time from the established residential address of the
immediate family member, such as the spouse, parent, child, or
sibling of the patient, who certifies that he or she is the family
member who will be most frequently visiting and helping with the
personal needs of the patient, or if there is such a freestanding
nursing facility, there is none able and willing, after reasonable
placement efforts, to accept the patient, and the distinct-part
nursing facility is within a shorter travel time than the closest
freestanding nursing facility.  In this case, the distinct-part
nursing facility shall submit with the treatment authorization
request a signed statement from the immediate family member
certifying that he or she is the person who will be most frequently
visiting and seeing to the personal needs of the patient.  The signed
statement of the family member shall contain an explanation of the
relationship to the patient, the residential address used in
calculating the distance to the distinct-part nursing facility, and
the mode of transportation to be used.  A copy of this certification
shall be kept in the patient's file at the distinct-part nursing
facility.
   (D) The immediate family member who will be most frequently
visiting and seeing to the personal needs of the patient cannot,
because of established health reasons, travel to a freestanding
nursing facility that is able and willing to admit the patient and
that is within 30 minutes actual travel time, but he or she is able
to travel to the distinct-part nursing facility.  The certification
so stating, and signed by that family member, shall be submitted with
the treatment authorization request.  A copy of this certification
shall be kept in the patient's file at the distinct-part nursing
facility.
   (E) The patient has a spouse residing in the same distinct-part
nursing facility.
   (F) The patient is currently, as of the time approval is sought,
residing in the distinct-part nursing facility and has been
continuously residing in that facility for at least 120 consecutive
days, and payment has been made or approved during the 120
consecutive days by Medicare, other health insurance, or by Medi-Cal
at a distinct-part nursing facility rate.  For patients who have met
this requirement and are later hospitalized, a treatment
authorization request at the distinct-part nursing facility rate
shall be reinstated if the patient returns to the same distinct-part
nursing facility during the seven-day bed-hold period specified in
Section 1599.79 of the Health and Safety Code.  Otherwise, to reside
in a distinct-part nursing facility, the patient shall meet one of
the conditions set forth unless the patient's attending physician
documents in the medical record that discharge to a freestanding
nursing facility would cause physical or psychological harm to the
patient.
   (2) "Actual travel time" means the amount of time it would usually
take the immediate family member to travel between two specific
points by means of whatever transport would be available to him or
her, taking into account actual road and weather conditions.
   (3) "Reasonable placement efforts" means that during the 25-day
time period beginning with the date that approval for the Medi-Cal
distinct-part nursing facility rate is first sought, the facility
shall do all of the following:
   (A) Contact on a daily basis, not including Saturdays, Sundays, or
holidays, Medi-Cal-certified freestanding nursing facilities within
the applicable mileage or travel time, to determine whether each such
freestanding nursing facility is able and willing to admit the
patient.  In meeting this requirement, facilities shall contact only
those freestanding nursing facilities that they, in good faith,
believe may be able and willing to admit this patient, taking into
account previous contacts.  Further attempts at placement calls will
be waived by the department.  Freestanding nursing facilities within
the applicable mileage or travel time are those within the
appropriate travel time plus any freestanding nursing facility within
a shorter actual travel time than the distinct-part nursing facility
from the appropriate residential address such as the patient's or
the immediate family member's.
   (B) Document that the facility contacted a person responsible for
admission decisions during each required contact, the date and time
of each contact with a freestanding nursing facility, the name and
title of each person contacted, the reason given for the freestanding
nursing facility not being able or willing to admit the patient on
the day contacted, and the date, if any, when the freestanding
nursing facility would be able and willing to accept the patient.
Contacts may be made by telephone or facsimile transmission.
   (C) Submit the documentation specified in subparagraph (B) to the
Medi-Cal field office at the conclusion of the 25-day placement
effort period.
   (4) Upon submission of documentation that reasonable placement
efforts requirement were met, the distinct-part nursing facility rate
or acute administrative days shall be approved as follows:
   (A) Hospitals seeking to place a patient into their own
distinct-part nursing facilities shall be approved for acute
administrative days for a patient determined to need long-term
nursing facility care, who remains in an acute care bed during the
placement period.  If a contacted freestanding nursing facility was
able and willing to admit the patient during the 25-day period, the
hospital's treatment authorization request shall be subsequently
authorized for approval of acute administrative days until the date
that the freestanding nursing facility is able to accept the patient.
   At the completion of the reasonable placement effort period, if no
freestanding nursing facility is able and willing to take the
patient, the hospital's treatment authorization request shall be
authorized for approval for acute administrative days for days of
care during the reasonable placement period.  The hospital, in order
to comply with this subparagraph, shall complete the 25-day placement
period if there is a freestanding nursing facility within the
applicable mileage or travel time willing to take the patient, but
due to occupancy, is unable to accept transfer on the days it was
contacted.  If, however, there is a freestanding nursing facility
within the applicable mileage or travel time, but the freestanding
nursing facility is not able or willing to admit the patient at the
time of the placement effort or in the future, the length of
placement time required shall vary and may be shorter than 25 days.
If documentation establishes that no freestanding nursing facility
within the applicable mileage or travel time, is, or will ever be,
able or willing to admit the patient, further placement efforts shall
not be required.  The distinct-part nursing facility rate of
reimbursement shall be approved upon the patient's admission to the
distinct-part nursing facility if reasonable placement efforts
requirement has been met and no freestanding nursing facility within
the applicable mileage or travel time standard was able and willing
to accept the patient.
   (B) When a patient is either admitted to a distinct-part nursing
facility from an acute hospital, nonacute facility, or community
setting, or was a distinct-part nursing facility resident whose care
has been, but is no longer being, paid by another payment source, a
treatment authorization request shall be approved at the
distinct-part nursing facility rate for a patient who has been
admitted and determined to need long-term nursing facility placement
when the reasonable placement efforts requirement has been met.  If a
contacted freestanding nursing facility is able and willing to admit
the patient during the 25-day period, the distinct-part nursing
facility treatment authorization request shall be subsequently
authorized for approval at the distinct-part nursing facility rate
until the date that the freestanding nursing facility is able to
accept the patient.  If the basis on which the final distinct-part
nursing facility approval is sought is the lack of any freestanding
nursing facility able and willing to take the patient after
reasonable placement efforts, this approval shall not be given until
after the completion of the reasonable placement period, but may be
given for days of care during that period.  The criteria for
shortening the reasonable placement period to less than 25 days shall
apply.  Notwithstanding the general requirement that skilled nursing
care must receive prior authorization, when a distinct-part nursing
facility admits a patient during the time it is making reasonable
placement efforts, authorization of the distinct-part nursing
facility rate may be given postadmission.
   However, no days of care shall be authorized for any period prior
to the receipt of the treatment authorization request from the
facility, unless retroactive authorization may be given.
   (C) When a patient spends some of the placement period in the
hospital and some of that time in a distinct-part nursing facility,
acute administrative days shall be authorized for the hospital days
and the distinct-part nursing facility rate for the distinct-part
nursing facility days, subject to the provisions of this paragraph.
   (5) Reasonable placement efforts, as defined in paragraph (3),
shall be conducted for all patients in need of long-term nursing care
who are seeking admission to a distinct-part nursing facility
pursuant to paragraph (1) of subdivision (a) of Section 51335 of
Title 22 of the California Code of Regulations.  Patients requiring
nursing care for postsurgical rehabilitative or therapy services
shall not be subject to the reasonable placement efforts required for
admission to a distinct-part nursing facility but they shall be
subject to all other Medi-Cal criteria for these admissions.  A
patient, who is a resident of a distinct-part nursing facility and
who has been hospitalized for more than the seven-day bed-hold
period, may be readmitted to the distinct-part nursing facility
without meeting the reasonable placement efforts requirement for
admission, if the attending physician documents that discharge to a
freestanding nursing facility will result in physical or
psychological harm.
   (6) If a distinct-part nursing facility desires of its own
volition to admit a patient needing nursing care at the freestanding
nursing facility rate, the department shall approve a treatment
authorization request submitted for approval at that rate.
Distinct-part nursing facilities shall obtain a freestanding nursing
facility provider number for that purpose, in addition to their
regular provider number.  A distinct-part nursing facility objecting
to the freestanding nursing facility rate in any other circumstance,
such as when it has not accepted the rate of its own volition, shall
not be deemed to have waived its rights to administrative appeal and
further review.
   (7) With respect to acute care hospitals that are licensed for
distinct-part nursing beds, and determined by the State Department of
Health Services to provide special services to a unique population,
the department shall enact and enforce no regulation, field office
instruction, or preadmission screening criteria that restricts a
Medi-Cal beneficiary's freedom to seek admission to a nursing
facility or unit that is a distinct part of an acute care hospital on
terms or conditions different from those governing admission to a
long-term care facility.
   (c) The department may waive the requirements of this section if
it can be demonstrated that both of the following apply:
   (1) Access to care is compromised for a specific patient
population.
   (2) The facility can demonstrate an increase in acute
administrative days that are attributable to unsuccessful placement
efforts.