(a) On or before July 1, 1983, the State Department of Health Care Services shall establish a subacute care program in health facilities in order to more effectively use the limited Medi-Cal dollars available while at the same time ensuring needed services for these patients. The subacute care program shall be available to patients in health facilities who meet subacute care criteria. Subacute care may be provided by any facility designated by the director as meeting the subacute care criteria that has an approved provider participation agreement with the department.
(b) The department shall develop a rate of reimbursement for this subacute care program. Reimbursement rates shall be determined in accordance with methodology developed by the department, specified in regulation, and may include the following:
(1) All-inclusive per diem rates.
(2) Individual patient-specific rates according to the needs of the individual subacute care patient.
(3) Other rates subject to negotiation with the health facility.
(c) Reimbursement at subacute care rates, as specified in subdivision (b), shall only be implemented if funds are available for this purpose pursuant to the annual Budget Act.
(d) The department may negotiate and execute an agreement with any health facility that meets the standards for providing subacute care. An agreement may be negotiated or established between the health facility and the department for subacute care based on individual patient assessment. The department shall establish level of care criteria and appropriate utilization controls for patients eligible for the subacute care program.
(e) For the purposes of this section, pediatric subacute services are the health care services needed by a person under 21 years of age who uses a medical technology that compensates for the loss of a vital bodily function.
(f) Medical necessity for pediatric subacute care services shall be substantiated in any one of the following ways:
(1) A tracheostomy with dependence on mechanical ventilation for a minimum of six hours each day.
(2) Dependence on tracheostomy care requiring suctioning at least every six hours, and room air mist or oxygen as needed, and dependence on one of the five treatment procedures listed in subparagraphs (B) to (F), inclusive:
(A) Dependence on intermittent suctioning at least every eight hours and room air mist and oxygen as needed.
(B) Dependence on continuous intravenous therapy, including administration of a therapeutic agent necessary for hydration or of intravenous pharmaceuticals, or intravenous pharmaceutical administration of more than one agent, via a peripheral or central line, without continuous infusion.
(C) Dependence on peritoneal dialysis treatments requiring at least four exchanges every 24 hours.
(D) Dependence on tube feeding by means of a nasogastric or gastrostomy tube.
(E) Dependence on other medical technologies required continuously, which, in the opinion of the attending physician and the Medi-Cal consultant, require the services of a professional nurse.
(F) Dependence on biphasic positive airway pressure at least six hours a day, including assessment or intervention every three hours and lacking either cognitive or physical ability of the patient to protect his or her airway.
(3) Dependence on total parenteral nutrition or other intravenous nutritional support, and dependence on one of the treatment procedures specified in subparagraphs (A) to (F), inclusive, of paragraph (2).
(4) Dependence on skilled nursing care in the administration of any three of the six treatment procedures specified in subparagraphs (A) to (F), inclusive, of paragraph (2).
(5) Dependence on biphasic positive airway pressure or continuous positive airway pressure at least six hours a day, including assessment or intervention every three hours and lacking either cognitive or physical ability of the patient to protect his or her airway and dependence on one of the five treatment procedures specified in subparagraphs (A) to (E), inclusive, of paragraph (2).
(g) The medical necessity determination outlined in subdivision (f) is intended solely for the evaluation of a patient who is potentially eligible and meets the criteria to be transferred from an acute care setting to a subacute level of care.
(Amended by Stats. 2011, Ch. 294, Sec. 2. (AB 667) Effective January 1, 2012.)
Last modified: October 25, 2018