Section 1367.09 Of Article 5. Standards From California Health And Safety Code >> Division 2. >> Chapter 2.2. >> Article 5.
1367.09
. (a) An enrollee with coverage for Medicare benefits who is
discharged from an acute care hospital shall be allowed to return to
a skilled nursing facility in which the enrollee resided prior to
hospitalization, or the skilled nursing unit of a continuing care
retirement community or multilevel facility in which the enrollee is
a resident for continuing treatment related to the acute care
hospital stay, if all of the following conditions are met:
(1) The enrollee is a resident of a continuing care retirement
community, as defined in paragraph (10) of subdivision (a) of Section
1771, or is a resident of a multilevel facility, as defined in
paragraph (9) of subdivision (d) of Section 15432 of the Government
Code, or has resided for at least 60 days in a skilled nursing
facility, as defined in Section 1250, that serves the needs of
special populations, including religious and cultural groups.
(2) The primary care physician, and the treating physician if
appropriate, in consultation with the patient, determines that the
medical care needs of the enrollee, including continuity of care, can
be met in the skilled nursing facility, or the skilled nursing unit
of the continuing care retirement community, or multilevel facility.
If a determination not to return the patient to the facility is made,
the physician shall document reasons in the patient's medical record
and share that written explanation with the patient.
(3) The skilled nursing facility, continuing care retirement
facility, or multilevel facility is within the service area and
agrees to abide by the plan's standards and terms and conditions
related to the following:
(A) Utilization review, quality assurance, peer review, and access
to health care services.
(B) Management and administrative procedures, including data and
financial reporting that may be required by the plan.
(C) Licensing and certification as required by Section 1367.
(D) Appropriate certification of the facility by the Health Care
Financing Administration or other federal and state agencies.
(4) (A) The skilled nursing facility, multilevel facility, or
continuing care retirement community agrees to accept reimbursement
from the health care service plan for covered services at either of
the following rates:
(i) The rate applicable to similar skilled nursing coverage for
facilities participating in the plan.
(ii) Upon mutual agreement, at a rate negotiated in good faith by
the health care service plan or designated agent on an individual,
per enrollee, contractual basis.
(B) Reimbursement shall not necessarily be based on actual costs
and may be comparable to similar skilled nursing facility
reimbursement methods available for other plan contracted facilities
available to the individual member.
(b) The health care service plan, or designated agent, shall be
required to reimburse the skilled nursing facility, continuing care
retirement facility, or multilevel facility at the rate agreed to in
paragraph (4) of subdivision (a).
(c) No skilled nursing facility, multilevel facility, or
continuing care retirement community shall collect, or attempt to
collect, or maintain any action of law, against a subscriber or
enrollee to collect reimbursement owed by the health care service
plan for health care services provided pursuant to this section, or
for any amount in excess of the payment amount that the facility has
agreed to accept in its agreement with the health care service plan.
(d) Reimbursement by the health care service plan or designated
agent shall be for those services included in the Medicare risk
contract between the health care service plan and enrollee.
(e) Nothing in this section requires a skilled nursing facility,
continuing care retirement facility, or multilevel facility to accept
as a skilled nursing unit patient anyone other than a resident of
the facility.
(f) This section shall apply to a health care service plan
contract that is issued, amended, or renewed on or after January 1,
1999.