10.2.20 Long-Term Care Services for Former Developmental Care Center Members Form

1

Policy Title: Long Term Care Services for Former Developmental Care Center Members POLICY #: 10.02.20 Line of business: Medi-Cal Department Name: Utilization Management Original Date 12/11 Effective Date 5/19 Revision Date 3/24 Governing Committee Approval: (If Applicable)

VP APPROVAL: Tracy Alvarez, VP, Medical Care Solutions Date: 3/11/2025 Medical Services/P&T Committee: (If Applicable) PHP CMO Jennifer Nuovo, MD Date: 3/11/2025

A. PURPOSE To arrange for or provide medically necessary covered services to former Developmental Center Members who require long term care.

B. DEFINITIONS Former Developmental Center Members – are members with unique medical health care needs who have transitioned from Developmental Centers into a community setting, and whose individual program plans document the need for coordinated medical and specialty care.

C. POLICY I. Blue Shield of California Promise (Blue Shield Promise) shall cover and provide long term care services from the time of admission, plus three (3) months after the month of admission. II. Blue Shield Promise shall provide all medically necessary services to the member until disenrollment is effective.

D. PROCEDURE I. Blue Shield Promise shall cover and provide long term care services from the time of admission, plus three (3) months after the month of admission. II. If a Former Developmental Center Member requires long term care in the facility for

2

longer than the month of admission plus 3 months, Blue Shield Promise shall submit a disenrollment request for the member to the Department of Health Care Services for approval.

3

III. Blue Shield Promise shall provide all medically necessary covered services to the member until disenrollment is effective. IV. For Former Developmental Center Members, the approved disenrollment request will become effective the first day of the fourth month following the month of the Former Development Center Member’s admission to the facility, provided the disenrollment request is submitted at least 30 calendar days prior to the first day of the third month of stay. If the disenrollment request is submitted less than 30 calendar days prior to that date, disenrollment shall be effective the first day of the month that begins at least 30 calendar days after the submission of disenrollment request. V. Prior to the disenrollment effective date, Blue Shield Promise shall notify the member and his or her guardian of the disenrollment; shall ensure appropriate transfer of medical records; shall assure that continuity of care is not interrupted; and shall complete all administrative work necessary to assure a smooth transfer of responsibility for the health care of Former Developmental Center Members.

VI. Admission to a nursing facility of a member who has elected hospice services does not affect the member’s eligibility for enrollment. Hospice services are covered services and are not long-term care services regardless of the Member’s expected or actual length of stay in a nursing facility.

E. MONITORING N/A F. REPORTING N/A G. ATTACHMENTS N/A H. REFERENCES N/A I. REVISION HISTORY

Date Modification (Reviewed and/or revised) E-Filing Number 3/2025 2025 Annual Review
• Reviewed regulatory requirements per DHCS

4

3/2024 2024 Annual Review • Formatting updates