10.2.55 Skilled Nursing Facility Form

Policy Title: Skilled Nursing Facility (SNF) POLICY #: 10.02.55 Line of business: Medi-Cal Department Name: Utilization Management Original Date 10/22 Effective Date 11/22 Revision Date: 3/23 Governing Committee: (If Applicable)

VP Approval: Tracy Alvarez, VP, Medical Care Solutions

Date: 3 / 1 1 / 2 0 2 5
Medical Services/P&T Committee: (If Applicable) PHP CMO Jennifer Nuovo, MD

Date: 3 / 1 1 / 2 0 2 5

A. PURPOSE To provide guidance on how Blue Shield of California Promise Health Plan (Blue Shield Promise) will establish the referral process for contracted Primary Care Physicians (PCPs), Specialists and Participating Provider Groups (PPGs) or other health care professionals, following identification of a Medi-Cal eligible member who may benefit from Skilled Nursing Facility (SNF) stay.

B. DEFINITIONS N/A

C. POLICY I. Blue Shield Promise will ensure that Members in need of SNF services are placed in a health care facility that provides the level of care most appropriate to the Member's medical needs. II. Beginning January 1, 2023, Members who are admitted into a SNF will remain enrolled in Blue Shield Promise , instead of being disenrolled from the Plan and enrolled in fee- for-service (FFS) Medi-Cal. Blue Shield Promise will coordinate benefits with other health coverage (OHC) programs or entitlements in accordance with All Plan Letter (APL) 21-

18. Blue Shield Promise will review drugs provided by the SNF and billed on a medical or institutional claim for medical necessity and approve accordingly.

    III. Blue Shield Promise members are not discriminated against in the delivery of

health care services based on race, ethnicity, national origin, religion, sex, age, mental or physical disability or medical condition, sexual orientation, claims experience,

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medical history, evidence of insurability (including conditions arising out of acts of domestic violence), genetic information, or source of payment. IV. Blue Shield Promise prohibits discrimination against individuals based on gender, including gender identity or gender expression. Blue Shield Promise and its delegates provide transgender members with the same level of health care benefits that are available to non-transgender members and prohibit discrimination against transgender persons. An individual shall be treated consistent with their gender identity. Blue Shield Promise and its delegated entities do not deny or limit coverage of any health care services that are ordinarily or exclusively available to members of one gender, to a transgender individual based on the fact that a person’s gender assigned at birth, gender identity, or gender otherwise recorded is different from the one to which such services are ordinarily or exclusively available nor does Blue Shield Promise or its delegates categorically exclude or limit coverage for health care services related to gender transition.

V. In accordance with the requirements of Title II of the Americans with Disabilities Act of 1990 ("ADA"), Blue Shield Promise will not discriminate against qualified individuals with disabilities on the basis of disability in its services, programs, or activities.

VI. Blue Shield Promise is responsible for ensuring its Subcontractors and Network Providers comply with all applicable state and federal laws and regulations, Contract requirements, and other DHCS guidance, including APLs and Policy Letters.

D. PROCEDURE I. When transitioning Members to and from SNFs, Blue Shield Promise will ensure timely Member transitions that do not delay or interrupt any Medically Necessary services or care by meeting the following requirements, at a minimum: a. Coordinate with facility discharge planners, care or case managers, or social workers to provide case management and Transitional Care Services during all transitions. b. Blue Shield Promise will work with the Department of Health Care Services (DHCS) and Network Providers, including discharging facilities or admitting nursing facilities, to obtain documentation validating the Preadmission Screening and Resident Review (PASRR) Requirements process completions and will follow any further implementation guidance published by DHCS. Reference UM P&P Long-Term Care Services 10.02.25. c. The Blue Shield Promise Utilization Management (UM) team will assist Members being discharged or Members’ parents, legal guardians, or authorized representatives by evaluating all medical needs and care settings available including, but not limited to, discharge to a home or community setting, and referrals and coordination with In- Home Supportive Services, Community

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Supports, Long- Term Services and Supports, and other Home and Community Based Services. If

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Case Management is required, Member will be referred to Case Management. d. The Blue Shield Promise UM team will assist in coordinating access to routine and specialty referrals, ancillary services, dental services, behavioral health services, and standing referrals while the member is admitted to the skilled nursing facility. Blue Shield Promise ’s accessibility and availability standards are established in compliance with the State of California Knox-Keene Act, Title 28 of the California Code of Regulations (CCR) §1300.67.2.1. e. For medically necessary services through Out-of-Network Providers, including allowing access for the completion of Covered Services by an Out-of-Network Provider or terminated Provider, please refer to UM P&P 10.02.40 Continuity of Care (CoC) for Medi-Cal Members.

II. Blue Shield Promise 's contracted physicians are available 24 hours a day, seven days per week either directly or through arrangements for after-hours coverage. An appropriately trained licensed registered nurse is also available after business hours to authorize medically necessary services. A 24-hour toll-free Member Services number is available to call in the event of an emergency. This number is printed on the member’s identification card.

III. Staff are available at least 8 hours a day during business hours for inbound or collect calls regarding UM issues. Member calls may be triaged by Member Services to the UM Department. Members and providers can also call the UM staff directly at 800-468-9935 for specific cases and discussion about UM decisions. IV. Transportation will be provided in accordance with Title 22 CCR Section 51323. Blue Shield Promise will provide NEMT and NMT to Members, including those residing in a SNF. Please refer to Medical Care Solutions P&P 10.31.1 Non-Emergency Medical Transportation (NEMT) and Non-Medical Transportation (NMT) Services and Related Travel Expenses.

V. Bed Hold Requirements/Leave of Absence a. Blue Shield Promise will provide continuity of care for Members that are transferred from a SNF to a general acute care hospital, and then require a return to a SNF level of care due to medical necessity. Requirements regarding leave of absence, bed hold, and continuity of care policies apply. b. Blue Shield Promise will ensure the provision of a leave of absence/bed hold that a SNF provides in accordance with the requirements of 22 CCR §72520 or California’s Medicaid State Plan. c. Blue Shield Promise will allow the Member to return to the same SNF where the Member previously resided under the leave of absence/bed hold policies in accordance with the Medi-Cal requirements for leave of absence and bed hold, which are detailed in 22 CCR §51535 and §51535.1. d. Blue Shield Promise will ensure that SNFs notify the Member or the Member’s authorized representative in writing of the right to exercise the bed hold provision. e. Blue Shield Promise will regularly review all denials of bed holds.

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VI. Blue Shield Promise will allow Members to complete medically necessary services through an out-of- network Provider/Terminated Provider for Medi-Cal covered services as stated in the 10.2.40 CoC for Medi-Cal Members policy. VII. Blue Shield Promise will provide newly enrolled Seniors and Persons with Disabilities (SPD) beneficiaries residing in SNFs access to an out-of-network provider for up to 12 months in accordance with APL 23-004 and 10.2.40 CoC for Medi-Cal Members policy.

VIII. Population Health Management (PHM) Requirements a. Blue Shield Promise has implemented a PHM Program that ensures all Medi- Cal managed care Members, including those using SNF services, have access to a comprehensive set of services based on their needs and preferences across the continuum of care, including Basic Population Health Management (BPHM), transitional care services (TCS), care management programs, and Community Supports. b. Care Management programs beyond transitions including Complex Care Management (CCM) and Enhanced Care Management (ECM) will be provided. If a Member is enrolled in either CCM or ECM, TCS must be provided by the Member’s assigned care manager from those programs. c. As part of the PHM Program, Blue Shield Promise will provide strengthened TCS: i. Blue Shield Promise will provide timely prior authorizations for all Members and know when all Members are admitted, discharged, or transferred from facilities, including SNFs ii. Blue Shield Promise will ensure that all TCS are completed for all high-risk Members:

1. Blue Shield Promise will ensure that all high-risk Members provided TCS are assigned a single point of contact, referred to as a care manager, to assist Members throughout their transition and ensure all required services are complete
2. Members receiving long term services and supports (LTSS), are one of the groups considered to be “high risk” iii. Blue Shield Promise will ensure all TCS are completed for all Members. d. Blue Shield Promise will provide care management beyond transitions for members. Blue Shield Promise SNF UM nurses will coordinate medically necessary care while the members are admitted in the skilled nursing facility. Upon discharge, high-risk members will be referred to the following programs: i. Complex Care Management (CCM) provides ongoing chronic care coordination and interventions for episodic, temporary needs with a goal of regaining optimum health or improved functional capability, in the right setting and in a cost-effective manner. ii. Enhanced Care Management (ECM) is a whole person, interdisciplinary approach to comprehensive care management for nursing facility residents transitioning to the community. Blue Shield Promise must identify all resources to address all needs of the member to ensure they will be able to transition and reside continuously in the community and

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provide longitudinal support beyond the transition. iii. Community Supports are medically appropriate and cost-effective

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alternatives to traditional medical services or settings that are designed to address social drivers of health, which are factors in people’s lives that influence their health iv. Basic Population Health Management (BPHM) will continue to be provided to members enrolled in care management programs. E. MONITORING I. Blue Shield Promise is responsible for maintaining a comprehensive Quality Assurance Performance Improvement (QAPI) program for long term care services provided. II. Blue Shield Promise ‘s comprehensive QAPI program incorporates the following: a. Contracted SNF’s QAPI programs, which includes the five key elements identified by CMS. b. Claims data for SNF residents, including but not limited to emergency room visits, healthcare associated infections requiring hospitalization, and potentially preventable readmissions as well as DHCS supplied Workforce and Quality Incentive Program (WQIP) data via a template provided by DHCS on a quarterly basis. c. Mechanisms to assess the quality and appropriateness of care furnished to enrollees using LTSS, including assessment of care between care settings and a comparison of services and supports received with those set forth in the Member’s treatment/service plan. d. Efforts supporting Member community integration. e. DHCS and CDPH efforts to prevent, detect, and remediate identified critical incidents. F. REPORTING a. Blue Shield Promise reports on LTC measures within the Managed Care Accountability Set (MCAS) of performance measures. Blue Shield Promise
calculates the rates for each MCAS LTC measure for each SNF within the Network for each reporting unit. Blue Shield Promise will be held to quality and enforcement standards in APL 19-017 and APL 22- 015, respectively, or any superseding APLs. b. Blue Shield Promise will annually submit QAPI program reports with outcome and trending data as specified by DHCS . c. Reference UM P&P 10.02.25 Long Term Care for more information on Blue Shield Promise 's comprehensive QAPI program.

G. ATTACHMENTS

1. 10.02.25 Long Term Care Services

2. 10.02.40 Continuity of Care for Medi-Cal Members

   H. REFERENCES

3. APL 19-017
4. APL 22-008
5. APL 22-015
6. APL 23-004

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5. 22 CCR §72520
6. 22 CCR §51535 and §51535.1
7. 28 CCR §1300.67.2.1.
8. 415344 Accessibility and Availability of Services

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9. 10.31.1 Non-Emergency Medical Transportation (NEMT) and Non-Medical Transportation (NMT) Services and Related Travel Expenses
10. Title II, Americans with Disabilities Act of 1990

11. UM Program Description, Section H5, Services, UM Access and Availability I. REVISION HISTORY

    Date Modification (Reviewed and/or revised) E-Filing Number 3/2025 2025 Annual Review
    • Reviewed regulatory requirements per DHCS 3/2024 2024 Annual Review • Formatting updates • Added references Response to AIR request from DHCS Access and Availability, CoC, CCM and ECM verbiage added 3/23 New Policy • Updated Regulatory Requirements DHCS, DMHC