HEALTHmatters MD

We want to make sure you are aware that the California Department of Health Care Services (DHCS) implemented some important reimbursement rate changes that took effect in November 2024. These changes were made to Share of Cost (SOC) payments for Skilled Nursing Facilities (SNF), Subacute Care Facilities and Intermediate Care Facilities for Individuals with Developmental Disabilities (ICF/DD). They include: 

Facility Payment

DHCS may periodically update Medi-Cal Fee-for-Service (FFS) per diem rates for SNF, subacute and ICF/DD services for specified dates of service. When DHCS updates these rates, HPSM will implement the new rates as soon as possible. 

• For claims received on or after 30 working days of the update, HPSM will use the new rate. 
• For claims with applicable dates of service processed before the update, HPSM will make any necessary retroactive payments within 45 working days after being notified by DHCS that the updated rates are published. 
• HPSM will automatically reprocess claims to reflect the updated rates. Network providers do not need to manually reprocess or resubmit the claims. 

SOC For Non-Covered Services

As a result of the Johnson v. Rank lawsuit, Medi-Cal members (not their providers) can elect to use the SOC funds to pay for necessary, non-covered medical or remedial care services, supplies, equipment and drugs (medical services) that are prescribed by a physician and are part of the plan of care authorized by the member’s attending physician. 

• The physician’s prescriptions for SOC expenditures must be maintained in the member’s medical record. 
• If the member spends part of their SOC on non-covered medical or remedial services or items, the SNF, subacute facility or ICF/DD facility should subtract those amounts from the member’s SOC and collect the remaining SOC amount owed. 
• The SNF, subacute facility or ICF/DD facility should adjust the amount on the claim and submit the claim to HPSM to pay the balance. 
• The SOC amount applied towards the balance must be noted on the claim using Value Code 23. If any of the SOC was applied towards non-covered charges, notify HPSM by adding this information as a claim comment.  
• Claims submitted without the member’s SOC accounted for are subject to denial. 

Learn more

• For further DHCS guidance regarding Johnson v. Rank requirements, please refer to the Medi-Cal LTC Provider Manual. 
• To read the full scope of changes, read DHCS All Plan Letters (APLs) 24-009, 24-010 and 24-011.