Long-term services and supports
Santa Clara Family Health Plan is a participating health plan in California's new Coordinated Care Initiative (CCI), with the goal of providing Long-Term Services and Supports (LTSS) in a coordinated manner. To do this, LTSS benefits will be managed by Medi-Cal managed care plans beginning July 1, 2014. For beneficiaries with both Medicare and Medi-Cal, their LTSS benefits will be part of new Cal MediConnect plans starting January 1, 2015. LTSS includes a range of home- and community-based services that support people living independently in the community, as well as services provided in a nursing facility.
The CA Department of Health Care Services (DHCS) requires all Primary Care Providers (PCPs) who treat patients covered by Medi-Cal managed care plans to complete training on LTSS. View the LTSS training module.
An example of a potential LTSS member is a patient with multiple chronic conditions and functional limitations that make it hard to live independently and safely at home without assistance. LTSS for this member may include:
- Nursing care in the home
- Personal care (help with dressing, bathing, grooming, or feeding)
- Help preparing or receiving meals, grocery shopping
- Case management, including linkage to resources
- Community day healthcare with physical therapy, occupational therapy, socialization, nutritionist services
- Transportation services
Frequently asked questions
Historically, Medi-Cal managed care plans covered acute, primary and rehabilitative care services, but not LTSS. Under the Coordinated Care Initiative (CCI), SCFHP is responsible for administering and coordinating expanded LTSS benefits. Beginning July 1, 2014, the first component of CCI takes effect – Managed Long-Term Services and Supports (MLTSS). Expanded Medi-Cal benefits under the health plan now include the following LTSS programs:
- In-Home Supportive Services (IHSS) - LTSS benefit managed by the Santa Clara County Department of Social Services. SCFHP case managers assist members with accessing IHSS benefits.
- Community-Based Adult Services (CBAS)
- Multipurpose Senior Services Program (MSSP)
- Long-Term Care in a nursing facility, including skilled, subacute and long-term custodial care
Refer to the Medi-Cal Member Handbook for additional information on these benefits.
In-Home Supportive Services (IHSS) is a State program (administered by the County Department of Social Services) that provides in-home care to seniors and persons with disabilities, allowing them to remain safely in their homes. Beneficiaries self-direct their care by hiring, supervising, and if necessary, terminating their caregivers. The majority of IHSS providers or caregivers (70%) are family or friends, with an independent IHSS provider registry available for those who need it.
Members do not qualify if they live in a nursing or community care facility and must be evaluated by a social worker to be determined financially and functionally eligible.
The types of services that can be authorized through IHSS are:
- Household and related services: housecleaning, chores, meal preparation and clean-up, grocery shopping
- Personal care services: bathing and grooming, dressing, feeding
- Paramedical services: administration of medication, puncturing skin, range-of-motion exercises
- Other services: protective supervision, transportation
IHSS program eligibility criteria:
- Live in own home
- Receive or be eligible for SSI or Medi-Cal benefits
- 65 years of age or older, legally blind, or disabled by Social Security standards
- Submit a healthcare certification form from a licensed healthcare professional indicating they need assistance to stay living at home
Referrals for IHSS:
- Members can call their case manager for assistance with applying for IHSS.
- The Santa Clara County Social Services Agency conducts a needs assessment in the member's home to determine eligibility and the monthly hours of support to be authorized.
- Providers can call SCFHP for assistance with the application process.
Community-Based Adult Services (CBAS) is a facility-based daytime healthcare program to restore or maintain optimal capacity forself-care and delay or prevent institutionalization in a long-term care facility. For each participant, a face to face assessment is done by a registered nurse to determine eligibility. If eligible, an individualized plan of care is developed with the member. Services are usually provided three days per week for a minimum of four hours on each day. Learn more about how CBAS may benefit your patients in this flyer (PDF).
CBAS services may include:
- Skilled nursing care
- Physical, occupational, and speech therapies
- Social services
- Personal care
- Transportation to and from the CBAS center
- Family/caregiver training and support
CBAS program eligibility criteria:
- 18 years of age or older
- Eligible for Medi-Cal
- Meet "Nursing Facility Level of Care A" (NF-A)
- Moderate to severe cognitive impairment including Alzheimer's disease or other dementia
- Mild to moderate cognitive disability*
- Chronic mental illness
- Brain injury*
- Developmental disability
* and need assistance with specific activities of daily living or supports
Changes to CBAS due to COVID-19 and shelter-in-place requirements:
Temporary Alternative Services (TAS) were put in place effective March, 2020 for the delivery of CBAS services remotely and online. These may include: daily wellness calls, meal delivery, doorstep / porch visits, activity packets, exercises and care coordination.
For information on referrals to CBAS TAS, contact SCFHP Customer Service at 1-800-260-2055, Monday through Friday 8:30 a.m. to 5 p.m.
SCFHP requires collaboration from CBAS centers to support ongoing access to care for our members. Centers have the following responsibilities:
- Providing SCFHP representatives with access to the center, nursing staff, program aids, directors, and the member’s medical information and records as required
- Documenting ongoing, planned, or member-declined interventions - with specificity
- Providing documentation and services that address person-centered needs under the center’s program, referral to mental health, clinicians, or other service providers that will aid the participant in reaching their goals
- Reviewing potentially eligible participants and receiving new referrals when appropriate
- Enrolling new participants into the program
Census and notification requirements
SCFHP requires timely and accurate updates from each center about member enrollment status. Timely notification of change in status or discharge is required to ensure that SCFHP has an accurate updated census count. If any of the following conditions apply, it is each center’s responsibility to notify and communicate with SCFHP.
Please notify SCFHP of:
- Critical incidents
- An adverse change in a member’s physical or mental condition or environment that could potentially lead to hospitalization or an emergency department visit. A center may modify its care of a member or discharge them if one of the following specified circumstances applies:
- The center is no longer capable of meeting the member’s health care needs
- The member’s health has improved sufficiently so that they need nursing facility service
- The member poses a risk to the health and safety of other individuals in the center
- Claims must include a valid authorization number, billing codes, and dates of service.
- All claims are to be submitted with revenue code 3103 (i.e, 3103 is adult day care, medical and social, daily).
- Please refer to your SCFHP Contract for rate information.
- H2000 – Comprehensive multidisciplinary evaluation
- S5102 – Day Care sevices, adult; per diem
- T1023 – Screeeing to determine appropriateness of consideration of an individual for participation in a specified program, project or treatment protocol, per encournte
Our case management team works in close communication with the CBAS center’s social service and clinical staff and the physician. This collaboration ensures our members are at the appropriate level of care and have timely access to covered benefits, carved out services, and connections to resources that support safe transitions.
Multipurpose Senior Services Program (MSSP) is an intensive case management program for people aged 65+ with disabilities who are eligible for nursing home placement, but who wish to remain in the community. The goal of the program is to arrange for and monitor the use of community services to prevent or delay premature institutionalization.
- Social and care management
- Linkage to available community services and resources
- Purchase of additional needed services to help beneficiaries remain at home
Services and resources may include:
- Chore and personal care assistance
- Communication services: translation and/or interpretation
- Environmental accessibility adaptations
- Housing assistance; minor home repair
- Meal services: congregate and/or home delivered
- Money management
- Personal emergency response system (PERS)/communication device
- Protective supervision
- Respite care (in-home and out-of-home)
MSSP eligibility criteria:
- 65 years of age or older
- Live in Santa Clara County
- Be eligible for Medi-Cal and enrolled in a managed care plan (as of October, 2014)
- Be certified for placement in a nursing facility
Referrals for MSSP:
- Contact Sourcewise (formerly Council on Aging) at 1-408-350-3200
Long-Term Care (LTC) is the provision of medical, social and personal care services that are not available in the community and are needed regularly due to a mental or physical condition. Services are provided in a skilled nursing facility (SNF).
An SNF is a licensed facility with the staff and equipment to provide nursing care and/or rehabilitative services at different levels as needed. The levels of care can vary, but usually include Subacute Care, Skilled Care and Long-Term Care.
- Subacute Care: needed by a patient who does not require hospital acute care, but who requires more intensive skilled care than is provided to the majority of patients in a skilled nursing facility. Example: patient on a ventilator or receiving IV antibiotics. Note that subacute care can also be provided in a dedicated subacute care facility.
- Skilled Care: for people who are physically disabled and/or require a high level of care. Skilled Care services are prescribed by a physician or certified nurse practitioner. Example: a person discharged from the hospital to an SNF for rehab from a broken hip.
- Long-Term Care (LTC): Long-term care provides what is called "custodial care," a level of care that is the least intensive care and is not skilled care. LTC provides assistance with daily living, including:
- Assistance getting in and out of bed
- Assistance with feeding
- Assistance with bathing and dressing
Changes to LTC with CCI
Prior to CCI, a beneficiary enrolled in a Medi-Cal managed care health plan was disenrolled from that plan when an SNF stay exceeded the month of admission and the following month. Under CCI, the beneficiary now remains enrolled in the Medi-Cal managed care health plan. The plan continues to pay for the SNF care and coordinates healthcare services for the member for the entire time they reside in an SNF.
Changes to LTC Long Term Care (LTC) Benefits and Services Guidance Update
Santa Clara Family Health Plan (SCFHP) has had long-term care “carved in” for nursing facilities since 2014. This guidance from SCFHP is intended to inform you of updates to long-term care (LTC) benefits in the state of California, and future expansion of our current network to include Intermediate Care Facilities.
As part of the of Department of Health Care Services’ (DCHS) California Advancing and Innovating Medi-Cal (CalAIM) initiative to reduce variations and complexities across delivery systems, long-term care (LTC) services (i.e. skilled nursing facilities), currently not within the scope of many Medi-Cal managed care plans (MCPs), will be “carved in” to all Managed Care Plans (MCPs) statewide for all Medi-Cal members enrolled in an MCP, effective January 1, 2023. LTC – ICF/DD, subacute (adult and pediatric) facilities will be will be carved in effective July 1, 2023.
Next steps: Please email LTSSHelpDesk@scfhp.com if your facility provides ICF services, including type of service.
Send follow-up comments or questions to: LTSSHelpDesk@scfhp.com.
Referrals for LTC
- LTC/SNF placement is made through a physician/licensed healthcare provider referral.
Please read about your role in caring for SCFHP members.
Community-Based Adult Services (CBAS)
Santa Clara Family Health Plan
Please review SCFHP's billing guidelines for Medi-Cal and Cal MediConnect claims.
This guide primarily addresses SCFHP operations for Long-Term Care (LTC) members with some reference to skilled level of care where differences may apply. You may address questions about utilization management or care coordination for skilled level of care by contacting 1-408-874-1821.