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)
- 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 Evidence of Coverage (EOC) for additional information on these benefits.
In-Home Supportive Services (IHSS) is a State program 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:
- Individuals can apply for IHSS by calling Santa Clara County Social Services Agency at 1-408-792-1600.
- 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.
- Members or 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 for self-care and delay or prevent institutionalization in a long-term care facility. For each participant, an assessment is done and an individualized plan of care developed. 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
Referrals for CBAS:
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 healthcare 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:
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.
Referrals for LTC
- LTC/SNF placement is made through a physician/licensed healthcare provider referral.
- Contact SCFHP Member Services Department for assistance with getting your patient/client into a facility.
Please read about your role in caring for SCFHP members here.
Multipurpose Senior Services Program (MSSP)
Sourcewise (formerly Council on Aging Silicon Valley)
Hours: 24-hour automated InfoLine
Please visit the following websites for tools and training for reducing preventable hospital readmissions.
- INTERACT® Interventions to Reduce Acute Care Transfers
- INTERACT® Guidance on Management of Possible Sepsis
- Health Services Advisory Group
Please review SCFHP's billing guidelines for Medi-Cal and Cal MediConnect claims here.