(a) Subject to the provisions of this section, the department shall establish, effective August 1, 2012, a reimbursement methodology and a reimbursement limit for adult day health care services on a prospective cost basis for services that are provided to each participant, pursuant to his or her individual plan of care. The prospective reimbursement methodology shall be determined by the department after consultation with the California Association for Adult Day Services and other interested stakeholders. (b) The following definitions shall apply for purposes of this section: (1) âDaily core servicesâ means the services described in Section 14550.5. (2) âSeparately billable servicesâ means services designated by the department, after consultation with the California Association for Adult Day Services, and shall include, but not be limited to, the following: (A) Physical therapy services. (B) Occupational therapy services. (C) Speech and language pathology services. (D) Mental health services. (E) Registered dietician services. (F) Transportation services. (c) The prospective reimbursement methodology for the daily core services provided by each adult day health care center shall be determined by the department based on the reasonable cost of providing all of the adult day health care services included within the core services and adjusted to the particular rate year. Services and costs included in the calculation of the daily core services rate shall include, but not be limited to, all of the following: (1) Fixed or capital-related costs representing depreciation, leases and rentals, interest, leasehold improvements, and other amortization. (2) Labor costs other than those for the separately billable services, including direct and indirect labor and contracted staff hours required by law or regulation. (3) All other costs exclusive of fixed or capital-related costs, leases or rentals, interest, leasehold improvements, and other amortization. (4) Add-ons, adjustments, and audit adjustments determined annually in the calculation of the core rate to allow for changes specified in subdivision (h), until those changes are reflected in the cost report. (5) Cost components required to comply with licensing and certification laws and regulations. (d) (1) The daily reimbursement rates for the separately billable services shall be determined based upon the reasonable cost of providing each service, how each of the individual billable services is defined, and which professional is providing the service, subject to the scope of his or her license. These reimbursement rates shall not exceed the Medi-Cal rates for the same service on file at the time the service is rendered. (2) In establishing the total reimbursement limit, direct patient care labor costs may be paid at a specified discrete percentile to ensure maintenance of quality of care. (e) The department shall determine a reimbursement limit applicable to each adult day health center peer group established pursuant to subdivision (m), taking into account total overall average costs per day of attendance for providing the entire array of adult day health care services, including the daily core services and the separately billable services. The department shall determine a reimbursement limit applicable to each adult day health care center peer group established pursuant to subdivision (m) based on cost containment principles applied to other acute care and long-term care providers. (f) By July 1, 2010, the department shall develop, after consultation with the California Association for Adult Day Services, all of the following: (1) An adult day health care center cost report meeting the requirements of subdivision (j) and a list of individual components to be included in the core rate calculation. (2) The methodology and documentation necessary to establish the reimbursement rate for the separately billable services. (3) The reimbursement rates for transportation services. Pay
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