Medi-Cal cost reporting: private duty nursing and congregate living health facilities.

Existing law establishes the Medi-Cal program, which is administered by the State Department of Health Care Services and under which qualified low-income individuals receive health care services. The Medi-Cal program is, in part, governed and funded by federal Medicaid program provisions. Existing law requires a private duty nursing agency, as defined, to be a provider of skilled nursing services covered under certain Medicaid waiver programs, subject to federal approval and availability of federal financial participation. Existing law requires the agency, in addition to satisfying any other requirements as a condition for participation in the Medi-Cal program, to satisfy specified requirements, including the provision of skilled nursing services on a shift basis in a patient's home or other community-based site appropriate for patient care. This bill would require, by January 10, 2026, the department to develop and submit a cost estimate, on private duty nursing services provided to pediatric patients, to the appropriate fiscal and policy committees of the Legislature. The bill would require the cost estimate to estimate the cost of raising the Medi-Cal rates of private duty nursing services provided to pediatric patients to 87% of, and to 100% of, rates for corresponding services under the federal Medicare Program. Existing law provides for the licensure and regulation of health facilities, including congregate living health facilities, by the State Department of Public Health. Existing law defines "congregate living health facility" as a residential home with a capacity of no more than 18 beds, with exceptions, that provides inpatient care that is generally less intense than that provided in general acute care hospitals but more intense than that provided in skilled nursing facilities. Existing law, the Medi-Cal Long-Term Care Reimbursement Act, requires the State Department of Health Care Services to implement a facility-specific ratesetting system for nursing facilities using a cost-based reimbursement rate methodology and to update these rates annually. This bill would require, under Medi-Cal provisions, by January 10, 2026, the State Department of Health Care Services to prepare and submit a cost study, on licensed congregate living health facilities, to the appropriate fiscal and policy committees of the Legislature. The bill would require the cost study to evaluate all financial and operational costs associated with those facilities, as specified. The bill would require the department to consult with facility providers, patients or families, caregivers, and other relevant parties in developing the study.