Skilled nursing facility workforce and quality incentive program

Eligible:

Freestanding SNF Level-B and Adult Freestanding Subacute Facility Level-B facilities that are eligible to participate in the Medi-Cal program and that furnish services under a network provider agreement

Not eligible:

• Distinct part facilities
• Freestanding pediatric subacute care facilities
• Intermediate care facilities for the developmentally disabled
• SNFs with 100% designated special treatment program
• Facilities in which all beds are designated for hospice services
• Facilities in which all beds are designated for special treatment program services for the mentally disordered

1. DHCS will calculate a per diem incentive amount for the program year for each SNF provider, using metrics established for the workforce, clinical quality, and equity domains. A provider’s WQIP score will be based on an aggregate of all the services they provided across all the MCPs they support. (SNFs will not receive separate scores for each MCP.) Please refer to the SNF WQIP Technical Program Guide for Program Year 1 for more information.
2. Blue Shield Promise will calculate the number of eligible bed days for each qualifying SNF during the program year and report them to DHCS. DHCS will then apply its determined per diem rate to those bed days and provide Blue Shield Promise with interim and final payment exhibits.

SNF WQIP qualifying bed days are calendar days during which a member receives SNF Level-B services, inclusive of the first day of the member’s stay and excluding the day of discharge unless it is also the first day of stay. 

SNF Level-B services include: 

• Room and board
• Nursing and related care services
• Commonly used items of equipment, supplies, and services
• Leave of absence days
• Bed holds

Bed days reimbursed outside of a network provider agreement, bed days for which Medi-Cal is a secondary payer, and bed days reimbursed through the Medi-Cal fee-for-service delivery system are not qualified for SNF WQIP.

Also, hospice services and special treatment program services for the mentally disordered do not qualify as bed days.

All payments will be calculated based on the per diem incentive amounts determined by DHCS and the criteria for eligibility contained in All Plan Letter 25-002. They will be processed twice for each program year, once as an interim payment and again, as the final payment for each program year.

Blue Shield Promise will make SNF WQIP payments to providers directly, based on the receipt of qualifying clean fee-for-service (FFS) claims from the provider that have been received for the incentive payment period. The payments will be processed and issued within 45 calendar days of receiving payment exhibits from DHCS or within 30 calendar days of receiving a clean claim from the provider, whichever is later.

SNF WQIP payments will be issued with a detailed cover letter describing the payments, whom to contact with any questions, and how to file a grievance. Along with the payment cover letter, you will also receive a detailed claims report showing the data upon which the payments were calculated. 

If you have a question about your SNF WQIP payment, please send an email to our LTSS liaisons at PHPSNFProvInquiries@blueshieldca.com.

If you need to dispute a claim, please refer to the Claim Issues & Disputes page on the Provider Connection website, here: Claim issues & disputes | Blue Shield of CA Provider

You can find detailed instructions on how to file a dispute here: Submit disputes online and check status (PDF, 2 MB)