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Second Certification Document for Reimbursement for Additional ACA Costs

December 19, 2016

The Department of Health Care Services (DHCS) is providing facility-specific reimbursement with an add-on to the Medi-Cal reimbursement rate for the additional cost of health care coverage solely due to Employer Shared Responsibility requirements in the Affordable Care Act (ACA) embodied in Section 4980H of the Internal Revenue Code .

Effective in the 2016 – 2017 Rate Year, DHCS is providing a facility-specific reimbursement. A provider may submit the Second Certification Form to Report Health Care Coverage Additional Costs Associated with Shared Responsibility for Employers Regarding Health Coverage 2016 & 2017 Calendar Year (Second Certification Form) for reimbursement if:

  • It was not an applicable large employer in 2015, but in 2016 became an ALE as defined by section 4980H, and;
  • The provider incurred additional costs due to this ACA requirement.

A provider may also submit the Second Certification Form with actual differences in 2016 insurance costs incurred if it was an applicable large employer in 2015 and submitted the first ACA Certification Form. The deadline for submitting requests for the add-on is February 28, 2017.

The add-on applies to the following facilities:

  • Free-Standing Skilled Nursing Facilities Level B (NF-B)
  • Free-Standing Adult Subacute
  • Nursing Facilities Level A (NF-A)
  • Distinct-Part Nursing Facilities Level B (DP/NF-B)
  • Rural Swing Beds
  • Distinct-Part Adult Subacute
  • Distinct-Part Pediatric Subacute
  • Free-Standing Pediatric Subacute
  • Intermediate Care Facilities for the Developmentally Disabled (ICF/DD)
  • Intermediate Care Facilities for the Developmentally Disabled/Habilitative (ICF/DD-H)
  • Intermediate Care Facilities for the Developmentally Disabled/Nursing (ICF/DD-N)

This is a two year add-on to the rate until the ACA-mandated health care coverage costs are in the facility’s cost report.

Providers may submit the Second Certification Form electronically to supp1629@dhcs.ca.gov with the subject line “2016–2017 ACA Certification Form” along with their facility’s NPI or Office of Statewide Health Planning and Development number, for example, “ACA Certification Form 206xxxxxx”.

Second Certification Form Instructions (PDF)
Second Certification Form (Excel)

Providers who are not able to submit electronically can mail a signed copy of the certification form to:

Department of Health Care Services
Fee-For-Service Rates Development Division
Long Term Care Section
ACA Second Cert Form
P.O. Box 997417, Ste. 71.3052, MS 4600
Sacramento, CA 95899-7417

This information must be received by DHCS no later than February 28, 2017. For assistance, providers can contact the Long Term Care System Development Unit at supp1629@dhcs.ca.gov.