Affordable Care Act (ACA) Information
Second Certification Document for Reimbursement for Additional Cost(s) Due to ACA Employer Shared Responsibility Mandate
The Department of Health Care Services (DHCS) is providing facility specific reimbursement by way of 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 ACA embodied in Section 4980H of the Internal Revenue Code (IRC).
Effective in the 2016 – 2017 Rate Year, the Department of Health Care Services (DHCS) is providing a facility specific reimbursement.
A provider may submit the Second Certification Form for reimbursement if it was not an Applicable Large Employer (ALE) in 2015, but in 2016, it became an Applicable Large Employer as defined by section 4980H and its implementing regulations, and if 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.
DHCS is no longer accepting add-on requests. The submission deadline was
February 28, 2017.
The add-on will apply to the following facilities:
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Free-Standing Skilled Nursing Facilities Level B (NF-B)
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Free-Standing Adult Subacute
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Nursing Facilities Level A (NF-A)
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Distinct-Part Nursing Facilities Level B (DP/NF-B)
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Rural Swing Beds
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Distinct-Part Adult Subacute
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Distinct-Part Pediatric Subacute
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Free-Standing Pediatric Subacute
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Intermediate Care Facilities for the Developmentally Disabled (ICF/DD)
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Intermediate Care Facilities for the Developmentally Disabled/Habilitative (ICF/DD-H)
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Intermediate Care Facilities for the Developmentally Disabled/Nursing (ICF/DD-N)
To qualify to receive an add-on, providers need to submit a Second Certification Form verifying that the employer is an ALE as defined by IRC Section 4980H (and its implementing regulations and guidance) and has incurred additional health care coverage costs solely as a result of the ACA Employer Shared Responsibility provision. 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 Certification Form electronically to
supp1629@dhcs.ca.gov with the subject line “2016-2017 ACA Certification Form” along with their facility’s NPI or OSHPD number (for example, “ACA Certification Form 206xxxxxx”). 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 was due to DHCS no later than
February 28, 2017. For assistance, providers can contact the Long Term Care System Development Unit at
supp1629@dhcs.ca.gov.
Two New Facility Specific Add-Ons for LTC Reimbursement
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ACA Employer Mandate Certification Form FAQs (PDF) Updated 1/8/16
The following article initially published with a form submission deadline of January 15, 2016. The form submission deadline has been extended until February 29, 2016.
Effective for dates of service on or after August 1, 2015, the following two add-ons are available for Long Term Care (LTC) facility specific reimbursement for Applicable Large Employers (ALE) to recover costs due to the Patient Protection and Affordable Care Act (ACA) Employer Shared Responsibility and Internal Revenue Service (IRS) employer reporting mandates. The deadline for submitting requests for the two add-ons listed below is January 15, 2016.
Reimbursement for Additional Cost(s) Due to ACA Employer Shared Responsibility Mandate
Effective in the 2015 – 2016 Rate Year, the Department of Health Care Services (DHCS) is providing facility specific reimbursement by way of 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 ACA embodied in Section 4980H of the Internal Revenue Code (IRC). The add-on will apply 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)
To qualify to receive an add-on, providers need to submit a Certification Form verifying that the employer is an ALE as defined by IRC Section 4980H (and its implementing regulations and guidance) and has incurred additional health care coverage costs solely as a result of the ACA Employer Shared Responsibility provision. 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 Certification Form electronically to
supp1629@dhcs.ca.gov with the subject line “ACA Certification Form” along with their facility’s OSHPD number (for example, “ACA Certification Form 206xxxxxx”). 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 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 January 15, 2016. For assistance, providers can contact the Long Term Care System Development Unit at
supp1629@dhcs.ca.gov.
Reimbursement for Additional Cost(s) Due to IRS Employer Reporting Mandate
Effective in the 2015 – 2016 Rate Year, DHCS will be providing facility specific reimbursement by way of an add-on to their Medi-Cal reimbursement rate for the additional cost
of complying with the reporting requirements imposed by IRC Section 6056 to
report employee health coverage information to the IRS through completion of Forms 1094-C and 1905-C. The add-on will apply to the following facilities:
Only the ICF/DD-H or ICF/DD-N providers that meet the ALE definition need to submit a Certification Form because the employer reporting add-on is already included in the 2015
- 2016 reimbursement rate for 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)
To qualify to receive an add-on, ICF/DD-H or ICF/DD-N providers need to submit a
Certification Form
verifying that the employer is an ALE as defined by IRC Section 4980H (and its implementing regulations and guidance) and has incurred additional health care coverage costs as a result of the ACA IRS employer reporting mandate.
Providers may submit this form electronically to
LTCReimbursement@dhcs.ca.gov, with the ICF/DD-H or ICF/DD-N National Provider Identifier (NPI), the facility’s nine digit ZIP code, and “Employee Reporting Cert.” in the email subject line. The form may also be submitted by fax to 1-916-449-5337. This information must be received by DHCS no later than January 15, 2016. For additional information, providers can email
LTCReimbursement@dhcs.ca.gov.
