Skilled Nursing Facility Workforce and Quality Incentive Program

Eligible SNF WQIP providers include Alliance contracted:

• Freestanding skilled nursing facilities level-B.
• Adult freestanding subacute facilities level-B.

Ineligible providers include:

• Freestanding pediatric subacute care facilities.
• Intermediate care facilities for the developmentally disabled (ICF/DD) homes.
• Distinct part facilities.
• SNFs with 100% designated special treatment program (STP) beds.

The opt-in period for this incentive will open June 2, 2025 and will end on Aug. 1, 2025. The opt-in form and all required supporting documents will be posted the DHCS website.

The WQIP program term is from Jan. 1, 2023 through Dec. 31, 2026. Each calendar year (CY) within this period is assigned a Program Year (PY) designation as follows:

• CY 2023: PY 1
• CY 2024: PY 2
• CY 2025: PY 3
• CY 2026: PY 4

To evaluate the quality of care within SNFs, DHCS established the following domains and measurement areas:

• Workforce Metrics Domain
  • Acuity-Adjusted Staffing Hour Metrics Measurement Area
  • Staffing Turnover Metric Measurement Area
• Clinical Metrics Domain
  • Minimum Data Set (MDS) Clinical Metrics Measurement Area
  • Claims-Based Clinical Metrics Measurement Area
• Equity Metrics Domain
  • Medi-Cal Disproportionate Share Measurement Area
  • MDS Racial and Ethnic Data Completeness Measurement Area

To read more about these measurement areas and what each entails, refer to DHCS’s most recent technical guide.

The Alliance will make interim and final payments to eligible SNFs, on a per diem basis, determined by each SNFs performance on the WQIP Metrics.

DHCS assesses provider performance metrics, calculates their WQIP score and determines the corresponding interim and final per diem payment amounts.

The Alliance will then calculate lump-sum interim and final payments for each facility. Payments are determined by multiplying the DHCS-determined per diem amounts by the qualifying bed days rendered during the PY.

Payments will be reduced or withheld for facilities that receive class A or AA citations from the California Department of Public Health (CDPH) applicable to the PY as follows:

• Class AA citations result from a facility’s actions that directly cause a resident’s death, disqualifying the facility from the program year.
• Class A citations result from a facility’s actions that pose an immediate risk of death or serious harm, or a high chance of such outcomes, reducing the facility’s per diem payment by 40%.

The Alliance is responsible for making payments for qualifying bed days within 45 calendar days of receiving payment from DHCS or within 30 calendar days of receiving a Clean Claim from the provider, whichever is later.

Qualifying bed days are calendar days that a member receives level-B services, including the first day of stay but excluding the discharge day (unless it’s the same day), provided during the program year. These days must be billed to the Alliance with Medi-Cal as the primary payer and not covered by Medicare.
Freestanding SNF level-B bed days qualify for WQIP payments if all the following conditions are met:

• Provided by a network provider during the PY.
• Reimbursed by a Managed Care Plan.
• Medi-Cal is the primary payer.

Bed days do not qualify for WQIP payments if:

• Reimbursed outside a network agreement.
• Medi-Cal is a secondary payer.
• Reimbursed via Medi-Cal Fee-For-Service (FFS).
• Provided under hospice care.

The Alliance will share a report of data provided by DHCS within 30 days with providers in the program.

The Alliance may make directed payments for qualifying bed days rendered to members under Network Provider agreements where the Alliance is the primary payer and all eligibility criteria are met. The Alliance will reconcile data against our records and provide each provider with summary-level reporting in accordance with the Health Insurance Portability and Accountability Act (HIPAA).

The Alliance is not responsible for directed payments when eligibility criteria are not met. For more information, please refer to the WQIP-Qualifying Bed Days section of this site.

Providers can submit grievances related to the processing or non-payment of SNF WQIP directed payments, including the calculation of SNF WQIP qualifying bed days. For more details on our Provider Dispute Resolution Process, please refer to our Provider Manual (Section 17). To file a claim inquiry or dispute, use the Provider Inquiry Form.

The Alliance has Long-Term Services and Supports (LTSS) liaisons to provide ongoing support to our providers. Our liaisons are trained in the full range of Medi-Cal rules and regulations related to long-term care (LTC) services.

Liaisons are available to help facilities with a wide range of needs, including claims and payment inquiries, placement facilitation, care transitions and other support related to LTSS services. They help providers meet member needs through seamless care coordination and communication across the provider community.

For assistance, please send your inquiry directly to the LTSS Liaison Team at [email protected]. You can also reach the team by phone at 831-430-5650

For details about upcoming informational webinars, please see our provider events calendar.