Medi-Cal is California's Medicaid program — a public health insurance program that provides needed health care services for low-income families with children, seniors, people with disabilities, foster caregivers, pregnant women and low-income people with specific diseases, such as tuberculosis, breast cancer or HIV/AIDS. Medi-Cal is financed equally by the state and federal governments.
Medi-Cal is California’s Medicaid program — a public health insurance program that provides needed health care services for low-income families with children, seniors, people with disabilities, foster caregivers, pregnant women and low-income people with specific diseases, such as tuberculosis, breast cancer or HIV/AIDS. Medi-Cal is financed equally by the state and federal governments.
The Government Accountability Office (GAO) reports that 5 percent of Medicaid-only enrollees – those not eligible for Medicare and with the highest Medicaid utilization – accounted for nearly half of Medicaid spending from 2009-11. The report, Medicaid: A Small Share of Enrollees Consistently Accounted for a Large Share of Expenditures, also concludes that “enrollees with mental health conditions also constituted about half of the high-expenditure group.” According to the GAO, less than 15 percent of all Medicaid-only enrollees had mental health conditions. Additionally, the report found that, of the high-utilization group, 71 percent of enrollees with a substance abuse condition also had one or more mental health conditions.
The California Department of Health Care Services (DHCS) has posted the draft Superior Systems Waiver (SSW) renewal application online for review and comment. The SSW describes the utilization review process for acute inpatient hospitals that serve fee-for-service Medi-Cal patients. Specifically, under the new waiver, private and non-designated public hospitals would transition to a utilization review system that no longer requires treatment authorization requests for the majority of acute inpatient stays. Instead, hospitals would use evidence-based medical criteria, such as Milliman or InterQual, to complete the utilization review. To ensure hospitals are appropriately using standardized medical review criteria, DHCS would review a statistically valid sample of cases approximately six months after claim submission.
The current SSW expires Sept. 30, and DHCS will submit the final renewal application to the federal Centers for Medicare & Medicaid Services no later than June 30. Comments on the draft may be submitted to DHCS no later than June 1 at SSWRenewal@dhcs.ca.gov. CHA requests that members who have comments also submit them to Amber Ott at firstname.lastname@example.org.
The Department of Health Care Services has notified providers that, when diagnosis-related group (DRG) hospitals bill Medi-Cal for a beneficiary stay that is covered by a managed care plan and fee-for-service (FFS), they must first obtain reimbursement from the managed care plan. The requirement is effective retroactively for dates of service on or after July 1, 2013. Additionally, when payment is received from the managed care plan, the hospital should then bill the entire stay to FFS, and the managed care plan payment will be deducted from the FFS payment amount.
We Care for California — a coalition of doctors, nurses, hospitals, workers and other health care leaders, including CHA — launched a statewide campaign today that includes $10 million in paid advertising, calling on the state of California to fully fund Medi-Cal to bring provider payments in line with rates paid by Medicare. The eight-week campaign includes English and Spanish television and radio ads, direct mail, outdoor billboards and online calls to action. Television ads will run in Los Angeles, San Francisco, San Diego and Sacramento; a selection can be viewed on Medi-CalMatters.org.
The paid media campaign is the beginning of a sustained effort to help Californians and state leaders understand how the severe underfunding of Medi-Cal harms millions of children, seniors in nursing homes, pregnant women and people with disabilities, all of whom have difficulty getting access to the health care they need. With the chronic underfunding of Medi-Cal, California ranks 48th in the nation in payments to health providers. As a result, 56 percent of Medi-Cal patients report difficulty finding a doctor.
The Department of Health Care Services has announced that Medi-Cal will conduct ICD-10 end-to-end testing in July. Providers and billers interested in participating in the testing can now register on the Medi-Cal website, which also includes instructions, more details about the testing and requirements for participation. The registration period ends June 5.
The Department of Health Care Services (DHCS) invites hospitals to participate in its second Superior Systems Waiver (SSW) Renewal stakeholder webinar April 16 from 10 a.m. – noon. The webinar agenda and presentation slides will be available on the DHCS stakeholder information web page at least five days before the webinar.
The current SSW expires Sept. 30, and DHCS will need to submit a renewal application to the Centers for Medicare & Medicaid Services no later than June 30. The waiver renewal will be effective for a two-year period — Oct. 1, 2015, through Sept. 30, 2017. The upcoming meeting will allow DHCS to solicit stakeholder input on this waiver. To register, visit https://attendee.gotowebinar.com/register/5725839108455364610. To dial in for the webinar, call (415) 655-0051 and use access code 646-637-912.
June 11, Sacramento
June 16, Pasadena
June 17, Costa Mesa
Reimbursement is shrinking, while coverage and cost of care are expanding. Hospitals are now in the position of fighting for every dollar. Just to maintain the status quo, health care providers must navigate increasing and costly regulatory requirements while working to improve quality of care, reduce readmissions and comply with the complex two-midnight rule. More changes are ahead, too. Register now to gain a better understanding of how to effectively manage in the current health care environment, and also prepare for what lies ahead.
The Centers for Medicare & Medicaid Services (CMS) has issued the attached proposed rule applying certain provisions of the Mental Health Parity and Addiction Equity Act of 2008 to Medicaid managed care organizations (MCOs), the Children’s Health Insurance Program (CHIP) and alternative benefit plans (ABPs). The proposed rule requires that all beneficiaries who receive services through MCOs or under ABPs have access to mental health and substance use disorder benefits regardless of whether services are provided through the MCO or another service delivery system. The full scope of the proposed rule applies to CHIP, regardless of whether care is provided through fee-for-service or managed care.
The U.S. Supreme Court ruled today in a 5-4 decision that the Supremacy Clause of the U.S. Constitution does not allow providers to sue state officials to force higher Medicaid payments under Section 30(A) of the Medicaid Act. Section 30(A) requires states to “assure payments [that] are consistent with efficiency, economy, and quality of care.” In Armstrong v. Exceptional Child, the court ruled that the Supremacy Clause — which requires courts to give federal law priority when federal and state law clash — does not create a private right of action permitting providers to sue state agencies to obtain higher reimbursement rates, even though such suits may be the only way to enforce federal payment requirements. The court’s ruling reverses a decision by the Ninth Circuit, which had affirmed a lower court ruling that the Supremacy Clause gave providers a private right of action to sue to enforce the federal Medicaid law.
The Medicare-Medicaid Coordination Office (MMCO) has issued its 2014 Report to Congress, as required by the Affordable Care Act (ACA). The report describes MMCO’s efforts to develop policies, programs and initiatives that promote coordinated, high‐quality and cost‐effective care for the dual eligible population. MMCO notes it is focusing its efforts on improved data analytics and two alignment initiatives. The report provides detail on an initiative to reduce preventable inpatient hospitalizations among residents of nursing facilities, as well as the financial alignment initiative. The full report is available for download on MMCO’s website.
CHA members joined lawmakers and dozens of patients and other health care providers at the state Capitol to announce legislation aimed at restoring Medi-Cal funding and increasing Medi-Cal payment rates.
Two U.S. senators have introduced legislation to extend the Medicaid Emergency Psychiatric Demonstration project now underway in 11 states and the District of Columbia. Initiated in 2012 under the Affordable Care Act, the demonstration was established to test whether Medicaid programs can support higher quality care at a lower total cost by reimbursing private psychiatric hospitals for services for which Medicaid reimbursement has historically been unavailable. The Improving Access to Emergency Psychiatric Care Act of 2015 (S.599) would extend the demonstration until the Secretary of Health and Human Services (HHS) submits recommendations to Congress based on the final evaluation or Sept. 30, 2016, whichever occurs first. HHS would also have the option to recommend extending the demonstration project for an additional three years and/or expanding it to include other states.
The Department of Health Care Services has released the attached all plan letter (APL). The letter clarifies the responsibilities of Medi-Cal managed care health plans to provide coverage of nursing facility services under the Coordinated Care Initiative for beneficiaries who are not enrolled in Cal MediConnect. The APL includes information on payment rates and policies, timelines and continuity of care.
The Center for Medicaid and CHIP Services (CMCS) has issued the attached informational bulletin describing 2015 updates to the core sets of measures for children and adults enrolled in the Children’s Health Insurance Program (CHIP) or Medicaid. The updates to the core sets will take effect in the federal fiscal year (FFY) 2015 reporting cycle, which will begin no later than December 2015. CMCS will release updated technical specifications for both core sets in spring 2015 and make them available at www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Quality-of-Care/Quality-of-Care.html. States with questions or that need further assistance with reporting, which is voluntary, and quality improvement regarding the child and adult core sets can submit questions or requests to MACQualityTA@cms.hhs.gov.
The Department of Health Care Services has issued two duals plan letters (DPLs) providing guidance to Medicare-Medicaid plans participating in Cal MediConnect.
DPL 14-004 provides clarification and guidance on continuity of care requirements — including who may make such requests — and limitations. DPL 14-005 establishes standards and provides updated due dates for facility site reviews and physical-accessibility reviews conducted by managed care plans that participate in Cal MediConnect. Both DPLs are attached.
The U.S. Department of Health and Human Services Office of the Inspector General (OIG) has issued a report evaluating the adequacy of access to care for enrollees in Medicaid managed care. OIG found that standards for access to care vary widely by state. The report also found that the Centers for Medicare & Medicaid Services (CMS) currently provides limited oversight of state access standards. OIG recommends that CMS strengthen its oversight of state standards and of its methods to ensure compliance with state standards. OIG also recommends that CMS provide technical assistance and share effective practices while ensuring states develop standards to measure access to Medicaid managed care. The full report is available at http://oig.hhs.gov/oei/reports/oei-02-11-00320.asp.
The Department of Health Care Services has issued revised enrollment materials for the Coordinated Care Initiative (CCI), which provides for the enrollment of dually eligible beneficiaries in eight designated counties into managed care. The materials and associated Choice Form were revised in response to stakeholder concerns that the current notices did not adequately communicate choices and required action for CCI-eligible individuals — in particular, the ability and process to opt out and maintain traditional Medicare coverage. Use of the revised Choice Form will begin in September with the 60-day notices sent to those subject to passive enrollment in November. Attached are samples of the revised Choice Form and enrollment materials.
The California Department of Health Care Services (DHCS) has announced that Medi-Cal has fixed an issue with an erroneous denial of All Patient Refined Diagnosis Related Group (APR-DRG) type of bill code 121.
The annual recertification of hospital 340B eligibility began Aug. 6 and continues through Sept. 10. All hospitals with an active 340B ID as of July 1 and without a future termination date are required to recertify and will be removed from the 340B program if they do not complete the process.
At a meeting yesterday of the Health and Human Service (HHS) Agency’s Olmstead Advisory Committee, HHS Secretary Diana Dooley and Department of Health Care Services (DHCS) Chief Margaret Tatar provided implementation updates on the Coordinated Care Initiative/Cal MediConnect, including that enrollment materials and the “choice” form will be made available in August. The materials have been revised in response to stakeholder concerns and developed and tested with consumer focus groups. CHA has requested that copies of the final form and materials be shared with providers, including hospitals, as soon as possible. In addition, DHCS reported that implementation of Cal MediConnect in Alameda and Orange counties, most recently anticipated for January 2015, will be delayed until July 1, 2015. Implementation must occur no later than July in order for the counties to be included in the demonstration program.