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 Department of Health Care Services (DHCS) has resolved a previously identified claim processing issue that caused diagnosis-related group (DRG) claims with remittance advice details code “9953: APR-DRG — Length of Stay Invalid for Interim Claim” to be erroneously denied. Hospital providers may resubmit previously denied level one or two administrative day claims and rehabilitation claims, provided the claims meet certain criteria. More information on resubmitting claims is available at the DHCS website.
The Centers for Medicare & Medicaid Services (CMS) has issued the attached final rule implementing reforms to the rebate and reimbursement systems for Medicaid prescription drugs, as required by the Affordable Care Act (ACA). CMS estimates the final rule, which is intended to address the rising cost of prescription drugs, will save federal and state governments $2.7 billion over five years. The final rule creates a regulatory definition for Average Manufacturer Price, which is the program’s key metric for determining manufacturer rebates and pharmacy reimbursement for certain generic drugs that are subject to the federal upper limit (FUL). The final rule updates the FUL formula for the payment of certain generic drugs, which is intended to create an incentive for pharmacies to utilize generic drugs. The final rule also implements an ACA provision extending rebates to covered outpatient drugs provided to beneficiaries enrolled in Medicaid managed care organizations.
February 17, 2016 Sacramento
February 23, 2016 Long Beach
At the annual Hospital Compliance Seminar participants will learn about new laws, regulations and judicial decisions impacting hospital operations. Expert faculty will simplify complex regulatory and legal actions into clear and practical terms and offer guidance for implementation in the hospital environment. All attendees receive a complimentary copy of the 2016 California Hospital Compliance Manual.
The Department of Health and Human Services (HHS) has announced the Accountable Health Communities (AHC) Model program, designed to assess whether screening Medicare / Medicaid beneficiaries for “health-related social needs and associated referrals to and navigation of community-based services” can improve patient outcomes and reduce costs. The five-year program, administered by the Centers for Medicare & Medicaid Services (CMS), could provide up to $157 million for participating grantees who use the AHC model at clinical delivery sites to address health-related social needs. AHC will support up to 44 bridge organizations to test three scalable approaches: community referral, community service navigation and community service alignment.
CMS will host a webinar to discuss AHC and the application process on Jan. 21 from 11 a.m. – 12:30 p.m. (PT) and again on Jan. 27 from noon – 1:30 p.m. (PT). Online registration is currently open.
The Office of Medicare Hearings & Appeals (OMHA) has published its quarterly update to the OMHA Case Processing Manual. The manual is used by OMHA adjudicators and staff to administer the OMHA program and offers day-to-day operating instructions, policies and procedures based on statutes, regulations and OMHA directives. The quarterly update addresses who qualifies as a party, as well as the roles and responsibilities of party representatives, the Centers for Medicare & Medicaid Services and its contractors in the administrative law judge hearing and review process. The full manual is available at www.hhs.gov/omha/OMHA_Case_Processing_Manual/index.html.
The Centers for Medicare & Medicaid Services (CMS) last week announced $32 million in funding for outreach efforts to families with children eligible for Medicaid and the Children’s Health Insurance Program (CHIP). This is the fourth cycle of funding available as part of the Connecting Kids to Coverage Outreach and Enrollment Grant, which supports activities such as identifying children likely to be eligible for coverage under Medicaid and CHIP, and assisting families with the application and renewal process. CMS plans to award approximately 30 cooperative agreements ranging in amounts from $250,000 to $1 million over a two-year period. State and local governments, certain health care provider organizations, and nonprofit organizations including community and faith-based groups are among the entities eligible to apply. Applicants are asked to target populations likely to be eligible for Medicaid and CHIP but generally less likely to be enrolled, including teens, Latino children and children in rural areas.
Proposals are due by Jan. 20, 2016. More information is available here.
The Department of Health Care Services reminds providers that misaligned paper claims can cause processing delays for Medi-Cal reimbursement. Providers are encouraged to save time and money by entering claim information directly into the claims processing system at www.medi-cal.ca.gov. More information can be found in the attached flyer or by contacting the Computer Media Claims Help Desk at 1-800-541-5555.
The Centers for Medicare & Medicaid Services has issued the attached proposed rule revising the discharge planning requirements for hospitals — including long-term care hospitals and inpatient rehabilitation facilities, critical access hospitals (CAHs) and home health agencies — as required by the Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014. Under the proposed rule, hospitals and CAHs would be required to develop a discharge plan within 24 hours of admission or registration and complete a discharge plan before the patient is discharged home or transferred to another facility. This would apply to all inpatients and certain types of outpatients, including patients receiving observation services, those undergoing surgery or other same-day procedures where anesthesia or moderate sedation is used, and emergency department patients who have been identified by a practitioner as needing a discharge plan.
The Centers for Medicare & Medicaid Services this week approved the Superior Systems Waiver (SSW) renewal application, effective for the period from Oct. 1, 2015 through Sept. 30, 2017. The SSW describes the utilization review process for acute inpatient hospitals that serve fee-for-service Medi-Cal patients. It also specifies how non-designated public hospitals and private hospitals will transition from using the current treatment authorization requests to using their own utilization management systems based on nationally recognized, evidence-based medical criteria. Under a previous waiver, California’s 21 designated public hospitals have piloted this new method. More information is available in CHA’s article on the proposed waiver, and the approved waiver is available on the DHCS website.
The Centers for Medicare & Medicaid Services (CMS) has issued the attached final rule with comment period, modifying the reporting period for the Medicare and Medicaid Electronic Health Records (EHR) Incentive programs in 2015 and defining stage 3 of meaningful use. In the final rule, CMS finalized provisions for two separate proposed rules issued in March. In addition, the Office of the National Coordinator for Health Information Technology released a companion rule that finalizes 2015 certification criteria, standards and implementation specifications for EHR technology.
The finalized modifications to EHR Incentive programs for 2015 through 2017 include moving from fiscal year to calendar year reporting for all providers beginning in 2015 and offering a 90-day reporting period in 2015 for all providers, as well as for new participants in 2016 and 2017, and for any provider moving to Stage 3 in 2017. CMS also reduces the number of objectives for eligible hospitals and critical access hospitals (CAHs) from 20 to nine — including one public health reporting objective — and maintains electronic clinical quality measure (eCQM) reporting as previously finalized.
The Health Resources and Services Administration (HRSA) has released “mega guidance” for its proposed 340B Drug Pricing Program. The guidance is included in a notice with a 60-day comment period. In the guidance, HRSA provides clarification on the areas of covered entity eligibility, patient definition, group purchasing organization prohibition, contract pharmacy, duplicate discounts and covered entity audits. It also includes enhanced program integrity requirements for pharmaceutical manufacturers participating in the program. CHA is reviewing the proposed guidance and will seek member input on the anticipated hospital impact. Comments are due Oct. 26.
The Health Resources and Services Administration (HRSA) recently produced a webinar for hospitals on recertification for the 340B Drug Pricing Program, available online. HRSA is required to annually recertify all participating covered entities enrolled in the 340B program to ensure they are listed appropriately in the 340B database and remain compliant with the program. Questions on registration or recertification should be directed to Apexus, the 340B prime vendor, at ApexusAnswers@340bpvp.com.
The California Department of Health Care Services (DHCS) encourages Medi-Cal providers and submitters to take the International Classification of Diseases, 10th Revision (ICD-10) Provider Readiness Survey, which aims to identify provider and submitter health care transaction preparedness. Participation is not required but will help Medi-Cal to assess concerns that may hinder ICD-10 compliance. For more information and to take the survey, visit the DHCS Medi-Cal website.
The Department of Health Care Services (DHCS) has developed a process that will allow Medi-Cal beneficiaries, including those enrolled in Cal MediConnect plans, to designate another individual as an “enrollment assistant,” to make enrollment or disenrollment decisions on their behalf. The new process, which became effective July 31, was developed in response to concerns voiced by beneficiaries and providers and will allow family members and caregivers, under certain circumstances, to make enrollment or disenrollment decisions on behalf of beneficiaries who are incapacitated but do not have a designated authorized representative, such as a conservator or individual designated in an advance health care directive. A fact sheet on the new process is attached.
The Government Accountability Office (GAO) has issued a report to Congress to provide information about access to behavioral health treatment for low-income, uninsured and Medicaid-enrolled adults. GAO studied six states that expanded Medicaid under the Affordable Care Act, as well as four non-expansion states, and examined how many low-income, uninsured adults may have a behavioral health condition.
The Department of Health Care Services (DHCS) has resolved a claims processing issue that caused diagnosis-related group (DRG) claims that included other health coverage to be erroneously denied. Timeliness will be waived for claims that were previously denied with remittance advice details (RAD) code 9968 (“no approved TAR on file for APR-DRG inpatient admission working”) for dates of service from July 1, 2013, through March 1, 2015. Hospital providers may resubmit claims until November 20.
The Department of Health Care Services has announced that payments for Medi-Cal and other services funded through state programs are being held until July 2, after the 2015-16 state budget is enacted on July 1. Payments to the Every Woman Counts program will not be deferred.
Medi-Cal funded fee-for-service programs scheduled for payment on June 18 that are now being held until July 2 include:
The Medicaid and CHIP Payment and Access Commission (MACPAC) has released its June 2015 Report to Congress on Medicaid and CHIP, focusing on Medicaid’s role in providing behavioral health services. The report — the second of two reports to Congress MACPAC issues annually — takes a first look at the use of Medicaid services by beneficiaries with behavioral health conditions while also considering two related issues: the program’s role in covering care for neglected and abused children and the extent to which program beneficiaries are being prescribed psychotropic medications. According to the report, one in five Medicaid beneficiaries has a diagnosed behavioral health condition, and their care accounts for almost half of total Medicaid expenditures.
The Department of Health Care Services (DHCS) has scheduled two training sessions to help providers prepare for year three of the DRG payment methodology, which begins July 1. DHCS will host webinars, in conjunction with Xerox, on June 11 from 9:30 – 11 a.m. (PT) and June 15 from 9:30 – 11 a.m. (PT). Online registration is required. Once registered, attendees will receive meeting details and instructions for joining the meeting.
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.