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 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 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.
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 email@example.com.
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.
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.