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.
Amber Ott represents members’ financial interests related to Medicare, Medi-Cal, commercial payers and other government entities. She is responsible for providing advocacy and support on financial and reimbursement issues affecting California hospitals and health systems, and represents CHA with state agencies and other stakeholders where hospital finance and technical knowledge is needed.
Amber is also involved with the development and implementation of the hospital fee and other financing programs.
CHA participated on a panel addressing the barriers that prevent access to care for Medi-Cal beneficiaries during yesterday’s Senate Budget Subcommittee on Health hearing. Other panelists included representatives from the California Medical Association, California Primary Care Association, California Dental Association and UC Health. Amber Kemp, CHA vice president, health care coverage, testified on CHA’s behalf and discussed the following:
The Medi-Cal expansion and reduced payments to primary care physicians enacted during the economic downturn are driving increased demand for hospital services
Medi-Cal members often seek preventive and other non-urgent care in hospital emergency rooms when they do not have access to primary care providers or specialists
Many Medi-Cal patients still lack appropriate access to mental health and substance use disorder treatment services, although the Affordable Care Act expanded coverage for these services
Many hospitals face significant difficulty securing needed post-acute care for Medi-Cal patients
The Department of Health Care Services has released a statistical brief analyzing the optional Medi-Cal expansion under the Affordable Care Act (ACA), which began in October 2016. The ACA extended Medicaid eligibility to non-elderly adults with incomes under 138 percent of the federal poverty level. In October 2016, nearly 4 million Californians aged 19 to 64 — 9.5 percent of the statewide population, or one in 11 Californians — were enrolled in Medi-Cal as a result of the ACA. The brief describes the Medi-Cal eligibility pathway for newly eligible individuals; historic growth of Medi-Cal’s optional adult ACA expansion population; demographic composition of the population; and the percent of each county and congressional district’s population that is eligible under the optional expansion.
The Department of Health Care Services (DHCS) has changed an eligibility rule for hospitals applying to the program year 2016 Medi-Cal Electronic Health Record Incentive Program for the first time. Previously, DHCS required hospitals to submit cost report data for a continuous 12-month period ending before the start of the federal fiscal year (Oct. 1-Sept. 30) that serves as the program year for the Medi-Cal EHR Incentive Program. Under the recent change, hospitals will be able to submit data for the 12-month period before the fiscal year ends. In addition, hospitals with a new CCN must reapply to the program.
Hospitals are reminded that program year 2016 marks the last opportunity to start the program; applications from hospitals that have not successfully participated in the 2016 program will not be accepted for 2017 and subsequent years. Applications are due May 2. For more information, visit http://medi-cal.ehr.ca.gov/ or call (916) 552-9181.
The Centers for Medicare & Medicaid Services (CMS) has issued the attached final rule that addresses how third-party payments are treated in calculating the hospital-specific limitation on Medicaid disproportionate share hospital (DSH) payments. Specifically, the rule defines uncompensated care costs as net of third-party payments, including payments by Medicare and private insurance. In California, the federal Medicaid DSH allotment is almost entirely allocated to the public hospitals, as private hospitals receive Medi-Cal DSH replacement payments.
In comments submitted last year, CHA urged CMS to withdraw the proposed rule and instead await the outcome of several pending court cases on the same issue. A federal court recently barred CMS from using subregulatory guidance to calculate Medicaid DSH payments, in a New Hampshire case where enforcement of the proposed calculation as implemented via subregulatory guidance was challenged. However, CMS is expected to appeal the decision and argue that the issuance of this final rule appropriately notifies hospitals of the policy change. CHA is analyzing the final rule and will provide members with more information in the coming weeks.
The Medi-Cal Inmate County program will begin April 1 for participating counties, including Alameda, Fresno, Kern, Los Angeles, Sacramento, Santa Clara and Stanislaus. Calaveras, Placer and San Luis Obispo counties are scheduled to begin July 1. Providers that treat inmates under the custody of counties that have opted into the Medi-Cal Inmate County program should bill Medi-Cal directly for services provided on or after their agreement date. Applicable services include inpatient services at a medical facility located off the grounds of the correctional facility for an extended stay of more than 24 hours. For more information and a full list of participating counties, visit the Medi-Cal website. Questions should be directed to DHCSIMCU@dhcs.ca.gov.
Seema Verma was confirmed this week as the Administrator for the Centers for Medicare & Medicaid Services. Verma was previously an Indiana-based consultant and worked with Vice President Mike Pence to reform Indiana’s Medicaid program. Verma was confirmed by the U.S. Senate by a vote of 55 to 43.
The California Department of Health Care Services (DHCS) has extended the deadline for 2016 attestations for the Electronic Health Record (EHR) Incentive program to May 2. Meaningful use (MU) attestations for program year 2016 will be accepted until that date; the State Level Registry will then switch to accepting 2017 MU attestations only, which initially will only be available for Stage 2. Providers will not be able to attest to Stage 3 until Oct. 24. Those that have previously attested to MU will be required to use a full year reporting period for clinical quality measures (CQMs), while providers that have not previously attested to MU will be able to use 90-day reporting periods for both CQMs and objectives. DHCS has requested that the reporting periods for objectives and CQMs be 90 days for all providers, but has not yet received approval from the Centers for Medicare & Medicaid Services. Providers that are ineligible for the Medicaid EHR Incentive program may submit an alternate MU attestation to avoid Medicare payment adjustments; that deadline has been extended to March 13. More information is available at http://medi-cal.ehr.ca.gov/.
The Centers for Medicare & Medicaid Services (CMS) has issued the attached final rule limiting states’ ability to increase or create new pass-through payments for hospitals, physicians or nursing homes under Medicaid managed care contracts.
Due to the late closure of applications for Meaningful Use (MU) for the 2015 program year, the California Department of Health Care Services (DHCS) was unable to send the Centers for Medicare & Medicaid Services (CMS) information on 2015 MU attestations until late December 2016. As a result, some Medi-Cal providers are now erroneously receiving letters from CMS warning that they are subject to Medicare payment adjustments in 2017 because they did not attest to MU in 2015. DHCS has received assurance from CMS that all providers who attested to MU with the Medi-Cal EHR Incentive program for 2015, even as late as Dec. 13, 2016, will not be subject to Medicare payment withholds in 2017. A complete list of providers that attested to MU is available on the DHCS website. CMS has now removed these providers from its list of those subject to payment adjustments in 2017. Questions should be directed to firstname.lastname@example.org.
The Health Resources and Services Administration has released its final rule addressing drug ceiling prices and civil monetary penalties for manufacturers in the 340B Drug Pricing program. Required by the Affordable Care Act, the rule amends Section 340B of the Public Health Service Act to impose monetary sanctions on drug manufacturers who intentionally charge a 340B hospital or covered entity more than the ceiling price established under the procedures of the 340B program. It also establishes a new drug pricing policy when sufficient information to establish a 340B ceiling price for a new drug is not yet available, requires manufacturers to refund 340B covered entities within 120 days if the manufacturer determines an overcharge occurred, and requires greater transparency in calculating the 340B ceiling drug prices to ensure that drug manufacturers are not overcharging 340B covered entities.
HRSA plans to begin enforcing the final rule on April 1, and to issue further guidance on the 340B ceiling price reporting system and how 340B covered entities can access ceiling price information.
The Centers for Medicare & Medicaid Services (CMS) has announced a new initiative – the Medicare-Medicaid Accountable Care Organization (ACO) Model – designed to improve the quality of care and lower costs for beneficiaries who are enrolled in both Medicare and Medicaid. Building on the current Medicare Shared Savings Program, the model aims to advance CMS’ partnerships with states to transform the health care delivery system. In current Medicare ACO initiatives, beneficiaries who are Medicare-Medicaid enrollees may be attributed to ACOs. However, Medicare ACOs often do not have financial accountability for the Medicaid expenditures for those beneficiaries. The Medicare-Medicaid ACO Model will allow Medicare Shared Savings Program ACOs to take on accountability for the quality of care and both Medicare and Medicaid costs for Medicare-Medicaid enrollees.
On Friday, the Department of Health Care Services (DHCS) notified several hospitals via e-mail that they need to review the data submitted to calculate the Medi-Cal Electronic Health Record (EHR) Incentive program payments and correct any errors. The request is being made in response to an audit of 64 California hospitals’ Medi-Cal EHR incentive payments, performed earlier this year by the Office of Inspector General (OIG). In its final audit report, the OIG reported that DHCS overpaid the audited hospitals over $22 million. The OIG determined that DHCS failed to confirm that hospitals properly excluded and included certain discharges, bed days or charges when calculating the EHR incentive payment amount. Most hospitals followed the instructions that were provided by DHCS and pulled the data directly from their cost reports. However, the DHCS instructions did not clearly define that some discharges, bed days and charges needed to be included or excluded when reporting the EHR data. Since the reporting instructions provided by DHCS — and approved by the Centers for Medicare & Medicaid Services — did not require that hospitals include or exclude these data elements, some hospitals may disagree with the OIG methodology. CHA recommends that hospitals consult with legal counsel before responding to DHCS’ request.
The California Department of Health Care Services (DHCS) has launched the Provider Application and Validation for Enrollment (PAVE) system, a web-based application designed to simplify and accelerate enrollment processes. Providers can use the portal to complete and submit applications, report changes to existing enrollments and respond to requests for continued enrollment or revalidation. PAVE features secure log-in, document uploading, electronic signature, application progress tracking, intuitive guidance, social collaboration and more. To assist providers in transitioning to the new system, DHCS will host several question-and-answer sessions in two formats: in-person labs on Tuesdays from noon-2 p.m. at 1700 K Street in Sacramento, and webinars on Thursdays at noon. More information is available on the PAVE website.
The Department of Health Care Services (DHCS) has updated the administrative day level 1 reimbursement rates for providers across the state. In accordance with current law, a distinct-part skilled-nursing facility (DP/SNF) will receive either its projected costs or the DP/SNF median rate (currently $489.28) as its administrative day rate, whichever is less. Acute care hospitals without a DP/SNF will receive the median rate as their administrative day rate. Because this update took effect Aug. 1, providers will be paid the new rate immediately for service dates on or after Aug. 1. However, providers do not need to rebill to adjust their payments; retroactive rate adjustments will be processed for claims paid at the old rate for services provided on or after the effective date. Providers can find their rates on the DHCS website.
The Centers for Medicare & Medicaid Services (CMS) has issued a proposed rule limiting states’ ability to increase or create new pass-through payments for hospitals, physicians or nursing homes under Medicaid managed care contracts. In a May final rule that modernized Medicaid managed care requirements, CMS provided for a 10-year phase out of pass-through payments beginning July 1, 2017. The new proposed rule would impose an annual cap on the pass-through payment amount, equal to the amount included in a state’s Medicaid managed care contracts on or before July 5, 2016. For California, supplemental Medi-Cal managed care payments made through the quality assurance fee (QAF) program would be capped at the state fiscal year 2013-14 QAF payment amounts, beginning on July 1, 2017. CHA will submit comments outlining its significant concerns about the financial impact of the proposed rule. Comments are due to CMS by Dec. 22. Contact Amber Ott, CHA vice president, finance, with questions or concerns.
Last week, the Centers for Medicare & Medicaid Services (CMS) released additional details about its reopened inpatient status claims settlement. Earlier this week, the agency hosted a call providing more details and answering questions about the new settlement process. The presentation from that call is attached. CMS states it will provide partial payment, equal to 66 percent of the net allowable amount of the claim, for pending administrative appeals of inpatient status denials. Only denied claims with dates of service prior to Oct. 1, 2013, with appeals pending before an administrative law judge or the Departmental Appeals Board, are eligible. In exchange for the partial payment, a hospital must withdraw all of its pending administrative appeals for these inpatient denials. Hospitals cannot choose to settle some claims and continue to appeal others. CMS will make the settlement process available beginning Dec. 1; the deadline for hospitals to submit an Expression of Interest is Jan. 31, 2017.
The Department of Health Care Services will reschedule its webinar providing information on the Medi-Cal County Inmate program (MCIP). MCIP is a fee-for-service program that provides Medi-Cal services to eligible individuals under the Adult County Inmate program, the Juvenile County Ward program, the County Compassionate Release program and the County Medical Probation program. A slide deck for the webinar, originally scheduled for today, is attached. More details on the new webinar date will be shared via CHA News when available.
The Department of Health Care Services will hold a webinar Nov. 14 at 10 a.m. (PT) to provide information on the Medi-Cal County Inmate Program (MCIP). MCIP is a fee-for-service program that provides Medi-Cal services to eligible individuals under the adult county inmate program, the juvenile county ward program, the county compassionate release program and the county medical probation program. To register for the webinar, visit https://attendee.gotowebinar.com/register/5099248335489517828.