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.
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.
The Centers for Medicare & Medicaid Services (CMS) has released additional details about its reopened inpatient status claims settlement. As previously reported in CHA News, the new hospital appeals settlement process will allow eligible hospitals to settle inpatient status claims under appeal. CMS 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. CMS will host a call at 10:30 a.m. (PT) on Nov. 16 to provide more details and answer questions.
The Centers for Medicare & Medicaid Services (CMS) has released the attached memorandum providing information on implementation of its recently issued emergency preparedness conditions of participation. The rule becomes effective Nov. 15; affected facilities have one year to reach full compliance. CMS is preparing interpretive guidelines as well as surveyor training, both of which are anticipated to be ready in spring of 2017. The memo also provides links to a variety of resources, as well as a frequently asked questions document.
Last month, the National Quality Forum (NQF) launched the Medicaid Innovation Accelerator Project, which will identify and recommend a set of Medicaid-relevant performance measures, measure concepts, or measures under development to the Medicaid Innovation Accelerator Program (IAP). The IAP targets four main program areas: reducing substance use disorders; improving care for Medicaid beneficiaries with complex care needs and high costs; promoting community integration for beneficiaries using long-term services and supports; and integration of physical and mental health.
The California Department of Health Care Services will accept 2016 meaningful use attestations in the state level registry Dec. 13, 2016, through March 31, 2017, for both eligible professionals and hospitals. 2016 attestations for adopt, implement or upgrade (AIU) are currently open and will remain open until March 31, 2017. 2016 is the last program year in which eligible professionals and hospitals can begin receiving Electronic Health Record (EHR) Incentive program payments. Several program changes have been made that should help more providers qualify for the program in 2016:
Professionals and hospitals can choose to use a 90-day representative period in the 12 months prior to attestation or in the last calendar year in order to qualify for the program.
Professionals can qualify for the program using the eligibility of a group/clinic if the professional delivered at least one Medicaid patient encounter with the group/clinic in either the 12 months prior to attestation or in the previous calendar year.
Contracts and other binding agreements for AIU of certified EHR technology can be signed as late as March 31, 2017, as long as they are signed before attesting for AIU in the state level registry.
The meaningful use reporting period for all professionals and hospitals will be 90 or more continuous days occurring within the 2016 calendar year.
The Department of Health Care Services reminds providers that claims not meeting the Affordable Care Act (ACA) ordering, referring and prescribing (ORP) provider requirement are currently receiving warnings on their Remittance Advice Details (RAD) forms with code 0558.
The warning states, “The ORP Provider is not enrolled. Correct or future claims will not pay.” Billing providers must take action to correct future claim billings and become ACA compliant, and should check their current RAD forms to determine whether they have received RAD code 0558. Providers should also consider the financial impact of claims denied for failing to meet ORP requirements. More information is available on the Medi-Cal website.
Beginning in mid-September, Medi-Cal will release a new benefits identification card design, commemorating its 50th anniversary. The new card, which features the California poppy, will be given to newly eligible recipients and beneficiaries who request a replacement card. Medi-Cal provides coverage to more than 13.4 million people and does not plan to provide the new card to the entire Medi-Cal population. Providers should accept both the current and new designs but must continue to verify eligibility, as possession of a card does not guarantee eligibility.
The Centers for Medicare & Medicaid Services (CMS) has created a mailbox for stakeholders to submit questions about the Medicaid and Children’s Health Insurance Program final rule for mental health parity, released in March. Technical assistance on the final rule will begin this fall and continue through 2018; however, questions may be submitted to email@example.com at any time.
This week, the Government Accountability Office (GAO) released a report evaluating the current payment methodology used to allocate Medicare uncompensated care (UC) payments to hospitals. Medicare UC payments are based largely on hospitals’ historic Medicaid days, rather than actual costs incurred treating the uninsured. The report states that the Centers for Medicare & Medicaid Services (CMS) is responsible for using the best available data to allocate payments based on hospitals’ actual uncompensated costs of providing care. According to GAO, CMS’ use of Medicaid patient days as the basis for distributing these payments results in poor alignment between payments and hospitals’ uncompensated care costs.
The GAO recommends that, when making Medicare UC payments, CMS base payments on uncompensated care costs and consider specific Medicaid supplemental payments a hospital has received that offset those costs. In its written response, the Department of Health & Human Services concurred with both recommendations. The GAO report was released one day prior to CMS’ inpatient prospective payment system final rule, which finalizes changes to the methodology used for distributing Medicare UC payments.
Yesterday, the Department of Health Care Services (DHCS) issued two all-plan letters (APLs) to provide Medi-Cal managed care health plans (MCPs) information about the appropriate billing of inpatient services for beneficiaries with California Children’s Services (CCS)-eligible conditions who are also enrolled in a MCP. One APL provides instructions for billing inpatient services at private, municipal and district hospitals; the other provides instructions for billing the same services at designated public hospitals.
The Health Resources and Services Administration’s (HRSA) Office of Pharmacy Affairs (OPA) will host a webinar July 20 from 10-11 a.m. (PT) to assist covered entities with the recertification process for the 340B Drug Pricing program. All 340B hospitals are required to recertify with HRSA to ensure they continue to meet the 340B hospital eligibility requirements. The hospital recertification process runs from mid-August to mid-September. Hospitals can join the webinar by visiting https://hrsa.connectsolutions.com/recertification/; the conference number is (888) 787-0207, and the participant passcode is 7814467.