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 will host a series of webinars addressing upcoming changes to the DRG payment methodology, including a transition to the statewide base rate. The 90-minute webinars will be offered at two times: May 24 at 1:30 p.m. (PT) and June 2 at 9:30 a.m. (PT). Both sessions address the same information. Attendees must register prior to the start of the webinar in order to receive meeting details, and will receive instructions for joining the meeting after the registration request has been approved.
The California Department of Health Care Services (DHCS) is seeking volunteers to be part of the second phase of district/municipal public hospitals, and private hospitals transitioning to a treatment authorization request (TAR) free process for fee-for-service Medi-Cal beneficiaries. To participate in the TAR-free process, hospitals must:
Use an evidence-based standardized utilization review (UR) criteria for acute inpatient hospital stays for any payer
Have the ability to provide DHCS electronic access to medical records and UR reviews/decisions
The Department of Health Care Services (DHCS) is initiating a pilot project to measure the effectiveness of newly created marketing materials, attached, for the Community Care Transitions (CCT) program. CCT, California’s Money Follow the Person demonstration, is funded through a federal grant awarded to rebalance the state’s Medicaid spending on long-term care for residents who wish to live and receive care in the community. Under CCT, eligible residents who have lived in an institution or facility for 90 consecutive days and want to transition back to the community are provided with transition coordination, support and follow-up from contracted service providers. Facilities unable to meet residents’ needs for long-term home and community-based services are required to refer identified residents to state-designated local contact agencies (LCAs).
The Centers for Medicare & Medicaid Services (CMS) has issued the attached final rule extending the deadline for states to develop and submit an access monitoring review plan for Medicaid beneficiaries from July 1 to Oct. 1. The rule also changes the deadline for subsequent review periods to Oct. 1.
The final rule with comment period, originally issued in November 2015, required the plans to provide for state reviews of five core services: primary care, physician specialists, behavioral health, pre- and post-natal obstetrics (including labor and delivery), and home health services. In comments on the previous final rule, CHA urged CMS to modify the core services to include hospital services — such as hospital inpatient/outpatient, long-term acute care hospital and inpatient psychiatric services — as well as skilled-nursing services and hospital-based post-acute care services in the review process by modifying the final rule or by reissuing it as a proposed rule for public comment. In the attached final rule, CMS declined to expand the list of core services subject to access reviews.
Labor and business groups have formed an alliance to seek voter passage of the Medi-Cal Funding and Accountability Act, CHA’s hospital fee initiative, on the November 2016 ballot. Recently, labor giant United Food and Commercial Workers Western States Council added its support, joining almost 70 other labor organizations in California. The growing list includes the State Building and Construction Trades Council of California, the California State Association of Electrical Workers, the International Brotherhood of Boilermakers and a range of union locals.
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Government has been busy this year. There’s been a lot of activity at federal and state levels that will impact how hospitals are reimbursed and also change the way we care for patients. New this year: NOTICE Act; CJR program and MACRA. Covered California is actively working to tie payment to outcomes, while Medi-Cal is considering implementing readmission measures. Plus, two important ballot initiatives have the potential to significantly impact your hospital’s bottom line.
Last year, the Centers for Medicare & Medicaid Services (CMS) finalized its Comprehensive Care for Joint Replacement (CJR) payment model. Starting April 1, the program will be mandatory for Los Angeles-Long Beach-Anaheim, Modesto and San Francisco-Oakland-Hayward hospitals that are not already participating in the bundled payment care initiative. In addition to the CJR Connect website, which CMS hopes to make available soon, the agency has scheduled a series of webinars aimed at helping providers prepare for the new program. Upcoming webinars, all scheduled for noon to 1 p.m. (PT), are March 10, focusing on quality measures and voluntary reporting; March 15, focusing on preparing for and key details about the program; and March 17, focusing on quality measures and quality composite scores.
Registration links for the webinars have been sent to primary points of contact at each affected CJR hospital but can also be obtained by contacting firstname.lastname@example.org. CJR program details — including model background documents, a list of hospitals and other materials — can be found at https://innovation.cms.gov/initiatives/cjr.
On March 1, the U.S. House of Representatives unanimously supported the Ensuring Access to Quality Medicaid Providers Act (H.R. 3716) to strengthen the Medicaid program. The legislation, also supported by the White House, would ensure that providers terminated from Medicare or a state Medicaid program for reasons related to fraud, integrity or quality are terminated from all other state Medicaid programs. It would also require state Medicaid programs that operate fee-for-service and/or primary care case management programs to include an electronic directory of physicians who served Medicaid patients in the prior year on the Medicaid program’s website. The Congressional Budget Office estimates the bill’s reforms would save $15 million by eliminating payments to fraudulent providers.
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.
The California Department of Health Care Services (DHCS) seeks private and district/municipal hospital volunteers for the second phase transition to a treatment authorization request (TAR) free process for fee-for-service Medi-Cal beneficiaries. To participate in the TAR-free process, hospitals must:
Utilize an evidence-based standardized utilization review (UR) criteria for acute inpatient hospital stays for any payer; and
Have the ability to provide DHCS electronic access to medical records and UR reviews/decisions.
In the TAR-free process, hospitals would no longer submit a TAR for most acute inpatient stays, and instead would utilize standardized medical review criteria — such as InterQual or Milliman Care Guidelines — to perform their own utilization review. DHCS would provide monitoring and oversight post-payment.
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.