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.
A three-judge panel of the U.S. Ninth Circuit Court of Appeals Monday released its decision that a 10 percent Medi-Cal outpatient fee-for-service rate cut, imposed by California from July 2008 through February 2009, was illegal because the state did not demonstrate that Medi-Cal patients’ access to services was equivalent to that of other patients. The 10 percent cut was replaced by a 1 percent cut in March 2009; in April of that year the Hospital Fee Program took effect, allowing hospitals to obtain reimbursement rates at or near the federal maximum.
CHA challenged the rate cut in 2008, and ultimately settled it as part of an overarching settlement involving other rate cases. However, a group of hospitals represented by a different law firm had separate litigation filed challenging the hospital outpatient rates, and continued with their case; these hospitals were deemed to have opted out of the CHA settlement. The case was sent back to the district court for further proceedings consistent with the Ninth Circuit’s opinion, which could range from issuing an order enjoining the state from implementing the rate cut to giving the government another opportunity to show that equal access existed. Regardless of the ultimate outcome, the decision is helpful to providers as it requires the state Medicaid agency to demonstrate equivalent access to care between Medi-Cal and other patients.
The Centers for Medicare & Medicaid Services (CMS) has released two new forms for providers’ use. The first form relates to electronic funds transfers, and is required to be completed by all Medicare Part A providers who are enrolling or revalidating, or who have changes to their employer identification number, pay-to address or legal business same. The second form released by CMS is an updated Advance Beneficiary Notice of Noncoverage; providers were required to begin using this form June 21. Any new notices submitted on the old form after June 21 will be considered invalid, and will result in provider liability if Medicare denies the claim.
Noridian, the Medicare administrative contractor for California, encourages providers to submit redetermination requests and associated documentation through its online portal, a faster option that also prevents requests from being dismissed for lack of signature. Additionally, providers may access decision letters immediately through the portal.
Noridian also announced that HMS Federal Solutions launched the new Region 4 recovery audit website, which provides information providers may use to prepare if selected as part of any new issue reviews.
On July 19, the California Department of Health Care Services (DHCS) finalized its Medicaid Managed Care Final Rule: Network Adequacy Standards. The document outlines California’s network standards that conform to the network adequacy provisions of the Medicaid managed care and Children’s Health Insurance Program (CHIP) managed care final rule, as well as DHCS’ approach and rationale for determining California’s standards. To strengthen access to services in a managed care network, the final rule requires states to establish network adequacy standards in Medicaid managed care for key types of providers, while giving states flexibility to set the actual standards. The final rule requires that states:
Develop and implement time and distance standards for primary and specialty care (adult and pediatric), behavioral health (adult and pediatric), OB/GYN, pediatric dental, hospital and pharmacy providers, and long-term services and supports (LTSS) that require the beneficiary to travel to the provider
Develop and implement timely access standards for LTSS for providers who travel to the beneficiary to provide services
Assess and certify the adequacy of a managed care plan’s provider network at least annually
The Centers for Medicare & Medicaid Services (CMS) has issued the attached proposed rule implementing reductions to Medicaid disproportionate share hospital (DSH) allotments, as required by the Affordable Care Act, beginning in federal fiscal year (FFY) 2018 through 2025. CMS proposes to establish the DSH Health Reform Methodology (DHRM) to generate a state-specific DSH allotment reduction. The proposal’s illustration of the DHRM’s impact reflects a reduction to California of more than $153 million for FFY 2018. CHA, along with the statewide DSH Task Force, will analyze the proposed rule and provide members with additional details in the coming weeks. Comments on the proposed rule are due Aug. 28.
Ways and Means Health Subcommittee Chairman Pat Tiberi (R-OH) has announced a new initiative to reduce legislative and regulatory burdens on Medicare providers. The “Provider Statutory & Regulatory Relief Initiative” will consist of three stages: receiving feedback from stakeholders, hosting roundtables with stakeholders across the country and taking congressional action based on stakeholder feedback.
The committee requests feedback from doctors, nurses, clinicians and health care professionals on how Congress can both deliver statutory relief from current mandates and work with Health and Human Services Secretary Tom Price, MD and Centers for Medicare & Medicaid Services Administrator Seema Verma to deliver regulatory relief through administrative action.
CHA will submit comments and encourages hospital members to do so as well. To submit comments by the Aug. 25 deadline, complete the attached form and send it to WMProviderFeedback@mail.house.gov.
The California Department of Health Care Services (DHCS) has announced it will submit State Plan Amendment (SPA) 17-030 to the Centers for Medicare & Medicaid Services (CMS) to authorize a time-limited supplemental payment program for selected physician services. These services include new and established patient office/outpatient visits, psychiatric diagnostic evaluations, psychiatric diagnostic evaluation with medical services and psychiatric pharmacological management services. The supplemental payment amounts are fixed and will be paid per claim, according to the current procedural terminology (CPT) codes below:
99202, 99212, 99213
99203, 99204, 99214, 99215
The payments are being made through the California Healthcare, Research and Prevention Tobacco Tax Act (Proposition 56), which increases the excise tax rate on cigarettes and tobacco products. Under Prop. 56, a specified portion of the tobacco tax revenue is allocated to DHCS for the nonfederal share of health care expenditures in accordance with the annual state budget process.
Manatt Health has developed a report for the California Health Care Foundation examining the impact proposed financing changes would have on Medi-Cal, the state’s Medicaid program. Developed in response to the per capita cap proposed under the Senate’s Better Care Reconciliation Act, the report finds:
California is projected to lose $37.6 billion in federal funding between fiscal years 2020 and 2027.
The actual impact will depend on the trend rates for the cap. If they turn out to be even slightly lower than expected, cuts will compound quickly.
A cap locks California into its relatively low Medi-Cal spending levels and puts the state at risk for unexpected health care costs.
A cap would pose major operational issues for California, including the need to make Medi-Cal and budget decisions prior to knowing the amount of federal funds available to the state.
To compensate for such a cap, the state will need to raise taxes, cut other programs, significantly reduce Medi-Cal expenditures or implement some combination of all of these measures.
The California Health Care Foundation has released data on Medi-Cal enrollment of seniors and people with disabilities, who represent about 15 percent of the program’s nearly 14 million enrollees. The data provide a county-by-county overview of enrollment and reflect variation ranging from 65 people in Alpine County to 637,304 in Los Angeles County. The program covers half of all Californians with disabilities, as well as close to a quarter of the state’s seniors.
Medi-Cal enrollees with disabilities include those with conditions such as multiple sclerosis, epilepsy and blindness; HIV/AIDS; spinal cord and traumatic brain injuries; disabling mental health conditions such as depression and schizophrenia; intellectual and developmental disabilities such as Down syndrome and autism; and other functional limitations. The program’s long-term care for seniors covers three of five nursing home residents in the state.
The California Health Care Foundation has released a report illustrating the breadth of Medi-Cal coverage — and the benefits of that coverage — to the program’s nearly 14 million Medi-Cal members across the state. The report’s sources include the California Health Interview Survey; studies by the Kaiser Family Foundation, Bay Area Economic Institute, and New England Journal of Medicine; local Medi-Cal managed care plan data; and more.
Key facts include:
62 percent of those covered by Medi-Cal are families with children.
Medi-Cal covers more than one in five California seniors and one in two people with disabilities.
Medi-Cal covers three in five nursing facility residents.
Two in three adult Medi-Cal members are in the labor force.
Nearly 80 percent of Californians with Medi-Cal report having a usual source of care (vs. 52 percent of the uninsured).
Californians with Medi-Cal are 38 percent more likely to receive routine checkups than the uninsured.
A new report from the California Health Care Foundation (CHCF) examines physician participation in Medi-Cal and whether supply is meeting demand. According to CHCF, the report’s findings support the conclusion that Medi-Cal provides a vital safety net to low-income Californians — and that further investments and improvements are needed to ensure adequate access to care for all beneficiaries. Based on self-reported data from physicians, findings include:
Primary care physicians in California were more likely to serve Medi-Cal patients than uninsured patients, but less likely to have Medi-Cal patients in their practices than patients with private health insurance.
Non-primary care physicians were more likely to serve Medi-Cal patients than uninsured patients, but less likely to have Medi-Cal patients in their practices than patients with either Medicare or private insurance.
Rates at which physicians accept new Medi-Cal patients and uninsured patients varied across specialties, practice settings, and regions.
The California Department of Health Care Services (DHCS) has issued an analysis of the Better Care Reconciliation Act (BCRA) that found a drastic shift in responsibilities and health care costs from the federal government to the state. The analysis found that the BCRA would add nearly $3 billion in costs to the state in 2020, with the annual cost growing to $30.3 billion by 2027. The cumulative cost to the state from 2020 through 2027 would total an estimated $114.6 billion, with a $92.4 billion impact to the state’s General Fund. The report notes that increased costs would require the state to consider reductions in services and coverage to the Medi-Cal population. The full analysis is available on DHCS’ website.
The California Health Care Foundation and UC Berkeley’s Institute of Governmental Studies have conducted a statewide survey to assess Californians’ attitude about the Affordable Care Act (ACA), Medi-Cal, and health insurance coverage of treatment for mental health and substance use disorders. The data are broken down by region, age, race, gender and income. Overall findings include:
More than half (56 percent) of Californians worry that they or a family member will lose coverage if the ACA is repealed and replaced.
Support for the ACA is at a record-high 65 percent.
Medi-Cal is recognized as an important program by 88 percent of Californians, spanning the state’s regions and political parties.
Three in four Californians believe that coverage for mental health and substance use disorder services is very important, and that this treatment can help people lead healthy and productive lives.
The Kaiser Family Foundation has released the attached issue brief analyzing which states are most at risk from the American Health Care Act (AHCA) proposal to end enhanced federal matching funds for Medicaid expansion, established as part of the Affordable Care Act (ACA). The proposal would cap – and significantly reduce – the amount of federal funding states receive for Medicaid through a per capita cap or block grant. According to the Congressional Budget Office, the AHCA as passed by the House would reduce federal Medicaid spending by $834 billion from 2017-26, and reduce enrollment by 14 million by 2026; the Trump Administration’s proposed budget would further reduce Medicaid spending. While all states would face challenges related to these cuts, states with limited Medicaid programs, poor health status, high cost markets or low state fiscal capacity would have the most difficulty responding to per capita cap or block grant policies. The brief finds that in states that expanded Medicaid coverage post-ACA, such as California, a scaling back or elimination of expansion coverage is likely.
Earlier this month, the Centers for Medicare & Medicaid Services (CMS) approved 15 applications for Whole Person Care (WPC) pilot projects, authorizing seven new pilots and expanding eight that were previously approved. The WPC pilot program — developed under California’s section 1115(a) demonstration waiver, titled “California’s Medi-Cal 2020 Demonstration” — is intended to provide locally based comprehensive care to particularly vulnerable Medi-Cal members. The pilots aim to coordinate physical health, behavioral health and social services in a patient-centered manner, improving the health and well-being of Medi-Cal members who are high users of multiple health systems and continue to have poor health outcomes. For a list of CMS’ approved WPC pilot projects for the first and second rounds, and for more information about the program, please visit the Department of Health Care Services website.
The California Budget & Policy Center has released a new fact sheet that offers updated and in-depth data on Medi-Cal coverage in every California county. Using California Department of Health Care Services data, the analysis provides Medi-Cal enrollment by age, enrollment as a share of the total statewide population and each county’s ranking by Medi-Cal enrollment. Medi-Cal provides health care services to more than 13 million low-income Californians who live in all 58 counties. Of the 10 counties with the highest share of residents enrolled in Medi-Cal, six are in the San Joaquin Valley: Tulare (54.8 percent), Merced (50.9 percent), Fresno (49.9 percent), Kern (45.9 percent), Stanislaus (45.1 percent) and Madera (45.1 percent).
The California Department of Health Care Services (DHCS) has released the attached All Plan Letter providing guidance to Medi-Cal managed care health plans on non-emergency medical transportation (NEMT) and non-medical transportation (NMT) services, pursuant to AB 2394 (Chapter 615, Statutes of 2016). AB 2394 provides that, effective July 1, 2017, NMT for a Medi-Cal managed care plan member seeking Medi-Cal medical, dental, mental health or substance use disorder services is covered, subject to utilization controls and permissible time and distance standards. The APL outlines the requirements for NEMT, NEMT physician certification forms, NMT, conditions for NMT services, NMT private vehicle authorization requirements, NMT authorization, and the NMT and NEMT access standards. The full All Plan Letter is attached. All DHCS All Plan Letters are available on the DHCS website.
The Kaiser Family Foundation has released an issue brief highlighting 10 facts about Medicaid, the public health insurance program that covers one in five Americans – including many with complex and costly needs for medical care and long-term services. The program is designed to support low-income children, adults, seniors and people with disabilities, many of whom would be underinsured or uninsured without it. The report examines Medicaid’s cost-effectiveness in providing health care coverage at a lower per-person cost than private insurance could. The report acknowledges that Medicaid keeps coverage and care affordable for low-income Americans – and in effect bolsters the private insurance market by acting as a high-risk pool. The report notes that more data on Medicaid’s impact on health outcomes are becoming available, and initial results indicate that not only does Medicaid improve access to care for both children and adults with low income, but it also may be associated with significant reductions in mortality.
The Centers for Medicare & Medicaid Services (CMS) has extended the deadline for program year 2016 attestations for the Medi-Cal Electronic Health Record Incentive Program to May 23. Because CMS’ website is non-operational as of April 28, expected to continue through May 2, the California Department of Health Care Services (DHCS) requested an extension for all providers. According to DHCS, hundreds of providers in California have yet to attest for 2016. Providers wishing to attest for program year 2017 must wait until 2016 attestations close; 2017 attestation may not be available until May 24. Questions should be directed to firstname.lastname@example.org or (916) 552-9181.