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.
Reps. David B. McKinley (R-WV) and Mike Thompson (D-CA) have introduced House Resolution 4392, a bipartisan bill that would block cuts for hospitals that participate in the 340B Drug Pricing Program.
The bill would reverse the Centers for Medicare & Medicaid Services’ finalized proposal to cut payments by 28 percent — $1.6 billion — to certain hospitals for drugs purchased under the 340B program. In September, a majority of House members signed on to a letter opposing the cuts. In the California delegation, 28 members cosigned the letter.
Hospitals that benefit from the 340B program should ask their member of Congress to cosponsor the bill. To find contact information for your representative, visit www.house.gov/representatives/find.
The California Care Act ballot initiative was filed with the Attorney General’s office today. The Act would impose a 1 percent tax on the portion of taxable income over $1 million. The proceeds would be deposited into special funds in the state treasury — separate from the General Fund — and would be used to make payments to not-for-profit and health care district safety net hospitals and community health clinics, and to increase the availability of frontline health care workers in California. Payments to hospitals would be distributed according to the proportion of adjusted Medi-Cal patient days that an individual hospital provides.
Through these distributions, the Act intends to improve the health and well-being of communities and community members, and to generally support hospitals’ ability to offer quality, accessible care. The distributions would not be considered as reimbursement by any payer for services rendered, and the funding will not offset any other funding provided by any government entity. Proponents of the measure include officials from Service Employees International Union-United Healthcare Workers West.
A new state law, effective Jan. 1, 2018, requires hospitals and other providers of health care services rendered under Medi-Cal or any other California Department of Health Care Services health care program to keep records for at least 10 years. Specifically, Assembly Bill 1688 (Chapter 511, Statutes of 2017) requires providers to keep a record of each service rendered, the beneficiary or person to whom rendered, the date of service and any additional information that the Department of Health Care Services may require. These records must be maintained for 10 years from the final date of the contract period between the plan and the provider (for Medi-Cal managed care enrollees), from the completion date of any audit or from the date the service was rendered, whichever is later.
The new law effectively changes the length of time a provider must keep medical records of Medi-Cal patients. Currently, state law requires medical records of adults or emancipated minors to be retained for seven years; and for unemancipated minors, until the minor reaches age 19, but no fewer than seven years.
The Centers for Medicare & Medicaid Services has released national data on Medicaid and Children’s Health Insurance Program enrollment and eligibility activity by states for August 2017. According to the report, enrollment has increased by 16.4 million individuals, representing a 29 percent increase, since the baseline period prior to the start of the first marketplace open enrollment period (July – Sept. 2013). A total of 74,305,276 individuals were enrolled in all 50 states and the District of Columbia as of August 2017. The report is available online, along with previous monthly reports dating back to 2013.
The Department of Health Care Services (DHCS) has issued the attached All Plan Letter outlining Medi-Cal managed care health plans’ obligation to provide alcohol screening and intervention services. Existing policy requires plans to ensure that primary care providers screen members as part of routine care, including administering an individual health education behavioral assessment. According to DHCS, plans must cover and pay for expanded alcohol screening for members 18 years of age and older who answer “yes” to questions in the assessment that identify potential alcohol misuse. Plans are also required to cover and pay for behavioral counseling interventions for members who screen positively for risky or hazardous alcohol use or a potential alcohol use disorder.
The Senate Budget Subcommittee on Health and Human Services will hold an oversight hearing on Nov. 9 at 10 a.m. addressing adequate provider networks in Medi-Cal managed care. Titled “Achieving and Maintaining Adequate Provider Networks in Medi-Cal Managed Care,” the hearing will include a presentation from Department of Health Care Services on Medi-Cal managed care rate-setting and implementation of new state and federal requirements; a panel on Medi-Cal managed care organizations featuring representatives from several health plans; and a panel with responses from Medi-Cal providers and consumers. Jeff Conklin, vice president, payer and network strategies, Adventist Health, will represent CHA on the panel.
The hearing is also scheduled to include a public comment session. The agenda and speaker biographies are attached, and the committee will post a background document to its website later this week. In April, CHA participated on a panel before the subcommittee addressing several barriers that prevent access to care for Medi-Cal beneficiaries.
The U.S. House of Representatives today passed H.R. 3922, the Championing Healthy Kids Act of 2017, which would extend funding for the Children’s Health Insurance Program (CHIP) for five years. The bill also delays reductions to Medicaid disproportionate share hospital (DSH) payments currently scheduled for federal fiscal years 2018 and 2019. To compensate for the delay, the bill increases DSH cuts scheduled for 2020-24. The bill, which passed the House by a vote of 242-174, will move to the Senate where 60 votes are needed to pass it. Earlier this week, CHA sent a letter supporting the CHIP and Medicaid DSH provisions in this legislation to all members of the California delegation.
A new report from the Kaiser Family Foundation examines recent changes in Medicaid programs across 50 states and the District of Columbia, and highlights policies in place in fiscal year (FY) 2017 as well as those implemented or planned for FY 2018. Findings show that many states continue efforts to expand managed care, move ahead with payment and delivery system reforms, increase provider payment rates and expand benefits and community-based long-term services and supports, despite uncertainty about the program’s future at the federal level. Current trends include Medicaid expansion, continued reliance on provider taxes and managed care organization inclusion of complex populations and behavioral health services. The report also outlines anticipated trends for 2018, such as state waivers to impose premiums and restrict eligibility, growing adoption of Centers for Disease Control & Prevention prescribing guidelines for opioids, and a focus on housing and direct care workforce shortages.
The Centers for Medicare & Medicaid Services (CMS) has released a frequently asked questions document related to the Mental Health and Substance Use Disorder Parity Rule for Medicaid and the Children’s Health Insurance Program (CHIP). In the rule, CMS applied certain provisions of the Mental Health Parity and Addiction Equity Act to insurance coverage for people enrolled in Medicaid managed care organizations, alternative benefit programs and CHIP. The provisions ensure that financial requirements and treatment limitations on mental health and substance use disorder benefits generally are not more restrictive than the requirements and limitations that apply to medical and surgical benefits in these programs. The FAQs outline which benefits are subject to the parity analysis, how to document compliance and whether states should apply non-quantitative treatment limits in certain scenarios.
Provisions of a proposed rule released earlier this year have been finalized, delaying the effective date of the Health Resources and Services Administration final rule addressing ceiling prices and civil monetary penalties in the 340B Drug Pricing Program. The final rule is now scheduled to take effect July 1, 2018. The delay is intended to allow additional time to consider alternative and supplemental regulatory provisions and for additional rulemaking. As previously reported in CHA News, the final rule had been delayed on multiple occasions to allow time to more fully consider the substantial questions of fact, law and policy raised by the rule.
The Centers for Medicare & Medicaid Services (CMS) has updated its instructions for Worksheet S-10. The update, attached, clarifies definitions and instructions for uncompensated care, non-Medicare bad debt, non-reimbursed Medicare bad debt and charity care to include uninsured discounts. It also modifies the calculation relative to uncompensated care costs. The changes are effective for cost reporting years from Oct. 1, 2013, onward. CHA is currently reviewing the revisions and will provide members with more detail in the coming weeks.
In addition, CMS has extended the deadline for hospitals to revise and submit amended cost reports for federal fiscal years (FFY) 2014 and 2015 from Sept. 30 to Oct. 31. CHA urges members to review Worksheet S-10 of their FFY 2014 and 2015 cost reports and submit amendments to their respective Medicare administrative contractors before the Oct. 31 deadline. More information is available in the attached MLN Matters article.
The California Department of Health Care Services (DHCS) has issued frequently asked questions that detail how the Deferred Action for Childhood Arrivals (DACA) rescission at the federal level impacts Medi-Cal eligibility for existing DACA recipients in California. In its FAQ, DHCS clarifies that there will be no changes to the Medi-Cal coverage for DACA recipients (adults or children) in California. Under existing Medi-Cal policy, individuals in a deferred action status category continue to be eligible for state-funded, full scope Medi-Cal if they otherwise meet all other Medi-Cal program eligibility requirements. Therefore, individuals with DACA status will not have their health coverage impacted unless they have other changes in their eligibility status (e.g., increase in income, no longer residing in California, etc.).
The California Department of Health Care Services (DHCS) has issued a plan for transitioning Medi-Cal eligible patients, now served by three state developmental centers that the state is closing, into Medi-Cal managed care plans (MCPs). The state Department of Developmental Services (DDS) is in the process of closing Sonoma Developmental Center (DC), Fairview DC and General Treatment Area of Porterville DC. Some of the state’s most vulnerable individuals, who have unique and often complex medical needs, reside in the areas of these three DCs. DHCS and DDS are coordinating efforts to provide a smooth transition for these individuals.
DHCS, in collaboration with DDS, will assist beneficiaries in making a choice of managed care plan, when applicable, and maintaining services currently provided by the DCs. DHCS will work closely with managed care plans and DDS to continue medically necessary covered services by establishing transition requirements for contractors congruent with existing policies and procedures. DDS will work with the regional centers and DCs to provide services in accordance with each person’s individual program plan.
A new report from the Kaiser Family Foundation (KFF) analyzes recent congressional debate over the future of Medicaid, establishing lessons learned and outlining what to watch for as Congress returns to session. According to KFF, more than half of states have a strong stake in continuing the Affordable Care Act’s Medicaid expansion, which has provided coverage to millions of low-income residents and has broad support – particularly among the special populations that rely on the program.
Additionally, the report notes that financing caps through a block grant or per capita cap may not be a good deal for many states. Although most states favor enhanced flexibility, uncertain future health care costs and needs as well as variation across states make it difficult to implement a pre-set growth rate for Medicaid under a capped financing structure. Looking to the future, KFF anticipates further activity related to health care legislation, administrative actions and other initiatives, all of which might significantly impact the Medicaid program.
In a recent bulletin, the Centers for Medicare & Medicaid Services (CMS) announced it has authorized Noridian, California’s Medicare administrative contractor, to conduct the targeted probe and educate (TPE) pilot review process required for providers targeted by medical review. The TPE process includes three rounds of a prepayment probe review with provider education. If high denials continue after the first three rounds, Noridian will refer the provider and results to CMS. CMS will determine additional action, which may include extrapolation, referral to the zone program integrity contractor (ZPIC) or referral to recovery audit contractor.
If selected for this review, providers would not be excluded from other medical review activities, such as automated reviews, comparative billing reports, mandated demand bill reviews, other pilot review strategies as directed by CMS or other contractor reviews. Additionally, Noridian will continue to work with other CMS contractors and collaborate with referrals to quality integrity organizations for concern of quality care, ZPIC for concerns related to potential fraud/abuse, and recovery audit contractors for collaboration of vulnerability and to ensure no duplication of reviews.
The California Department of Public Health has issued the attached All Facilities Letter notifying certified Medicare and Medicaid nursing facilities that an updated California Minimum Data Set (MDS) 3.0 Section S form is now available. The form, which will take effect Oct. 1, reflects changes on the California Physician Orders for Life Sustaining Treatment form dated January 2016. MDS Section S completion is required for MDS comprehensive assessments, quarterly assessments, discharge assessments and tracking records. Facilities are not required to complete Section S for Medicare Part A prospective payment system assessments.
The Centers for Medicare & Medicaid Services’ (CMS’) federal fiscal year (FFY) 2018 inpatient prospective payment system final rule establishes changes to fund distribution for Medicare disproportionate share hospital (DSH) uncompensated care (UCC) payments. CMS determined that it will phase-in payments based on information collected from Line 30 on the S-10 Worksheet of the Medicare cost report to determine the UCC payment factor, starting with FFY 2014 cost reports for DSH UCC payments in FFY 2018.
As previously reported in CHA News, hospitals may submit revisions to Worksheet S-10 of their Medicare cost report for FFYs 2014 and 2015. CHA urges members to review Worksheet S-10 of their FFY 2014 and 2015 cost reports and submit amendments to their respective Medicare administrative contractors before the Oct. 31 deadline.
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.