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.
Hospitals can play an important role in reducing the number of uninsured through the Hospital Presumptive Eligibility (HPE) program. The HPE program will allow all hospital Medi-Cal providers — including any clinic on a hospital’s license — to provide potentially-eligible individuals with temporary, full-scope Medi-Cal benefits.