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.
According to a recent update from the Department of Health Care Services, 19 counties — representing nearly 75 percent of the Medi-Cal population — are currently approved to deliver Drug Medi-Cal Organized Delivery System (DMC-ODS) services. The DMC-ODS waiver is a voluntary pilot program that offers California counties the opportunity to expand access to care for Medi-Cal enrollees with substance use disorders.
Providers are reminded that they can now use their secure Medi-Cal login to view and download PDF versions of remittance advice details (RADs) and Medi-Cal financial summaries on www.medi-cal.ca.gov. RADs, along with their embedded financial summary information, are available online sooner than in paper versions. The site offers up to six calendar weeks of current RADs for immediate download. Historical RADs in PDF dating back to April 2017 are available on the Medi-Cal website; a larger database will be built over time. When complete, three years of historical RADs will be available within one business day of a request.
Providers may submit printed versions of the online RADs as supporting documentation with claims inquiry and appeal forms.
The Centers for Medicare & Medicaid Services (CMS) announced in the attached memo that its interpretive guidance for helping to reduce suicide and self-harm in health care facilities will include The Joint Commission’s ligature risk recommendations. CMS states in the memo that, until it releases its guidance, state survey agencies and accrediting organizations “may use their judgment as to the identification of ligature and other safety risk deficiencies, the level of citation for those deficiencies, as well as the approval of the facility’s corrective action and mitigation plans to minimize risk to patient safety and remedy the identified deficiencies.”
The American Society for Health Care Engineering, a professional membership group of the American Hospital Association, has created several tools and resources to help hospitals address ligature risk and patient safety.
New research indicates that the Medicaid program can play a key role in helping mothers and babies affected by the opioid crisis. According to a new report from Health Affairs, Medicaid covers roughly half of all births — and more than 80 percent of babies born with neonatal opioid withdrawal. The report identifies opportunities for further research, including evaluation of the causes of opioid use in pregnant and postpartum women as well as the evidence-based interventions designed to reduce that use. The report also identifies policy opportunities specific to pregnant and postpartum women, including:
Replacing criminal penalties, prosecution and incarceration with opioid treatment programs
Streamlining Medicaid enrollment processes to facilitate expedited access to routine prenatal care
Expanding workforce development to increase the number of clinicians trained to prescribe and provide medication assisted treatment, including nurse-midwives
CHA has been selected to serve on the California Department of Health Care Services (DHCS) Care Coordination Advisory Committee. The newly created committee will review the findings of DHCS’ systemic assessment of care coordination across the Medi-Cal delivery system and develop policy recommendations. DHCS’ assessment, conducted this year, evaluated the full spectrum of care coordination in Medi-Cal managed care: screenings, health assessments, case management, care management, data, transitions in care, communication, governance, training and monitoring through meaningful metrics. Each advisory committee meeting will address a specific aspect of care coordination.
The meetings begin in August and will continue through the end of October, when DHCS will draft a concept paper of proposed policy changes, vet the proposals with stakeholders and work to implement the changes. DHCS has indicated that this initiative will inform California’s section 1115(a) demonstration waiver renewal. California’s current waiver, titled “California’s Medi-Cal 2020 Demonstration,” expires Dec. 31, 2020. CHA will keep members apprised of developments on this initiative via CHA News and engage members on work related to the initiative via CHA’s centers and committees.
On Aug. 8 from 10-11 a.m. (PT), the Health Resources and Services Administration (HRSA) Office of Pharmacy Affairs will host a webinar to assist covered entities with the recertification process for the 340B drug savings program. All 340B hospitals are required to recertify between Aug. 12 and Sept. 12 to ensure they meet 340B hospital eligibility requirements. To participate in the webinar, visit https://hrsaseminar.adobeconnect.com/dpp_340b_pepi/ or call (800) 967-7154 and enter passcode 847321.
Participating hospitals should note that HRSA recently announced it may require additional information — specific to hospital eligibility documentation and contract pharmacy agreements — during the recertification process. In addition, HRSA has released best practices for covered entities when resolving non-compliance from contract pharmacies.
Under the federal Medicaid managed care final rule, states are required to establish network adequacy standards in Medicaid managed care for key types of providers. Beginning with the July 1, 2018, health plan contract year, states must:
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
Develop and implement timely access standards for long-term services and supports 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
To meet those requirements, the Department of Health Care Services (DHCS) earlier this month submitted four network adequacy certification documents to the Centers for Medicare & Medicaid Services. The results — which pertain to Medi-Cal managed care health plans (MCPs), mental health plans (MHPs), Drug Medi-Cal organized delivery systems (DMC-ODS) plans and dental managed care plans — are available on the department’s network adequacy web page.
The Department of Health Care Services has submitted its final Managed Care Quality Strategy Report to the Centers for Medicare & Medicaid Services. As previously reported in CHA News, DHCS developed this report as required under the federal Medicaid managed care final rule. The report addresses quality strategies across all of California’s Medicaid managed care delivery systems, including managed care plans, county mental health plans, Drug Medi-Cal Organized Delivery Systems and dental managed care plans. The report also discusses how California’s Medicaid quality strategy meets federal requirements related to:
The state-defined network adequacy standards
The state’s goals and objectives for continuous quality improvement, a description of the quality metrics, performance targets and performance improvement projects
Arrangements for annual, external independent reviews
A description of the state’s transition of care policy
The state’s plan to identify, evaluate and reduce health disparities
Policies regarding sanctions
The state’s definition of ‘‘significant change”
The final version incorporates feedback received during the public comment period and will be updated annually to reflect significant changes.
The Department of Health Care Services (DHCS) recently updated its policy for hospitals reimbursed under the All Patient Refined Diagnosis-Related Group (APR-DRG) for claims with dates of service in state fiscal year 2018-19.
Effective July 1, the following changes apply to general acute inpatient hospital services provided by private hospitals and non-designated public hospitals in California, out-of-state (border and non-border) hospitals and Medicare-designated critical access hospitals:
Changes to the APR-DRG grouping algorithm Version 34 to Version 35
Modifications to Version 35 relative weights under the hospital-specific relative value methodology
Decrease in the policy adjustor-age for pediatric services from 1.45 to 1.25
Application of the following policy adjustors for high severity of illness (SOI) 4:
Policy adjustor of 1.4 is additionally applied to the SOI 4 Pediatric (Age) and Neonate (NICU services and NICU surgery) care categories.
Policy adjustor 1.1 is additionally applied to SOI 4 Adult (Miscellaneous, Respiratory, Gastroenterology and Circulatory) and Obstetrics care categories.
Last week, the Department of Health Care Services announced that UnitedHealthcare Community Plan of California (UHC) will stop serving Medi-Cal members in Sacramento County beginning Oct. 31. The department has frozen enrollment in Sacramento County and, in coordination with UHC, will begin outreach to the approximately 4,400 Medi-Cal members impacted by the change. The outreach, to begin by Aug. 1, will provide information about other health plan choices and continuity of care, and assist enrollees in transitioning to a new plan. UHC will continue to provide Medi-Cal managed care services in San Diego County.
Phase 1 of the California Children’s Services Whole-Child Model was implemented on July 1. Senate Bill (SB) 586 (Chapter 625, Statutes of 2016) authorized the Department of Health Care Services (DHCS) to establish the Whole-Child Model (WCM) Program in designated County Organized Health System or Regional Health Authority counties. The WCM program incorporates services for Medi-Cal-eligible children and youth who are covered under the California Children’s Services (CCS) Program into a Medi-Cal managed care plan contract. The WCM Program is expected to improve care coordination for primary, specialty and behavioral health services for CCS and non-CCS conditions. The benefits are consistent with CCS program standards and provided by CCS paneled providers, specialty care centers and pediatric acute care hospitals. The WCM approach meets the six goals for CCS redesign:
Implement patient and family-centered approach.
Improve care coordination through an organized delivery system.
The Centers for Medicare & Medicaid Services (CMS) has announced new and enhanced initiatives on Medicaid program integrity aimed at creating greater transparency and accountability.
The initiatives include stronger audit functions, enhanced oversight of state contracts with private insurance companies, increased beneficiary eligibility oversight and stricter enforcement of state compliance with federal rules.
CMS will begin targeted audits of select states based on the amount spent on clinical services and quality improvement compared to administration and profit. The medical loss ratio audits will also include a review of states’ managed care rate setting.
To help providers understand and predict estimated payment for inpatient stays covered by fee-for-service Medi-Cal, the Department of Health Care Services (DHCS) has released a new pricing calculator. The calculator applies to stays with dates of admission beginning July 1, 2018, through June 30, 2019, and reflects new wage index values, hospital-specific base rates and other changes.
For stays with dates of admission prior to July 1, 2018, visit the DHCS web page. Providers should note that the calculator is intended to be a helpful tool, but cannot capture all editing and pricing complexity of the Medicaid claims processing system. If the calculator estimates a payment that differs from that of the claims processing system, the claims processing system is correct.
Last week, the Medicaid and Children’s Health Insurance Program (CHIP) Payment and Access Commission (MACPAC) released its June 2018 Report to Congress on Medicaid and CHIP. The report includes recommended statutory changes that would allow state Medicaid programs to pay the lowest price for certain drugs, as well as clarifications related to protecting the privacy of patients with substance use disorders. MACPAC’s recommendations seek to close a loophole in the Medicaid Drug Rebate Program that allows a manufacturer to sell its authorized generic at a low price to a corporate subsidiary, reducing the rebate obligation for its brand drug. In addition, MACPAC recommends giving the Secretary of the U.S. Department of Health and Human Services clear authority to impose intermediate financial sanctions on manufacturers that misclassify a brand drug as a generic to lower their rebate payments.
The Department of Health Care Services (DHCS) has announced that specific checkwrites scheduled for the last two weeks of the current fiscal year will be delayed until the start of the next fiscal year.
Medi-Cal funded fee-for-service programs scheduled with a warrant date of June 21 will be held until July 6. Checkwrites and payments to the following programs will be held during this period:
Child Health and Disability Prevention (CHDP) program
Family Planning, Access, Care and Treatment (Family PACT) Program
Medi-Cal (Medicaid and state-only)
Medi-Cal funded fee-for-service and state-funded programs scheduled for June 28 will be held until July 6. Checkwrites and payments to the following programs will be held during this time period:
California Children’s Services (Medi-Cal and state-only)
CHDP (Medi-Cal and state-only)
Family PACT Program
Genetically Handicapped Persons Program (Medi-Cal and state-only)
Medi-Cal (Medicaid and state-only)
Separate Children’s Health Insurance Programs, including:
Medi-Cal Access Program
Medi-Cal Access Infant Program
Due to increased program utilization, claim payments for May 24 and June 1 associated with the Every Woman Counts program have been delayed until June 7.
The Kaiser Family Foundation has released a new report that examines how potential changes at the federal level would impact participation in Medicaid, the Children’s Health Insurance Program (CHIP), marketplace coverage and other programs. The changes would, for the first time, allow the federal government to consider health, nutrition and non-cash programs — including use of Medicaid, CHIP and subsidies for marketplace coverage — when making public charge determinations.
According to the report, these changes could result in the federal government denying an individual a “green card” or adjustment to lawful permanent status or entry into the U.S. and would likely result in reduced participation in these programs — despite the fact that citizen children with a noncitizen parent would remain eligible. In 2016, there were 10.4 million citizen children with at least one noncitizen parent. The report illustrates the potential impact of different Medicaid/CHIP disenrollment rates and shows that, if the policy leads to disenrollment rates from 15 to 35 percent, an estimated 875,000 to 2 million citizen children with a noncitizen parent could drop Medicaid/CHIP coverage despite remaining eligible. Such coverage losses would reduce access to care, contributing to worse health outcomes.
Today, CHA joined a coalition — including California HealthPlus Advocates and the California HIV Alliance — in hosting a lobby action day to protect the 340B Drug Pricing Program. During the event, hospitals and safety-net providers that depend on the program met with key budget committee legislators and staff, as well as Assembly and Senate leadership, to share their opposition to the Department of Health Care Services’ budget proposal that would eliminate the program in Medi-Cal.
The event opened with a press conference (view slideshow) featuring Sen. Richard Pan (D-Sacramento) and representatives from safety-net providers that would be negatively impacted by the program’s elimination. During the conference, Sen. Pan stated that the proposed elimination of the program would represent a major “step backward” for the state’s vulnerable populations.
“The 340B Drug Discount program has been the source of important funds for hospitals and clinics to provide care for Californians on Medi-Cal. The state government needs to ensure these resources remain available for patient care,” said Pan.
The California Association of Public Hospitals and Health Systems and the California Health Care Safety Net Institute have developed an issue brief highlighting the efforts that California’s 21 public health care systems are undertaking to identify and reduce specific health disparities. Through the Public Hospital Redesign and Incentives in Medi-Cal (PRIME) program — a component of California’s Medi-Cal 2020 waiver — all health care systems are undertaking concurrent and harmonized efforts to improve the collection of race, ethnicity and language data and to begin compiling gender identity and sexual orientation data for the first time ever. The public health care systems have used that data as the foundation to identify disparities, as well as to develop and implement disparity reduction plans. The brief includes selected highlights and summaries of each public health care system’s disparity reduction plan, common themes in disparity efforts across systems, and a description of the PRIME project requirements.
Providers can now use their secure Medi-Cal login to view and download PDF versions of remittance advice details (RADs) and Medi-Cal financial summaries on www.medi-cal.ca.gov. RADs, along with their embedded financial summary information, are available online sooner than in paper versions. The site offers up to six calendar weeks of current RADs for immediate download. Currently, historical RADs in PDF, dating back to April 2017, are available on the Medi-Cal website; a larger database will be built over time. When complete, three years of historical RADs will be available within one business day of a request.
Providers may submit printed versions of the online RADs as supporting documentation with claims inquiry and appeal forms. More information is available in the attached flyer.
The Centers for Medicare & Medicaid Services (CMS) has released the attached informational bulletin describing its plans for enforcement of the Medicaid Home Health final rule. The rule expands coverage for medical supplies, equipment and appliances under the Medicaid (Medi-Cal) home health benefit. The rule was effective on July 1, 2016, but CMS delayed the compliance date for up to two years — based on state legislative cycles — recognizing that states are experiencing operational and budgetary issues as they implement the rule.
The bulletin states CMS’ intent to work with states on a case-by-case basis to provide flexibility for certain provisions of the rule. It also clarifies which provisions of the rule are not subject to enforcement flexibility. CMS asks states to contact it by May 31, 2018, to request flexibility.