Medi-Cal Update

Pharmacy | October 2019 | Bulletin 953

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1. Alternative Payment Option for Pharmacy Retroactive Payment Adjustments

Pursuant to California’s State Plan Amendment 17-002, as approved by the Centers for Medicare & Medicaid Services (CMS) on August 25, 2017, the Department of Health Care Services (DHCS) implemented a new fee-for-service reimbursement methodology for covered outpatient drugs on February 23, 2019. As was discussed during a statewide pharmacy stakeholder engagement on March 26, 2019, DHCS is operating under a federal mandate and must make retroactive rate adjustments for claims with dates of service between April 1, 2017 (policy effective date), and February 23, 2019 (system implementation date).

Medi-Cal Pharmacy providers experiencing hardship as a result of the retroactive adjustments may apply for an alternative payment arrangement through the Third Party Liability and Recovery Division (TPLRD) prior to the recommencement of retroactive payment adjustments in February 2020. All fee-for-service Medi-Cal Pharmacy providers who submitted pharmacy claims from April 1, 2017, through February 23, 2019, and that have outstanding balances due to DHCS over $1,500 are eligible to submit an application with required documentation (as delineated below) to TPLRD to be considered for an alternative payment arrangement.

Note:

Providers may estimate their total liability outstanding to DHCS by identifying the amount offset from the initial recoupment and multiplying that amount by 22 (the number of remaining months of claims from the retroactive period).

An online form for alternative payment arrangement applications will be open from October 28, 2019, through November 22, 2019. The online form will close on November 22, 2019. Applications will not be accepted after that time.Chain pharmacies must complete individual forms specific to each National Provider Identifier (NPI) for which they are seeking this arrangement.

All applicants must submit the following information via the online form:

Medi-Cal Pharmacy providers will receive additional information regarding this alternative payment arrangement via a mailer, to be sent to the provider mailing address on file in mid-October.

Providers may refer to the Pharmacy Reimbursement Project web page of the DHCS website for additional information regarding this project.

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2. Drug Onasemnogene Abeparvovec-xioi Requires Own SAR

Effective for dates of service on or after May 1, 2019, the drug onasemnogene abeparvovec-xioi is excluded from any California Children’s Services and Genetically Handicapped Persons Program (GHPP) Service Code Grouping (SCG). Therefore, providers must submit a separate Service Authorization Request (SAR) for the drug.

This information is reflected in the following provider manual(s):

Provider Manual(s) Page(s) Updated
Audiology and Hearing Aids
Chronic Dialysis Clinics
Clinics and Hospitals
Durable Medical Equipment
General Medicine
Home Health Agencies/Home and Community-Based Services
Inpatient Services
Local Educational Agency
Medical Transportation
Obstetrics
Orthotics and Prosthetics
Pharmacy
Psychological Services
Rehabilitation Clinics
Therapies
Vision Care
cal child sar (7, 8); genetic (11)
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3. Hospice Recipients are Eligible for End of Life Option Act Services

Medi-Cal would like to clarify that beneficiaries who have elected to receive hospice care are also eligible for End of Life Options Act services, including aid-in-dying drugs and medical services related to prescribing these drugs.

This information is reflected in the following provider manual(s):

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
eloa (2); hospic (11)
Hospice Care Programs
Inpatient Services
hospic (11)
Pharmacy
Psychological Services
eloa (2)
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4. Updated Medi-Cal Benefit for Cough Stimulating Device and Replacement Components

Prior to this update, HCPCS code E0482 (cough stimulating device, alternating positive and negative airway pressure) included both purchase and rental as a benefit for California Children’s Services (CCS)-enrolled recipients only.

Effective for dates of service on or after October 1, 2019, to align with Medicare policy, only monthly rental is allowed, and HCPCS code E0482 is reimbursable for all Medi-Cal recipients who meet the specified criteria. The item is considered purchased after 10 months of rental for the same recipient. Modifier NU (new equipment) is no longer allowed. Modifier RR (rental) or modifier RB (replacement as part of a repair) is required.

HCPCS code E0482 requires a Treatment Authorization Request (TAR) for monthly rental.

Effective for dates of service on or after October 1, 2019, HCPCS code A7020 (interface for cough stimulating device, includes all components, replacement only) is reimbursable for all Medi-Cal recipients who meet the specified criteria. Prior to this update, HCPCS code A7020 was reimbursable for CCS-enrolled recipients only.

This information is reflected in the following provider manual(s):

Provider Manual(s) Page(s) Updated
Durable Medical Equipment
Pharmacy
dura cd (13); dura cd ccs (1); dura oxy (1, 2, 32, 33)
Orthotics and Prosthetics
Therapies
dura cd (13); dura cd ccs (1)
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5. ESRD Pilot Project Extended for VillageHealth

The End Stage Renal Disease (ESRD) Pilot Project for VillageHealth has been extended through December 31, 2020. All existing billing instructions remain the same and are applicable to the participating provider.

The ESRD Pilot Project was established to accept and process claims for participating providers who meet the criteria for Medi-Cal secondary payments. This allows for payment of coinsurance and deductibles for dual-eligible recipients in a Medicare Advantage plan. VillageHealth is the only Medicare Advantage plan for which its providers meet the criteria for Medi-Cal secondary payments.

An Erroneous Payment Correction (EPC) will be implemented to reprocess affected claims.

This information is reflected in the following provider manual(s):

Provider Manual(s) Page(s) Updated
Acupuncture
Adult Day Health Care Centers
AIDS Waiver Program
Audiology and Hearing Aids
Chiropractic
Durable Medical Equipment
Expanded Access to Primary Care Program
Heroin Detoxification
Home Health Agencies/Home and Community-Based Services
Hospice Care Program
Inpatient Services
Local Educational Agency
Medical Transportation
Multipurpose Senior Services Program
Obstetrics
Orthotics and Prosthetics
Pharmacy
Psychological Services
Rehabilitation Clinics
Therapies
Vision Care
oth hlth (1)
Chronic Dialysis Clinics
Clinics and Hospitals
General Medicine
dial end (5); oth hlth (1)
Part 1 mcp spec (7); medicare (3)
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6. Updated MSRP Information Reorganized in DME Provider Manual

Durable Medical Equipment provider sections have been reorganized to include, but not limited to, the following:

This information is reflected in the following provider manual(s):

Provider Manual(s) Page(s) Updated
Adult Day Health Care Centers
Audiology and Hearing Aids
Clinics and Hospitals
Rehabilitation Clinics
dura spe (1–6)
Durable Medical Equipment dura (1, 5–7, 10, 11); dura bil (1–14); dura bil wheel (1, 4, 12, 13); dura cd (1, 2); dura cd ccs (1); dura inf (1–7); dura other (1–34); dura oxy (1–49); dura spe (1–6); dura thp (1–20); dura wheel guide (1)
Orthotics and Prosthetics
Therapies
dura cd (1, 2); dura cd ccs (1); dura spe (1–6)
Pharmacy dura (1, 5–7, 10, 11); dura bil (1–17); dura bil wheel (1, 4, 12, 13); dura cd (1, 2); dura cd ccs (1); dura inf (1–7); dura other (1–34); dura oxy (1–49); dura thp (1–24); dura wheel guide (1)
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7. Medi-Cal Celebrates Medi-Cal Subscription Service Milestone Achievement

The Department of Health Care Services (DHCS) is excited to announce that its Medi-Cal Subscription Service (MCSS) reached and surpassed 20,000 total subscribers as of September 2019.

DHCS first launched its new MCSS in December of 2012, and since that launch, it has witnessed steady growth each year in the volumes of providers and stakeholders who have joined up and officially subscribed to this free and tailored information-based notification service.

Since launching in 2012, DHCS has marketed its MCSS via informational flyers, online articles and at annual Provider Training Seminars throughout California. It’s at these seminars where MCSS representatives directly informed and assisted providers in signing up for the MCSS at the MCSS information booth.

DHCS has received an impressive array of positive and encouraging feedback from countless providers about the MCSS including their individual and satisfied experiences with this service each year.

The MCSS offers an array of provider communication notifications that subscribers can choose to receive including NewsFlash articles, Medi-Cal Update Bulletins and System Status Alerts (SSAs). In addition, each subscriber is able to tailor their individual MCSS experience by selecting only the provider communications and subject matters that interest them and pertain to their Medi-Cal business.

MCSS is a terrific way for providers and stakeholders to save time and ensure that they never miss important program updates and policy changes. The MCSS notifies subscribers the same day whenever the Medi-Cal program releases articles, bulletins and SSAs on the Medi-Cal website.

Providers who have not yet subscribed to the MCSS are encouraged to join this growing community of more than 20,000 subscribers and take full advantage of this free informational service. DHCS invites providers and other interested parties to subscribe today by completing the MCSS Subscriber Form located online.

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8. Get the Latest Medi-Cal News: Subscribe to MCSS Today

MCSS Logo

The Medi-Cal Subscription Service (MCSS) is a free service that keeps you up-to-date on the latest Medi-Cal news. Subscribers receive subject-specific emails shortly after urgent announcements and other updates post on the Medi-Cal website.

Subscribing is simple and free!

  1. Go to the MCSS Subscriber Form

  2. Enter your email address and ZIP code and select a subscriber type

  3. Customize your subscription by selecting subject areas for NewsFlash announcements, Medi-Cal Update bulletins and/or System Status Alerts

After submitting the form, a welcome email will be sent to the provided email address. If you are unable to locate the welcome email in your inbox, check your junk email folder.

For more information about MCSS, please visit the MCSS Help page.

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9. Provider Manual Revisions

Pages updated due to ongoing provider manual revisions:

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