Medi-Cal Logo

Medi-Cal Update

General Medicine | January 2021 | Bulletin 559

Print Medi-Cal Update Print Icon

1. DHCS Announces New Program to Enhance Hospital Capacity Amid COVID-19 Surge

On November 25, 2020, the Centers for Medicare & Medicaid Services (CMS) announced an expansion of the Hospital Without Walls initiative to include the Acute Hospital Care at Home program. The intent of this program is to increase hospital capacity by allowing patients to be seen outside of a traditional hospital setting, while also protecting patients to ensure that they are treated appropriately and safely in at-home settings during the COVID-19 public health emergency.

The Acute Hospital Care at Home program clearly differentiates the delivery of acute hospital care at home from more traditional home health services, which provides skilled nursing and other skilled care services at a beneficiary’s home. In contrast, the Acute Hospital Care at Home program is for patients who require acute inpatient admission to a hospital and require at least daily rounding by a physician and a medical team monitoring their care needs on an ongoing basis. Acute Hospital Care at Home services provide health care to acutely ill patients in their homes by using methods that include telehealth, remote monitoring, and regular in-person visits by nurses. Hospitals interested in this program need to apply directly with CMS for the waiver at the Acute Hospital Care at Home Individual Waiver webpage to submit the necessary information to ensure they meet the program’s criteria to participate. CMS will closely monitor the program, to safeguard beneficiaries, by requiring hospitals to report quality and safety data to CMS on a frequency that is based on their prior experience with the Hospital At Home model.

General acute care hospitals (GACH) are required to coordinate with the California Department of Public Health (CDPH) to operate under the state's emergency preparedness or pandemic plan during this PHE to help meet surge needs in their community. Hospitals must meet state licensure requirements for GACHs and receive program flexibility from CDPH for any requirement that will be met using an alternative method as indicated under the Program Flex heading. In addition to receiving approval from CMS, a hospital seeking to offer acute hospital care at-home services may not begin providing this service until it has also received approval from CDPH.

Medi-Cal will pay hospitals for acute inpatient care in both fee-for-service and managed care for Medi-Cal beneficiaries who receive care under this program. Managed care plans (MCPs) must authorize and reimburse hospitals providing inpatient acute care services at-home through the Acute Hospital Care at Home program at the same rate they would if the services were provided in a traditional hospital setting. DHCS will reimburse fee-for-service care as if the services were provided in a traditional hospital setting, following current payment authorization processes and reimbursement methodologies.

For Medi-Cal enrolled hospitals participating in the program, MCPs are responsible for knowing each participating hospital’s waiver authorities and for authorizing members to receive acute care inpatient services at home as medically appropriate. MCPs are responsible for tracking each hospital’s approved waiver. MCPs are responsible for ensuring that their subcontractors and network providers comply with all applicable state and federal laws and regulations, contract requirements, and other DHCS guidance, including APLs and policy letters. Each MCP must communicate these requirements to all subcontractors and network providers.

Currently, CMS has approved Adventist Health for Hospital at Home services in California for hospitals located in Bakersfield, Glendale, Ukiah and Simi Valley. Additionally, Adventist Health is awaiting federal approval for hospitals in Boyle Heights and Marysville. In addition, the University of California, Irvine Health is in the process of applying to CMS and CDPH for the program.

Providers are also encouraged to review All Facility Letter 20-90, published by the CDPH, for program flexibility requirements before providing acute Hospital Care at Home services. DHCS will publish additional information on the DHCS COVID-19 Response webpage and the All Plan Letters webpage in the future regarding program operations and approved providers of the Acute Hospital Care at Home services.

For additional COVID-19 information and resources, we encourage you to review the following resources:

2. Infectious Agent Antigen Detection by Immunoassay is a Medi-Cal Benefit

Effective for dates of service on or after November 10, 2020, CPT® code 87428 (infectious agent antigen detection by immunoassay technique, [eg, enzyme immunoassay (EIA), enzyme-linked immunosorbent assay (ELISA), fluorescence immunoassay (FIA), immunochemiluminometric assay (IMCA)] qualitative or semiquantitative; severe acute respiratory syndrome coronavirus [eg, SARS-CoV, SARS-CoV-2 (COVID-19)] and influenza virus types A and B) is a Medi-Cal benefit.

The frequency limit for code 87428 is once per day, any provider, per patient. Code 87428 is reimbursable for Presumptive Eligibility for Pregnant Women (PE4PW) services.

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

Code 87428 is exempt from the 10 percent payment reductions in the Welfare and Institutions (W&I Code) section 14105.192, as described at Attachment 4.19-B, page 3.3, paragraph 13 of the State Plan.

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Obstetrics
path micro (10); presum bill (6)
Pharmacy presum bill (6)

3. Infectious Agent Antigen Detection by Immunoassay Tests are CLIA-Waived

The following tests are considered to be Clinical Laboratory Improvement Amendments (CLIA)-waived when performed with a CLIA-waived test kit:

CPT® Code Effective Date Description
87428 For dates of service on or after November 10, 2020 Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], fluorescence immunoassay [FIA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative; severe acute respiratory syndrome coronavirus (eg, SARS-CoV, SARS-CoV-2 [COVID-19]) and influenza virus types A and B
87811 For dates of service on or after October 6, 2020 Infectious agent antigen detection by immunoassay with direct optical (ie, visual) observation; severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19])

These codes may be billed with modifier QW to be recognized as a waived test.

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

Provider Manual(s) Page(s) Updated
Chronic Dialysis Clinics
Clinics and Hospitals
General Medicine
Obstetrics
path bil (11, 12)

4. Rates Are Updated for CPT COVID-19 Testing Codes 87636, 87637 and 87811

Effective for dates of service on or after October 6, 2020, the rates for CPT® codes 87636 (infectious agent detection by nucleic acid [DNA or RNA]; severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2] [coronavirus disease (COVID-19)] and influenza virus types A and B, multiplex amplified probe technique), 87637 (infectious agent detection by nucleic acid [DNA or RNA]; severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2] [coronavirus disease (COVID-19)], influenza virus types A and B, and respiratory syncytial virus, multiplex amplified probe technique) and 87811 (infectious agent antigen detection by immunoassay with direct optical [ie, visual] observation; severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2] [coronavirus disease (COVID-19)]) are updated.

Codes Description Medicare Rate
87636 Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) and influenza virus types A and B, multiplex amplified probe technique $142.63
87637 Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), influenza virus types A and B, and respiratory syncytial virus, multiplex amplified probe technique $142.63
87811 Infectious agent antigen detection by immunoassay with direct optical (ie, visual) observation; severe acute respirator syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) $41.38

The codes above are exempt from the 10% payment reductions in Welfare and Institutions (W&I) Code section 14105.192, as described in Attachment 4.19-B, page 3.3, paragraph 13 of the State Plan.

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

5. 2021 Quarter 1 HCPCS Updates Not Yet Adopted

The 2021 Quarter 1 updates to the Healthcare Common Procedure Coding System (HCPCS) Level II codes are effective for Medicare on January 1, 2021. However, due to a delay caused by the coronavirus disease 2019 (COVID-19), Medi-Cal is not able to adopt the updates in time to publish the associated policy in the January Medi-Cal Update.

Providers should not use the 2021 Quarter 1 HCPCS Level II codes to bill for Medi-Cal or Presumptive Eligibility for Pregnant Women (PE4PW) services until notified to do so in a future Medi-Cal Update.

6. Teprotumumab-trbw is a New Medi-Cal Benefit

Effective for dates of service on or after October 1, 2020, HCPCS code J3241 (Injection, teprotumumab-trbw, 10 mg) is a Medi-Cal benefit. An approved Treatment Authorization Request (TAR) is required for reimbursement.

No action is required of providers. An Erroneous Payment Correction (EPC) will be implemented to reprocess affected claims.

Provider Manual(s) Page(s) Updated
Chronic Dialysis Clinics
Clinics and Hospitals
General Medicine
Obstetrics
Pharmacy
Rehabilitation Clinics
inject cd list (22); inject drug s-z (11,12)

7. Automated Form Completion Now Available: POS Network/Internet Agreement

The Medi-Cal Point of Service (POS) Network/Internet Agreement form is now available electronically. The DocuSign application form will be accessible from the initial page of the Transaction Services log-in page of the Medi-Cal Provider website.

Providers must have this form on file for a variety of reasons, including downloading PDF versions of the Remittance Advice Details and submitting POS, Computer Media Claims (CMCs) and Real-Time Internet Pharmacy claim transactions.

Other uses of the POS Network/Internet agreement are included in the Transaction Enrollment Requirements chart.

Providers who submit their POS Network/Internet agreement form electronically will have the agreement processed more quickly and save on envelope and postage costs.

The paper version of the Medi-Cal Point of Service (POS) Network/Internet Agreement form will still be available. Providers can request a hard copy agreement form from the Telephone Service Center (TSC) at 1-800-541-5555 or print the form from the Medi-Cal Provider website Forms page, under the “Billing (CMC, EFT Payments, Hardcopy & POS” heading. TSC is available from 8 a.m. to 5 p.m., Monday through Friday, except national holidays. Border providers and Out-of-State billers billing for in-state providers call (916) 636-1200.

Provider Manual(s) Page(s) Updated
Part 1 claim sub (2); tar (7)
Family PACT tar (1)
Pharmacy compound comp (1); pcf30-1 comp (2); pcf30-1 spec (3)

8. Policy Updates for Selected Injection HCPCS Codes

Effective for dates of service on or after February 1, 2021, policy for HCPCS codes J0490 (injection, belimumab, 10 mg), J1335 (injection, ertapenem sodium, 500 mg) and J2182 (injection, mepolizumab, 1 mg) have been updated.

HCPCS code J0490 has been approved for treatment of Systemic Lupus Erythematosus (SLE) for children 5 years of age and older. HCPCS code J1335 is now a benefit. HCPCS code J2182 has been approved for children 6 to 11 years of age with severe eosinophilic asthma.

9. Alcohol or Substance Misuse Assessments No Longer Medi-Cal Benefits

Effective for dates of service on or after February 1, 2021, HCPCS codes G0396 (alcohol and/or substance [other than tobacco] misuse structured assessment [e.g., AUDIT, DAST], and brief intervention 15 to 30 minutes), G0397 (alcohol and/or substance [other than tobacco] misuse structured assessment [e.g., AUDIT, DAST], and intervention, greater than 30 minutes) and G2011 (alcohol and/or substance [other than tobacco] misuse structured assessment [e.g., audit, DAST], and brief intervention, 5 to 14 minutes) are no longer Medi-Cal benefits.

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Obstetrics
non ph (10, 25); presum bill (13, 15)
Pharmacy presum bill (13, 15)
Rehabilitation Clinics non ph (10, 25)

10. Updates to Billing Policy for Lanreotide

Effective for dates of service on or after February 1, 2021, policy has been updated for HCPCS code J1930 (injection, lanreotide, 1 mg). Code J1930 is for the treatment of patients 18 years of age and older. A Treatment Authorization Request (TAR) is no longer required for reimbursement.

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Obstetrics
Rehabilitation Clinics
inject cd list (14); inject drug i-m (16, 17); modif used (13); non ph (14, 28)
Chronic Dialysis Clinics inject cd list (14); inject drug i-m (16, 17); modif used (13)
Pharmacy inject cd list (14); inject drug i-m (16, 17)

11. Update to Age Limit for Preventive Medicine Services

Effective for dates of service on or after February 1, 2021, the Current Procedural Terminology (CPT®) codes 99385 (Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; 18–39 years) and 99395 (Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; 18–39 years) has an updated age range of 18 through 20 years of age instead of 18 through 21 years of age as written in parts of the provider manual.

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Obstetrics
eval (16)

12. Billing Assistance Program Available to Medi-Cal Providers

The Small Provider Billing and Training Program is a free, full-service program offered to providers who submit fewer than 100 Medi-Cal claim lines per month and who are not conducting business with an outside billing service or agency. In this program, Claim Specialists and Regional Field Representatives work directly with providers during the 12-month structured program assisting providers with completing and submitting their Medi-Cal claims.

If you are interested in learning more about Medi-Cal billing and want for more information on how to enroll in the Small Provider Billing Assistance Unit (SPBU) and Training Program, call the SPBU at 1-916-636-1275 or contact the Telephone Service Center (TSC) at 1-800-541-5555 from 8 a.m. to 5 p.m., Monday through Friday, excluding holidays.

13. Updated Policy Effective Date for Billing Immune Globulins

The below article, originally published October 6, 2020, has been corrected to remove Xembify from the list of immune globulins billable with CPT code 90284.

Superseding communication from the Department of Health Care Services (DHCS) in the July 2020 General Bulletin, new changes are introduced for billing and claims submission of various HCPCS Level II and Current Procedural Terminology (CPT®) codes for Physician Administered Drugs (PAD).

As part of ongoing efforts to ensure consistency and accuracy in billing and provider reimbursements, providers must note the following when submitting claims for specific biologicals and drugs.

Preferred Codes for Billing Biologicals With Both CPT and HCPCS Codes:

The biologicals below are billed with both CPT and HCPCS codes. The HCPCS codes are often more specific than the CPT codes. Now effective for dates of service on or after October 1, 2019, for reimbursement, providers must submit claims for the listed CPT codes using the corresponding HCPCS codes as shown in the table below:

Procedure Codes Procedure Descriptions Code(s) to Bill with
90281 Immune globulin (Ig), human, for intramuscular use J1460 or J1560
90283 Immune globulin (IgIV), human, for intravenous use J1459, J1556, J1557, J1561, J1566, J1568, J1569, J1572 or J1599
90284 Immune globulin (SCIg), human, for use in subcutaneous infusions, 100 mg, each Bill J1555 (Cuvitru) & J1559 (Hizentra)

Continue to bill 90284 for all other immune globulins used for subcutaneous infusions
90291 Cytomegalovirus immune globulin (CMV-IgIV), human, for intravenous use J0850
90384 Rho(D) immune globulin (RhIg), human, full-dose, for intramuscular J2790 or J2791
90385 Rho(D) immune globulin (RhIg), human, mini-dose, for intramuscular use J2788
90386 Rho(D) immune globulin (RhIgIV), human, for intravenous use J2791 or J2792
90389 Tetanus immune globulin (TIg), human, for intramuscular use J1670

Providers may continue to bill for Gammagard liquid, Gammaked, Gammunex-C and Cutaquig with CPT code 90284.

Cuvitru must be billed with J1555 and Hizentra with J1559.

Processes for Rebilling and Payment Correction of Rho (D) Immune Globulins for Dates of Service On or After October 1, 2019 to August 31, 2020 for Providers Who Billed With CPT Codes and Were Denied or Underpaid:

For providers who previously billed with CPT codes 90384 and 90385 and claims were denied:

  • Rebill with the corresponding J codes as indicated in the table above.

    • It is not necessary to submit a Treatment Authorization Request (TAR).

    • This ensures that providers are reimbursed at the full Medi-Cal rate available.

      • If rebill is submitted beyond the 6-month billing limitation, timeliness of the rebill is waived.

For providers who billed with CPT codes 90384 and 90385 and were reimbursed only the injection administration fee of $4.46:

  1. Submit a Claims Inquiry Form (CIF) to void the claim billed with the CPT code.
    • There is no time restriction on this process.

    • When completing the CIF, providers must enter the information exactly as it appears on the Remittance Advice Details (RAD) to ensure the claim is located within the claims processing system.

  2. Rebill using the corresponding J code as indicated in the table above for appropriate reimbursement following the void of the CPT code.

    • These steps ensure that providers are paid at the full Medi-Cal rate available.

    • It is not necessary to submit a TAR.

      • If rebill is submitted beyond the 6-month billing limitation, timeliness of the rebill is waived.

Instructions regarding the submission of CIF can be found here in the Billing Basics Outreach & Education workbook.

Erroneous Payment Correction (EPC) for Dates of Service from August 1, 2020 to August 31, 2020

  • EPCs are processed for all claims billed with J-codes, which were inappropriately denied for dates of service from August 1, 2020, to August 31, 2020.

    • EPCs are processed automatically. No action is required on the part of providers.

14. System Issue Resolved for Electronic Void/Replace Block-Billed Claims

The Department of Health Care Services (DHCS) announced in November 2020 that outpatient and medical providers were receiving a Computer Media Claims (CMC) reject error message “001” (CMC replacement/void claim cannot be billed with multiple claims), when submitting a block-billed or from-through electronic claim and using frequency code “7” (replacement of prior claim) or claim frequency code “8” (void) on previously paid claims. The system issue has now been resolved.

15. Monthly Six Prescription Limit and Pharmacy Copay are Terminated

On May 13, 2020, in light of the coronavirus disease 2019 (COVID-19) pandemic and pursuant to federally approved State Plan Amendment 20-0024, the Department of Health Care Services (DHCS) temporarily suspended the monthly six prescription (6 Rx) per beneficiary limit outlined in Welfare and Institutions Code (W&I Code), Section 14133.22, until further notice. The 2020 Budget Health Omnibus Trailer Bill – AB 80/SB 102 made that change permanent along with the elimination of the one-dollar pharmacy copay. Therefore, effective January 1, 2021, the monthly 6 Rx per beneficiary limit and the one dollar pharmacy copay will be permanently eliminated.

16. Medi-Cal List of Contract Drugs: COVID-19 Vaccines Pfizer-BioNTech and Moderna Added

The following provider manual sections have been updated with Corona Virus Disease 2019 Vaccines: Drugs: Contract Drugs List Part 1 – Prescription Drugs and Drugs: Contract Drugs List Part 4 – Therapeutic Classifications.

A summary of drug that has been added is shown below. For additional information, click on the link to the manual section and scroll to the page indicated or use the find feature to search for the particular drug.

Added Drug(s)
Effective Date Drug Summary of Changes Page(s) Updated
December 11, 2020, and December 18, 2020 Corona Virus Disease 2019 Vaccine Drug added, administration added, restriction added drugs cdl p1a (73),
drugs cdl p4 (29)

17. Medi-Cal List of Contract Drugs

The following provider manual section(s) have been updated: Drugs: Contract Drugs List Part 1 – Prescription Drugs and Drugs: Contract Drugs List Part 4 – Therapeutic Classifications.

A summary of drugs that have been added or changed is shown below. For additional information, click on the link to the manual section and scroll to the page indicated or use the find feature to search for the particular drug.

Effective Date Drug Summary of Changes    Page(s) Updated
January 1, 2021 Insulin Aspart (Niacinamide) Drug added, administration added, restriction added drugs cdl p1b (63),
drugs cdl p4 (23)
January 1, 2021 Insulin Degludec Drug added, administration added, restriction added drugs cdl p1b (64),
drugs cdl p4 (23)
January 1, 2021 Insulin Detemir Drug added to part 4 only, Restrictions added and removed drugs cdl p1b (64),
drugs cdl p4 (23)
January 1, 2021 Lasmiditan Succinate Drug added, administration added, restriction added drugs cdl p1b (78),
drugs cdl p4 (14)
January 1, 2021 Liraglutide Drug added, administration added, restriction added drugs cdl p1b (87),
drugs cdl p4 (23)
January 1, 2021 Methylphenidate HCl Drug added, administration added, restriction added drugs cdl p1b (104),
drugs cdl p4 (18)
January 1, 2021 Pancrelipase Drug added, administration added, restriction added drugs cdl p1c (32),
drugs cdl p4 (21)
January 1, 2021 Semaglutide Drug added, administration added, restriction added drugs cdl p1d (3),
drugs cdl p4 (23)

Effective Date Drug Summary of Changes    Page(s) Updated
October 1, 2020 Ulipristal Acetate Restrictions added drugs cdl p1d (44)
November 1, 2020 Naloxegol Oxalate Restriction added drugs cdl p1c (3)
January 1, 2021 Albuterol Sulfate Restriction removed drugs cdl p1a (7)
January 1, 2021 Apraclonidine Restriction removed drugs cdl p1a (22)
January 1, 2021 Diazepam Restriction added, restriction updated drugs cdl p1a (89)
January 1, 2021 Dulaglutide Strengths added drugs cdl p1a (100)
January 1, 2021 Elbasvir/Grazoprevir Note added, note deleted drugs cdl p1b (3)
January 1, 2021 Glecaprevir/Pibrentasvir Restriction updated, note added, note deleted drugs cdl p1b (44)
January 1, 2021 Insulin Aspart Administration added, restriction added drugs cdl p1b (63)
January 1, 2021 Insulin Aspart Protamine Suspension/Insulin Aspart, (rDNA origin) Administration added, restriction added drugs cdl p1b (63)
January 1, 2021 Insulin Lispro (rDNA Origin) Administration updated, restriction updated drugs cdl p1b (65)
January 1, 2021 Ledipasvir/Sofosbuvir Administration added, restriction updated, restriction removed, note added, note deleted drugs cdl p1b (79)
January 1, 2021 Sofosbuvir Restriction updated, administration added, note added, note deleted drugs cdl p1d (7)
January 1, 2021 Sofosbuvir/Velpatasvir Strength added, restriction updated, restriction removed, note added, note deleted drugs cdl p1d (8)
January 1, 2021 Triazolam Restrictions added drugs cdl p1d (40)

18. Authorized Drug Manufacturer Labeler Codes Update

The Drugs: Contract Drugs List Part 5 – Authorized Drug Manufacturer Labeler Codes section has been updated as follows.

Additions, effective January 1, 2021
NDC Labeler Code Contracting Company's Name
71390 Acacia Pharma Ltd
71671 Agile Therapeutics, Inc.
72769 Biocryst Pharmaceuticals, Inc.
73292 NS Pharma, Inc.
73380 Innate Pharma, Inc.
73473 Solaris Pharma Corporation
73594 Pharmacosmos Therapeutics Inc.
79672 Nextgen Pharmaceuticals LLC
Terminations, effective January 1, 2021
NDC Labeler Code Contracting Company's Name
00327 Guardian Labs Div United-Guardian Inc.
11788 AiPing Pharmaceutical, Inc.
24090 Akrimax Pharmaceuticals LLC
42238 Vidara Therapeutics Inc.
52747 U.S. Pharmaceutical Corporation (USPCO)
53014 Celltech Pharmaceuticals
58281 Medtronic, Inc.
61364 Biocryst Pharmaceuticals, Inc.
61971 Vista Pharmaceuticals, Inc.

Provider Manual(s) Page(s) Updated
Adult Day Health Care Centers
AIDS Waiver Program
Chronic Dialysis Clinics
Clinics and Hospitals
Expanded Access to Primary Care Program
General Medicine
Heroin Detoxification
Home Health Agencies/Home and Community-Based Services
Hospice Care Program
Multipurpose Senior Services Program
Obstetrics
Pharmacy
Rehabilitation Clinics
drugs cdl p5 (3, 5–7, 10–23)

19. Updates to the List of Contracted Incontinence Absorbent Products

Effective for dates of service on or after January 1, 2021, the List of Contracted Incontinence Absorbent Products is updated. Contracted products have been added, updated and/or deleted for manufacturers Cardinal, Essity, First Quality and Medline.

20. Medi-Cal and Family PACT Cover Prescriptions for STI Reinfection Prevention

Medi-Cal and Family Planning, Access, Care and Treatment (Family PACT) programs reimburse medication treatment of a sexually transmitted infection (STI) and reimburse for medication quantities sufficient to prevent reinfection by sex partners of the beneficiary. Expedited Partner Therapy (EPT) is the clinical practice of treating sex partners of patients diagnosed with a STI without first examining the partner. This form of reinfection prevention usually involves patient-delivered partner therapy, an evidence-based practice to reduce reinfection. Since repeat infections are often due to untreated partners, ensuring all recent partners have been treated is a core aspect of clinical management of patients diagnosed with chlamydia, gonorrhea and/or trichomoniasis.

Medi-Cal and Family PACT cover medically necessary services for the treatment of STIs. If a Medi-Cal or Family PACT provider determines preventative treatment of sex partners is necessary to prevent gonorrhea, chlamydia and/or trichomoniasis reinfection, the provider may dispense an appropriate amount of medication directly to the Medi-Cal or Family PACT patient to provide to partner(s). Alternatively, the provider may provide a prescription written in the beneficiary’s (patient’s) name for medications sufficient to treat both the patient and the partner(s).

For Medi-Cal family planning programs, pursuant to family planning encounters, treatment regimens for chlamydia, gonorrhea and/or trichomoniasis may be dispensed in the clinic or by prescription to be dispensed by a pharmacy. For more information about family planning-related services, providers may refer to the Family Planning section of the appropriate Part 2 section of the Medi-Cal Provider Manual or the ben fam rel section of the Family PACT Policies, Procedures and Billing Instructions Manual. For non-family planning encounters, Medi-Cal covers treatment regimens for chlamydia, gonorrhea and/or trichomoniasis by prescription only.

For additional prescribing and clinical guidelines on treating partners of patients diagnosed with STIs, providers may review guidance from the U.S. Centers for Disease Control and Prevention (CDC) and the California Department of Public Health (CDPH).

California legislation allowing EPT

In 2001, Senate Bill 648 (Ortiz, Chapter 835, Statutes of 2000) amended California law to allow EPT for chlamydia. In January 2007, Assembly Bill 2280 (Leno, Chapter 771, Statutes of 2006) amended the law to allow EPT for gonorrhea and other sexually transmitted infections.

The current law, Health and Safety Code Section 120582, allows specified health care providers to prescribe and/or dispense, furnish or otherwise provide antibiotic therapy for sex partners of individuals infected with Chlamydia trachomatis, Neisseria gonorrhoeae, or other STIs as determined by the CDPH, even if the provider has not performed an exam of the partner(s). The law provides an exception to the Medical Practice Act, which states that prescribing, dispensing or furnishing dangerous drugs without a good-faith prior examination and medical indication constitutes unprofessional conduct.

To reduce the spread of STIs, the CDC and the CDPH recommend EPT to treat partners of persons with chlamydia or gonorrhea without waiting for a clinical evaluation.

A prescriber can legally write prescriptions to include the partner(s) in the following ways:

  • The prescriber may write a separate prescription if the patient provides the partner’s name.

  • The prescriber may write a single prescription for both the patient and the partner by adding the partner’s name to the prescription and increasing the quantity appropriately.

  • The prescriber may simply add “partner(s)” to the prescription and increase the quantity appropriately.

The preferred option is a separate prescription for each partner; however, all three options are valid prescriptions and can be filled by a pharmacist.

Medi-Cal and Family PACT reimbursement for STI reinfection prevention

Effective February 1, 2020, Medi-Cal and Family PACT have updated their policy for reimbursement for EPT:

  • For the prevention of reinfection from chlamydia, gonorrhea, and trichomoniasis.

  • Allowable by prescription for any visit type or dispensed in clinic for family planning-related visits only.

  • Reimbursement for client dose and up to five partner doses per dispensing.

  • Prescriptions must be written in the name of the enrolled client to be covered by Medi-Cal.

References for EPT guidelines

CDC References

CDPH References

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

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.

22. Provider Manual Revisions



Note:
Download PDF (Portable Document Format) reader from the Web Tool Box.