Medi-Cal Update

Long Term Care | September 2020 | Bulletin 523

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1. CPT Code for COVID-19 Testing Exempt from AB 97 10 Percent Payment Reduction

Effective for dates of service on or after June 25, 2020, the American Medical Association created CPT® code 87426 (infectious agent antigen detection by immunoassay technique, [eg, enzyme immunoassay (EIA), enzyme-linked immunosorbent assay (ELISA), immunochemiluminometric assay (IMCA)] qualitative or semiquantitative, multiple-step method; severe acute respiratory syndrome coronavirus [eg, SARS-CoV, SARS-CoV-2 (COVID-19)]) for reporting antigen testing of patients suspected of being infected with the coronavirus disease 2019 (COVID-19).

Additionally, the Department of Health Care Services (DHCS) is establishing the reimbursement rate at 100 percent of the Medicare rate for the new code. It is exempt from the ten percent payment reductions in Welfare and Institutions Code (W&I Code) Section 14105.192.

Upon expiration of the public health emergency or national emergency, this rate will be amended to correspond with the clinical laboratory services methodology in W&I Code Section 14105.22, including the application of the Assembly Bill 97 (AB 97) payment reduction.

An erroneous payment correction (EPC) will be implemented to reprocess the affected claims.

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2. New Policy Changes to the Hospital Presumptive Eligibility Program

As California continues to respond to coronavirus disease 2019 (COVID-19), the Hospital Presumptive Eligibility (HPE) Program will temporarily expand presumptive eligibility (PE) coverage to a new coverage group of individuals who are 65 or older and whose income is below 138 percent of the Federal Poverty level (FPL), effective immediately. This new coverage group is referred to as the “Aged” HPE group. This coverage group is allowed two (2) periods of PE in a twelve-month period and will be assigned aid code 7D. This expansion will be in effect through the end of the COVID-19 public health emergency.

DHCS is also expanding presumptive eligibility periods through HPE for adults that are age 19 years and over. HPE will now provide two (2) periods of presumptive eligibility in a twelve-month period for adults age 19 and over. This change is effective immediately and will be in effect through the end of the COVID-19 public health emergency.

DHCS has received federal approval on these new policy changes through California State Plan Amendment 20-0024.

It is critical that HPE Providers monitor the Hospital PE Program Medi-Cal website for future articles and materials scheduled to publish during May and June 2020.

Questions concerning the HPE expansion should be sent to

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3. CPT Codes 86408 and 86409 for COVID-19 Testing are Medi-Cal Benefits

Effective for dates of service on or after August 10, 2020, CPT® codes 86408 (neutralizing antibody, severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2] [Coronavirus disease (COVID-19)]; screen) and 86409 (neutralizing antibody, severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2] [Coronavirus disease (COVID-19)]; titer) for coronavirus disease 2019 (COVID-19) are now Medi-Cal benefits. Codes 86408 and 86409 do not have any gender or age restrictions; have a frequency limit of one per day, any provider, per patient; and may be billed with any ICD-10-CM codes.

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4. Introducing the RAD Repository

Providers now have access to Remittance Advice Details (RAD) codes and messages in one central location: the RAD Repository.

The RAD Repository is a one-stop shop for information about remittance details, billing tips and code descriptions. Previously, RAD codes and messages were presented in separate documents. The new RAD Repository pulls all of the documents into one spreadsheet that streamlines claims billing data for providers.

The new RAD Repository will help providers find pertinent billing information more quickly. In addition, users with cognitive, visual or hearing disabilities will have an enhanced experience as the spreadsheet complies with Americans with Disabilities Act (ADA) standards.

This information is reflected in the following provider manual(s):
Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
eval (3)
Medical Transportation cont ah (4)
Part 1 0c get start (4)
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5. New Medi-Cal Provider Website: Provider Survey and Feedback

The Department of Health Care Services (DHCS) invites all Medi-Cal providers, stakeholders and interested parties to participate in a brief Medi-Cal Provider website survey after visiting the new Medi-Cal Provider website. Survey results will provide valuable information to DHCS for future website improvements.

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6. Updated ICF/DD, ICF/DD-H and ICF/DD-N Reimbursement Rates for Long Term Care

Pursuant to State Plan Amendment 16-012, and Welfare and Institutions Code (W&I Code) Section 14105.075, the California Department of Health Care Services (DHCS) is authorized to reimburse facilities at the 2008-09 65th percentile per diem rate established for the facility’s respective peer group, increased by 3.7 percent. The reimbursement rate will also include the projected cost of complying with any new state or federal mandates to the extent applicable to the reimbursement methodology associated with the type of facility.

DHCS is providing a facility-specific reimbursement by way of an add-on to the Medi-Cal reimbursement rate for the additional cost of health care coverage solely due to Employer Shared Responsibility requirements in the Affordable Care Act (ACA) embodied in Section 4980H of the Internal Revenue Code (IRC). The rates, effective August 1, 2020, will include the additional facility-specific add-on related to the ACA Employer Shared Responsibility Mandate, and the ACA IRS Employer Reporting Mandate, only for the facilities that submitted a certification form. Note that individual rate letters will be mailed to the providers that submitted a certification form, since the add-ons are facility specific.

DHCS is providing an additional supplemental payment, effective August 1, 2020. The Centers for Medicare & Medicaid Services (CMS) approved SPA 19-0022 to extend the ICF/DD Proposition 56 supplemental payment and provide an additional time-limited per diem amount for the below peer groups, through December 31, 2021.

Facility Peer Group Long Term Care Accommodation Code (Regular Services) Bedhold Accommodation Code Supplemental Payment Per Diem
ICF/DD (1–59 beds) 41 43 $15.47
ICF/DD (60+ beds) 41 43 $0.00
ICF/DD-H (4–6 beds) 61 63 $10.75
ICF/DD-H (7–15 beds) 65 68 0.00
ICF/DD-N (4–6 beds)

62 64 $12.47
ICF/DD-N (7–15 beds) 66 69 $22.30

Note: Facilities in peer groups in which the unfrozen 2017-18 65th percentile rate is lower than the current reimbursement rate will not receive the supplemental payment.

The California MMIS Fiscal Intermediary will provide the supplemental payment per diem amounts to the respective peer groups, in addition to the regular reimbursement rates, for every claim that is billed for dates of service August 1, 2020 through July 31, 2021. Providers should bill using the new rates for dates of service on or after August 1, 2020.

Providers do not need to rebill to adjust their payments; the FI will process any retroactive rate adjustments for claims paid at the old rate. If you have any questions regarding claims and payments, please contact the Telephone Service Center (TSC) at 1-800-541-5555.

The new rates, ACA add-ons, Supplemental Payment and other information related to ICF/DD, ICF/DD-H, and ICF/DD-Ns are available on the DHCS website at:

This information is reflected in the following provider manual(s):
Provider Manual(s) Page(s) Updated
Long Term Care rate facil diem (5, 9)
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