Medi-Cal Update

Long Term Care | October 2020 | Bulletin 524

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1. Temporary COVID-19 Increased Rates for FS/PSA Facilities

Facility-specific reimbursement rates for Freestanding Pediatric Subacute (FS/PSA) for the rate year August 1, 2020 – July 31, 2021 are established, effective for dates of service on or after August 1, 2020.

The facility-specific rates include a temporary COVID-19 increased reimbursement of 10 percent based on the facility’s prior 2019–2020 facility-specific rate. The 10 percent increase is provided throughout the Coronavirus Public Health Emergency and National Emergency. The temporary COVID-19 increased rates are listed below and posted on the Long-Term Care Reimbursement AB 1629 page of the Department of Health Care Services (DHCS) website:
https://www.dhcs.ca.gov/services/medi-cal/Pages/AB1629/LTCAB1629.aspx.

Facilities should begin using these rates to bill for services provided on or after August 1, 2020. Facilities do not need to rebill to adjust reimbursements; the California Medicaid Management Information System (MMIS) Fiscal Intermediary (FI) will automatically adjust all claims with effective dates of service on or after August 1, 2020. Provider rate letters will be sent to all FS/PSA facilities to notify them of the rate updates. An Erroneous Payment Correction (EPC) will be implemented to reprocess affected claims. No additional action is required on the part of providers.

Temporary COVID-19 Increased FS/PSA Reimbursement Rates
The temporary COVID-19 increased FS/PSA reimbursement rates for the 2020–2021 rate year are listed below. The rates are based on the facility’s frozen 2008–2009 rates, plus the cost of new state and federal mandates (add-ons), and the 2019–2020 COVID-19 10 percent increase. The add-ons are not applied to rehabilitation therapy and ventilator weaning rates.

Temporary COVID-19 Increased FS/PSA Rates for 2020–2021
91 92 93 / 95 94 / 96 97 98
$879.81 $804.32 $871.06 $795.57 $55.39 $51.63

Mandates
2020–2021 Add-Ons

2019–2020 Add-Ons

2018–2019 Add-Ons

2017–2018 Add-Ons

2016–2017 Add-Ons

2015–2016 Add-Ons

2014–2015 Add-Ons

2013–2014 Add-On Carry Over

2012–2013 Add-On Carry Over

2011–2012 Add-On Carry Over

This information is reflected in the following provider manual(s):
Provider Manual(s) Page(s) Updated
Long Term Care rate facil diem (7–9)
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2. Temporary COVID-19 Increased Rates for DP/PSA Facilities

Facility-specific reimbursement rates for Freestanding Pediatric Subacute (FS/PSA) for the rate year August 1, 2020 – July 31, 2021 are established, effective for dates of service on or after August 1, 2020.

The facility-specific rates include a temporary COVID-19 increased reimbursement of 10 percent based on the facility’s prior 2019–2020 facility-specific rate. The 10 percent increase is provided throughout the Coronavirus Public Health Emergency and National Emergency. The temporary COVID-19 increased rates are listed below and posted on the Long-Term Care Reimbursement AB 1629 page of the Department of Health Care Services (DHCS) website: https://www.dhcs.ca.gov/services/medi-cal/Pages/AB1629/LTCAB1629.aspx

Facilities should begin using these rates to bill for services provided on or after August 1, 2020. Facilities do not need to rebill to adjust reimbursements; the California Medicaid Management Information System (MMIS) Fiscal Intermediary (FI) will automatically adjust all claims with effective dates of service on or after August 1, 2020. Provider rate letters will be sent to all FS/PSA facilities to notify them of the rate updates. An Erroneous Payment Correction (EPC) will be implemented to reprocess affected claims. No additional action is required on the part of providers.

Temporary COVID-19 Increased DP/PSA Reimbursement Rates
The temporary COVID-19 increased DP/PSA reimbursement rates for the 2020–2021 rate year are listed below. The rates are based on a model developed from comparable peer group cost information, in addition to the cost of new state or federal mandates (add-ons), and the 2019–2020 COVID-19 rate increase amount. The calculated ventilator dependent rate and non-ventilator dependent rate are both calculated this way.

Temporary COVID-19 Distinct Part Pediatric Subacute Rates for 2020–2021
83 84 85 86 87 / 89 88 / 89
$82.21 $76.64 $1,324.11 $1,212.82 $1,315.36 $1,204.07

Mandates
The 2020–2021 rate year mandates total $1.74. This includes Minimum Wage (January 2019 SB 3) $0.23, Minimum Wage (January 2020 SB 3) $0.86, Minimum Wage (January 2021 SB 3) $0.63 and SB219 LGBT Training Add-On $0.02.

This information is reflected in the following provider manual(s):
Provider Manual(s) Page(s) Updated
Long Term Care rate facil diem (7–9)
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3. Temporary COVID-19 Increased FS/NF-B Rates

The August 1, 2020 – December 31, 2020 facility specific reimbursement rates for Freestanding Nursing Facilities Level B (FS/NF-B) are established, effective for dates of service on or after August 1, 2020.

FS/NF-B facility-specific reimbursement rates are computed annually. The August – December 2020 rates are posted on the Long-Term Care Reimbursement AB 1629 page of the Department of Health Care Services (DHCS) website: http://www.dhcs.ca.gov/services/medi-cal/Pages/AB1629/LTCAB1629.aspx.

In addition, the facility-specific rates include a temporary COVID-19 increased reimbursement of 10 percent, based on the facility’s prior 2019-20 facility-specific rate. The 10 percent increase is provided throughout the Coronavirus Public Health Emergency and National Emergency. The temporary COVID-19 increased rates are posted on the website listed above.

Providers should use these rates to bill for dates of service on or after August 1, 2020. An Erroneous Payment Correction (EPC) will be implemented to reprocess affected claims. No additional action is required on the part of providers.

Mandates
The August – December 2020 rate period mandates total $4.10. This includes Minimum Wage (January 2020, SB 3) $1.36, Minimum Wage (January 2019, SB 3) $0.55, Minimum Wage (January 2018, SB 3) $0.86, Standards of Participation $1.31, and LGBT $0.02. Additionally, there is an add-on for the SB 97 Staffing Standard Mandate that is calculated on a facility specific basis.

Change of Ownership
Facilities with changes of ownership or changes of licensed operator do not qualify for facility specific reimbursement rates and will continue to receive the prior owner’s or licensed operator’s rate. For more information, please refer to the AB 1629 Facility-Specific Rate Methodology Clarifications article on the Department of Health Care Service (DHCS) website: https://www.dhcs.ca.gov/services/medi-cal/Documents/AB1629/Provider%20Bulletins/Medi-Cal%20Bulletin%20387.pdf.

Leave of Absence/Bed Hold Reduction
The August – December 2020 rate period reduction for Leave of Absence or Bed Hold is $8.49.

Quality Assurance Fee (QAF)
Approved FS/NF-B QAF amount for facilities reporting less than 100,000 days is $15.68, and $14.80 for facilities reporting equal to or greater than 100,000 days.

August – December 2020 Rate Period Peer Group Weighted Averages
Peer Group ID Includes QAF Without QAF
1 $246.16 $228.91
2 $294.41 $277.16
3 $298.67 $281.42
4 $285.62 $268.37
5 $275.20 $257.95
6 $265.16 $247.91
7 $260.40 $243.15
8 $248.26 $231.02
9 $231.00 $213.75
10 $255.20 $237.96
11 $246.74 $229.49
Statewide Weighted Average $262.08 $244.83

This information is reflected in the following provider manual(s):
Provider Manual(s) Page(s) Updated
Long Term Care rate facil diem (7–9)
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4. Temporary COVID-19 Increased FSSA/NF-B Rates

The August 1, 2020 – December 31, 2020 facility-specific reimbursement rates for Freestanding Adult Subacute Skilled Nursing Facility Level B (FSSA/NF-B) are established, effective for dates of service on or after August 1, 2020.

FSSA/NF-B facility-specific reimbursement rates are computed on an annual basis. The August – December 2020 rates are posted on the Long-Term Care Reimbursement AB 1629 page of the Department of Health Care Services (DHCS) website: http://www.dhcs.ca.gov/services/medi-cal/Pages/AB1629/LTCAB1629.aspx.

In addition, the facility-specific rates include a temporary COVID-19 increased reimbursement of 10 percent, based on the facility’s prior 2019-20 facility-specific rate. The 10 percent increase is provided throughout the Coronavirus Public Health Emergency and National Emergency. The temporary COVID-19 increased rates are posted on the website listed above.

Mandates
The August – December 2020 rate period mandates total $4.10. This includes Minimum Wage (January 2020, SB 3) $1.36, Minimum Wage (January 2019, SB 3) $0.55, Minimum Wage (January 2018, SB 3) $0.86, Standards of Participation $1.31, and LGBT $0.02.

These rates are posted on the Long-Term Care Reimbursement AB1629 Web page of the Department of Health Care Services (DHCS) website: www.dhcs.ca.gov/services/medi-cal/Pages/AB1629/LTCAB1629.aspx.

Providers should use these rates to bill for services.

Bed Hold/Leave of Absence
The August – December 2020 reduction for Leave of Absence or Bed Hold is $8.49.

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5. COVID-19 Quantitative Antibody Test Added as a Medi-Cal Benefit

Effective for dates of service on or after September 8, 2020, CPT® code 86413 (severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2] [Coronavirus disease (COVID-19)] antibody, quantitative) is added as a Medi-Cal benefit.

CPT code 86413 may be billed with any ICD-10-CM code.

An Erroneous Payment Correction (EPC) will be processed for affected claims.

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6. October 2020 HCPCS Quarterly Update

The October 2020 updates to the Healthcare Common Procedure Coding System (HCPCS) codes are available in the October 2020 HCPCS Policy Updates PDF.  Only those codes representing current or future Medi-Cal benefits are included in the list of updates.

The code additions, changes and deletions are effective for the dates of service on or after October 1, 2020. Please refer to the 2020 HCPCS code book for complete code descriptions.

This information is reflected in the following provider manual(s):
Provider Manual(s) Page(s) Updated
AIDS Waiver Program
Audiology and Hearing Aids
Durable Medical Equipment
Home Health Agencies/Home and Community-Based Services
Medical Transportation
Orthotics and Prosthetics
Therapies
Vision Care
medi non hcp (2); modif app (13, 26)
Chronic Dialysis Clinics inject cd list (3, 4, 6, 9, 13, 15, 18, 20); inject drug a-d (17, 18, 25, 26); inject drug e-h (15, 16); inject drug i-m (26); medi non hcp (2); modif app (13, 26); modif used (5, 6, 12–15)
General Medicine
Clinics and Hospitals
chemo drug a-d (30, 31); chemo drug e-o (20, 29); chemo drug p-z (7–9, 20–23); inject cd list (3, 4, 6, 9, 13, 15, 18, 20); inject drug a-d (17, 18, 25, 26); inject drug e-h (15, 16); inject drug i-m (26); medi non hcp (2); modif app (13, 26); modif used (5, 6, 12–15); non ph (10, 13–15, 25, 27); ophthal (24); presum bill (12, 14–16); radi dia (21–25); surg digest (7); surg integ (4, 6); surg urin (5, 7)
Heroin Detoxification
Hospice Care Program
Psychological Services
medi non hcp (2)
Local Educational Agency modif app (13, 26)
Obstetrics inject cd list (3, 4, 6, 9, 13, 15, 18, 20); inject drug a-d (17, 18, 25, 26); inject drug e-h (15, 16); inject drug i-m (26); medi non hcp (2); modif app (13, 26); modif used (5, 6, 12–15); non ph (10, 13–15, 25, 27); presum bill (12, 14–16); radi dia (21–25); surg urin (5, 7)
Pharmacy inject cd list (3, 4, 6, 9, 13, 15, 18, 20); inject drug a-d (17, 18, 25, 26); inject drug e-h (15, 16); inject drug i-m (26); medi non hcp (2); presum bill (12, 14–16)
Rehabilitation Clinics inject cd list (3, 4, 6, 9, 13, 15, 18, 20); inject drug a-d (17, 18, 25, 26); inject drug e-h (15, 16); inject drug i-m (26); medi non hcp (2); modif app (13, 26); modif used (5, 6, 12–15); non ph (10, 13–15, 25, 27)
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7. Medi-Cal Business Operations Fiscal Intermediary Name Change

Effective October 1, 2020, providers may notice that the Department of Health Care Services (DHCS) California Medicaid Information System (CA-MMIS) Fiscal Intermediary (FI) for the Medi-Cal program, formerly DXC, LLC, is operating under a new company name, “Gainwell Technologies.” Operations and interactions with providers are not impacted by this FI name change. There are no changes in the telephone numbers used by providers, including the Telephone Service Center (TSC) number (1-800-541-5555), as a result of this name change. The mailing addresses used by providers to conduct business with DHCS and the FI will remain the same as well.

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8. Fiscal Intermediary Technology Refresh Implementation

As previously announced in a July 16, 2020 article, DXC Technology, the Business Operations Fiscal Intermediary (FI), has staged the deployment of various business oriented IT solutions to occur July 2020 onward.

As of August 2020, the following technological refreshes have already been implemented:

On September 14, 2020, the remaining technological refreshes are scheduled to be live in production:

As with the initial operational transition in October 2019, and the first wave of technical changes in August 2020, the primary objective is a successful transition without disruption to state programs, providers and/or members (beneficiaries). Given the type of IT services slated for the second wave of technological changes, providers and members may notice differences in processes and/or may experience longer call wait times pre- and post-implementation as the operations prepare for deployment and stabilize.

The Department of Health Care Services (DHCS) will continue to provide updates as this effort progresses. Please continue to monitor the Medi-Cal Provider website for future updates on this topic.

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9. July 2020 NCCI Updates with Announced Correction

The Centers for Medicare and Medicaid Services (CMS) updated payment policy as part of the National Correct Coding Initiative (NCCI) Quarterly Updates for July 2020. The mandatory national edits were incorporated into the Medi-Cal claims processing system and were effective for dates of service on or after July 1, 2020.

Upon release, the Medically Unlikely Edit (MUE) values and MUE Adjudication Indicators (MAI) were inaccurate for the following HCPCS codes. CMS issued replacement MUE Quarter 3 2020 files for Practitioners (PRA) and Outpatient providers (OPH) retroactive to July 1, 2020.

Providers may refer to The National Correct Coding Initiative in Medicaid page of the Medicaid website for information.

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

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10. Administrative Hearings to be Conducted by Telephone or Video Conference

The Office of Administrative Hearings and Appeals (OAHA) will conduct informal reviews, pre-hearing matters, settlement conferences, formal hearings and other matters via telephone or video conference, while Executive Orders N-55-20 and N-63-20 are in effect. The Department of Health Care Services (DHCS) recently issued guidance on timeframe extensions and data submittal deadlines for audits, and updates to administrative hearing timelines and processes, available on the DHCS website. For questions regarding this guidance, please email the OAHA inbox at OAHAmailbox@dhcs.ca.gov.

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11. Medi-Cal Rx Portal Registration Launched for Pharmacy Providers and Prescribers

The Department of Health Care Services (DHCS) continues to make significant towards a successful transition of pharmacy services on January 1, 2021 to Medi-Cal Rx.

To help facilitate a smooth and effective transition for Medi-Cal providers, beneficiaries, and other interested parties, DHCS has taken proactive steps to deploy a robust and multi-faceted outreach campaign, which includes, developing comprehensive beneficiary notices, developing call center scripts, conducting targeted provider outreach and providing for and advertising publicly various training opportunities available starting in October and continuing through the end of the year.

Additional activities include developing a dedicated Medi-Cal Rx website with secure portal components for Medi-Cal providers, health plans, beneficiaries and other interested parties.

Recently, DHCS launched the dedicated Medi-Cal Rx secure web portal, https://medi-calrx.dhcs.ca.gov/home/, and a registration page for Medi-Cal provider access, including but not limited to physician prescribers and pharmacies. This registration is the first step in the process for pharmacies and prescribers to use the Medi-Cal Rx secure web portal andits web-based tools for pharmacy services. For detailed registration and training instructions, access the Medi-Cal Rx Web Portal and Training Registration article located on the Pharmacy News Page (https://medi-calrx.dhcs.ca.gov/provider/pharmacy-news).

Access to the Medi-Cal Rx secure web portal will include key functions such as:

Other functions within the Web Portal include:

DHCS reminds Medi-Cal providers, health plans, beneficiaries and other interested parties that it is very important registration be completed early so user training and access are complete and active by January 1, 2021. Doing so will help to remove any potential challenges for successful utilization of the Medi-Cal Rx secure web portal.

The entire dedicated Medi-Cal Rx website will be fully operational by January 1, 2021. In the meantime, DHCS encourages Medi-Cal pharmacy providers and prescribers, health plans, beneficiaries, and other interested parties to sign up for the Medi-Cal Rx Subscription Service, which allows interested parties to receive Medi-Cal Rx updates in near real-time by email.

For general project questions and/or comments, please visit the DHCS website or email RxCarveOut@dhcs.ca.gov. In addition, DHCS encourages stakeholders to review the Medi-Cal Rx Frequently Asked Questions (FAQ) document, which continues to be updated as the project advances.

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12. National Correct Coding Initiative Quarterly Update for October 2020

The Centers for Medicare & Medicaid Services (CMS) has released the quarterly National Correct Coding Initiative (NCCI) payment policy updates. These mandatory national edits have been incorporated into the Medi-Cal claims processing system and are effective for dates of service on or after October 1, 2020.

For additional information, refer to The National Correct Coding Initiative in Medicaid page of the Medicaid website.

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13. 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.

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