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Medi-Cal Update

Pharmacy | August 2021 | Bulletin 997

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1. Update to Medi-Cal Rx Implementation Date

Medi-Cal Rx is an important initiative for improving health care delivery by standardizing the Medi-Cal pharmacy benefit under one delivery system and improving access to pharmacy services with a network that includes a large majority of the state’s pharmacies. The Department of Health Care Services (DHCS) is pleased to announce that on July 27, 2021, it accepted a Conflict Avoidance Plan submitted by its Medi-Cal Rx vendor, Magellan Medicaid Administration (MMA), Inc., a subsidiary of Magellan Health, Inc. (Magellan), to mitigate conflicts associated with the proposed acquisition of Magellan by Centene Corporation. As a result of the acceptance of the Conflict Avoidance Plan, DHCS has determined that full Medi-Cal Rx implementation will begin January 1, 2022. The Conflict Avoidance Plan is posted on the DHCS website.

DHCS has determined the Conflict Avoidance Plan meets conflict avoidance/mitigation requirements around the two areas of identified conflict which are: Since articles are published on the Medi-Cal Provider website, hyperlinks should be used as necessary and when appropriate. For proper formatting rules for hyperlinks, refer to the Medi-Cal Style Guide and Formatting Guide. If using a brand or name that is trademarked, the appropriate symbol (® or ™) and superscript needs to be used on first instance. A prominent example includes:

  • As Centene owns managed care plans that participate in the Medi-Cal program, beneficiary pharmacy claims data submitted to MMA as the Pharmacy Benefit Administrator could, if shared with Centene, give their subsidiary plans access to proprietary data of non-Centene plans and create unfair advantage.

  • As Centene owns six specialty pharmacies that provide drugs to the Medi-Cal program, neither Centene nor any subsidiary can be involved in prior authorization or claim approvals and payments to those pharmacies or with program integrity/fraud, waste and abuse activities.

The major features of the Conflict Avoidance Plan are:

  • If Centene acquires Magellan, and for so long as Magellan is under contract to DHCS, the operations, staffing, information technology systems, and data of MMA will be kept completely separate from Centene’s health plan business line. This commitment is affirmed by Centene;

  • A third party monitor selected by DHCS will be in place to ensure this organizational separation is maintained; and

  • DHCS will handle all aspects of claims processing and authorization for the Centene-owned pharmacies and MMA will incorporate such system-wide data as needed for DHCS to run analytics in support of quality assurance and program integrity for those claims. The DHCS work efforts will not result in State General Fund costs.

DHCS will take the necessary steps to ensure beneficiaries are able to receive their prescriptions and that pharmacies will have available needed information regarding claims and prior authorizations and to ensure that Medi-Cal managed care plans will receive the necessary data to ensure appropriate utilization and continuity of care for beneficiaries enrolled in managed care.

DHCS will resume Medi-Cal Rx stakeholder engagements and update schedules accordingly. For project questions or comments, visit the DHCS website or email RxCarveOut@dhcs.ca.gov.

2. New DME Rental Benefit: Phototherapy Light for Infants

Effective for dates of service on or after September 1, 2021, HCPCS code E0202 (phototherapy [bilirubin] light with photometer) is a Medi-Cal benefit for infants as a daily rental only. Because the light is rented, modifier RR is required. For reimbursement, documentation must indicate that the recipient meets the following criteria:

  • The infant’s total serum bilirubin is in the “optional range” as defined by the American Academy of Pediatrics Subcommittee on Hyperbilirubinemia; and

  • The infant is feeding, voiding and stooling well and appears well; and

  • Close follow-up evaluation can be accomplished

Claims submitted to bill for the phototherapy light may be submitted under the mother’s Medi-Cal ID if the infant’s Medi-Cal eligibility has not yet been established. Claims that use the mother’s Medi-Cal ID for the infant, must indicate in the Patient Relationship to Insured field (Box 6) that the “patient is the child of the insured.”

The frequency limit for HCPCS code E0202 is 10 days per lifetime, per infant. A Treatment Authorization Request (TAR) can override the frequency limit when more than one infant born to the same mother (for example, twins, or infant from subsequent birth) requires phototherapy. When phototherapy is needed for more than one infant, claims for phototherapy require a statement in the Additional Claim Information field (Box 19) specifying the number of infants needing phototherapy at this time or that a previous claim was submitted for a sibling who also required phototherapy.

Provider Manual(s) Page(s) Updated
Durable Medical Equipment
Pharmacy
dura cd (9); dura cd fre (2); dura other (2, 15, 16)
Orthotics and Prosthetics
Therapies
dura cd (9); dura cd fre (2)

3. HIV Pre-exposure and Post-exposure Prophylaxis Now Pharmacy Benefits

Effective for dates of service on or after September 1, 2021, HIV pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP) medications are pharmacist services benefits.

The following CPT® codes are for PrEP and PEP billing:

  • New Patients: CPT code 99202 (office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using time for code selection, 15-29 minutes of total time is spent on the date of the encounter).

  • Existing Patients: CPT code 99212 (office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using time for code selection, 10-19 minutes of total time is spent on the date of the encounter).

CPT codes 99202 and 99212 should be billed in conjunction with the following ICD-10-CM diagnosis codes: Z20.2, Z20.6 or Z77.21.

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
prev (7)
Pharmacy pharm serv (1, 2, 7)

4. Updates to the List of Medical Supplies Billing Codes, Units and Quantity Limits

Effective for dates of service on or after November 1, 2021, HCPCS code A4459 (manual pump-operated enema system, includes balloon, catheter and all accessories, reusable, any type) is added as a medical supply billing code, requiring a Treatment Authorization Request (TAR), on the List of Medical Supplies Billing Codes, Units and Quantity Limits.

In addition to TAR approval, claims submitted using HCPCS code A4459 require documentation of product cost (an invoice, manufacturer’s catalog page or price list) attached to the claim for reimbursement.

Effective for dates of service on or after January 1, 2022, claims with approved TARs using HCPCS code T5999 (supply, not otherwise classified) for reimbursement of a manual pump-operated enema system and its accessories will be denied.

Correction Made to Quantity Limits for Wound Care HCPCS Code A6245

The List of Medical Supplies Billing Codes, Units and Quantity Limits is updated with the correct quantity limits for wound care supply HCPCS code A6245, (hydrogel dressing, wound cover, sterile, pad size 16 sq in or less, with any size adhesive border, each dressing). The correct quantity limit without authorization for HCPCS code A6245 is 12 dressings per wound per 27-day period.

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6. Provider Manual Revisions



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