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Medi-Cal Update

Psychological Services | January 2021 | Bulletin 544

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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. 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.

3. 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.

4. 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.

5. 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.

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7. Provider Manual Revisions

Pages updated due to ongoing provider manual revisions:

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