Updated August 29, 2022
Originally published August 8, 2022
The Department of Health Care Services (DHCS) continues to closely monitor the Mpox situation. DHCS will continue to update and inform all Medi-Cal providers on any reimbursement policy for vaccine administration, testing and treatment specific to Mpox as guidance becomes available, including specific billing codes, rates and instructions. Providers are advised to deliver Medi-Cal covered services related to Mpox when medically indicated. For Mpox specific codes for which DHCS has not yet issued guidance, providers are advised to hold claims for submission pending further guidance.
Mpox Vaccine Administration
To assist the provider community to deliver vaccines for Mpox, DHCS is seeking federal authority to establish the Medi-Cal Fee-For-Service (FFS) reimbursement rate for Mpox vaccine administration at 100 percent of the corresponding Medicare rate for the same or similar service, effective August 17, 2022, medical and pharmacy claims. Vaccines are currently being allocated by national and state public health authorities and those eligible for vaccination should contact their local health departments for available administration location sites in their area.
For beneficiaries enrolled in Medi-Cal Managed Care, providers should bill medical claims to the managed care plan for Mpox vaccine administration.
DHCS will inform providers when additional guidance is available.
Mpox Vaccine Administration in Federally Qualified Health Centers (FQHC), Rural Health Clinics (RHCs), Indian Health Services Memorandum of Agreement (IHS-MOA) and Tribal FQHCs
FQHC, RHC, IHS-MOA and Tribal FQHC providers will receive their Prospective Payment Systems (PPS) or All-Inclusive Rate (AIR) when a service related to Mpox is provided during a medical visit with a billable provider. Informational lines should include the appropriate Mpox CPT code(s) when billing for PPS or AIR services. As the reimbursement in this scenario is associated with the claim line indicating the PPS or AIR service, these claims should be submitted timely and not be held.
DHCS is also seeking federal approval for Medi-Cal to reimburse FQHC, RHC, IHS-MOA and Tribal FQHC providers a supplemental amount for Mpox vaccine-only visits that do not qualify for the PPS or AIR. The Alternative Payment Methodology (APM) payment is equal to the established FFS rate when an Mpox vaccine is administered on its own outside of a billable visit.
Medi-Cal managed care plan reimbursement for Mpox vaccine only visits to clinic providers will be excluded from the annual reconciliation process.
For additional information regarding claims processing, please refer to this resource page for Medi-Cal FFS providers: Medi-Cal: Mpox Medi-Cal Response. This page houses Medi-Cal FFS policy, benefits and provider billing instructions in a single location for ease of reference. Providers are encouraged to regularly check this page for updates on Medi-Cal’s response to Mpox.