Saturday, December 16, 2017

OCMA Blog

DHCS Releases Online UCR Attestation Form for ACA Primary Care Rate Increase

The federal Affordable Care Act (ACA) included an increase in reimbursement to eligible primary care physicians for specified services provided from January 1, 2013 through December 31, 2014. Payments for services rendered to Medi-Cal patients will be reimbursed at Medicare rates for the two-year period.
 
However, according to DHCS and CMS policy, total payment for services rendered may not exceed a provider's billed charges. Due to system limitations at the DHCS, providers may be restricted from billing their usual and customary rates on the PM-160 billing form. In most cases, providers have adapted to this restriction by billing at the expected Medi-Cal reimbursement rate for services provided to Child Health and Disability Prevention Program (CHDP) participants. This has created a problem for physicians anticipating the higher reimbursements, as according to DHCS and CMS policy, the providers have been paid at billed charges and are not owed additional ACA reimbursement.  As a result, millions of dollars in payments to California physicians have not been released.
 
CalOptima and other California managed care plans have been working with the DHCS for several months to develop a solution that wouldn't require physicians to re-bill all eligible CHDP claims in order to obtain the increase. At the urging of physician advocacy groups such as CMA, OCMA and other stakeholders, the DHCS has agreed to a workaround that would allow these practices to be paid at the higher rate without the inconvenience of rebilling each claim. 
 
DHCS recently released an online form where providers may attest to their usual and customary rates for CHDP services, allowing the practice to receive the higher reimbursement intended by the ACA rate increase. This attestation must be completed by November 28, 2014. The form may be found online at: http://files.medi-cal.ca.gov/pubsdoco/ACA/articles/acanews_23115_1.asp
 
DHCS recently announced it intends to make an interim payment on CHDP claims in December, with a true up to occur in 2015.

Mental Illness and the ACA — Expanding Behavioral Health Benefits and Fighting Stigmas

By Donald Sharps, M.D.
CalOptima Behavioral Health Medical Director

The phrase, “people fear what they do not understand,” is true when dealing with the stigma that surrounds mental illness. In the media, behavioral health is often blamed for irrational behavior and acts of violence. In schools and offices, you can hear name-calling using words like crazy, insane or psycho. A lack of awareness continues to spread this stigma and it can be a barrier for people to get behavioral health services to improve their quality of life. 

Just as diabetes is a disease of the pancreas, mental illness is a disease of the brain. People are not their diseases. Be aware and do not label a person as schizophrenic or bipolar. A person can have schizophrenia or a bipolar disorder, just as a person can have diabetes. It is important that people increase their awareness of mental health and wellness to reduce the stigma of mental illness. To accept and cope with having a mental illness is difficult enough. It is even harder when a person feels there is a stigma associated with mental illness. Treatment is available for behavioral health issues and it is possible for people to achieve and maintain recovery.

How has the Affordable Care Act changed the way people access behavioral health services and treatment for mental health disorders?

As of January 1, 2014, the Affordable Care Act (ACA) expanded health care benefits to include behavioral health services. However, many people still do not access services for reasons ranging from lack of awareness, to the fear of being labeled and being treated differently. By reducing the stigma of behavioral health issues, we can assist people in getting the needed treatment that is available to them.
With ACA, Medi-Cal has expanded so that more people are eligible, by providing coverage for people who earn up to 138 percent of the federal poverty level (about $15,800 for an individual). It has also increased coverage among non-elderly adults by extending Medi-Cal eligibility to childless adults and increasing Medi-Cal eligibility for parents who lose access when their income fluctuates and slightly exceeding the poverty level.

The ACA also ensures that all health plans offer a comprehensive package of services, known as essential health benefits, which includes Mental Health and Substance Use Disorder Services. 

These Behavioral Health Services are now available to all Medi-Cal members:

  • Individual and group psychotherapy
  • Psychological testing to evaluate a mental health condition
  • Psychiatric consultation and ongoing treatment, that cannot be managed at the primary care level of health care
  • Screening, Brief Intervention, and Referral to Treatment (SBIRT) provided in a primary care setting for alcohol misuse
  • Drug Medi-Cal Services

Members can call the Orange County Mental Health Plan Access Line at 1-800-723-8641 for screening and referral to services. Primary care providers, network providers, community-based organizations and county programs can also call the Access Line. This line is available 24 hours a day, 7 days a week.

To get information regarding the Drug Medi-Cal County Alcohol and Other Drug Program (AOD), call the OC LINKS behavioral health services and referral line at 1-855-OC-LINKS (1-855-625-4657).


Health Reform Heats Up

By James Noonan, CMA Staff Writer

More than three years have passed since the Affordable Care Act (ACA) was into law, setting into motion some of the most dynamic and volatile years the nation’s health care industry has ever seen.

Since its inception, the law has been a subject of controversy, inspiring hotly contested debates in Washington, D.C., Sacramento and across the entire nation. For some, this dramatic overhaul of the nation’s health care system represents our national leaders finally making good on the long-overdue promise of “health care for all.” Others claim that the law is a clear overreach of federal authority that threatens to overburden an already fragile economy.

Although the law remains controversial, the United States Supreme Court has ruled that the law is constitutional and active steps are being taken to move forward at the federal and state level.

Despite being signed into law more than three years ago, the vast majority of activity has yet to come. With many of the provisions set to take effect on January 1, 2014, state officials across the nation are scrambling to make sure they’re ready to implement the law’s sweeping changes.

The road has already been a somewhat rocky one.

Throughout the implementation process, the U.S. Department of Health and Human Services has been narrowly meeting its own deadlines, often times leaving states waiting for federal guidance that could dramatically alter their own implementation plans. With several major deadlines coming in the next few months, many observers expect this problem to only get worse.

Adding to the headache for the federal government is the fact that the ACA has received mixed support from the states, which has complicated implementation efforts nationwide. As of early February, only 19 states had elected to develop their own state-run “exchange,” an online marketplace where consumers can purchase subsidized coverage. An additional five states will form state-federal partnerships to operate their marketplaces, while the remaining states have declined to participate, meaning the federal government will be responsible for operating exchanges in those areas.

Despite these problems, the march toward reform continues on.

The Next Major Milestone

The next major milestone toward full implementation is set to take place on October 1, 2013, when state exchanges are set to begin their pre-enrollment. In the first years following these marketplaces going live, more than 32 million currently uninsured Americans are expected to gain coverage, either through an exchange plan or the ACA’s massive expansion of the Medicaid program. Some analysts expect as many as 5 million of these newly insured to come from California.

Three months after the pre-enrollment begins, January 1, 2014, exchanges are set to go live, meaning that millions of Americans will, for the first time, be able to purchase coverage using the federal subsidies promised in the ACA.

In order to navigate this massive undertaking, states will need to decide which plans will be offered through their exchanges, construct the actual online marketplaces through which consumers will purchase coverage and implement major public outreach campaigns to ensure that these citizens – many of whom have never had the benefit of “open enrollment” or a similar purchasing period – understand how and where they can sign up for coverage under the reform law.

The task is daunting on its own, but with a deadline looming only months out, skeptics would be forgiven for questioning whether such a task is even possible.

California Leads the Way

Despite the uncertainty swirling around the ACA’s implementation, California looks to be on track to meet the coming deadlines.

In the days following the ACA’s passage, California was the first state to establish a health benefit exchange (Utah and Massachusetts were operating their own versions of an exchange before the ACA was signed into law) and has been working toward implementation ever since. That exchange, recently named Covered California, has already launched its online consumer marketplace, www.coveredca.com, and is one of 25 states that have gained conditional approval from the federal government to operate its own insurance marketplace.

There is, however, still much work to be done at the state level.

Unlike most other states, California opted to adopt an “active purchaser” model when building its new exchange, meaning Covered California’s Board of Directors will be responsible for selecting which insurance providers will be allowed to offer products on the exchanges. The selected products, known as qualified health plans (QHPs), will be required to meet a set of benefit standards finalized by the Covered California board late last year. The QHPs will be selected through a competitive bidding process set to begin in the coming months, and it’s anticipated that somewhere between three to five QHPs will be selected for each one of California’s 19 geographical rating regions.

While the selection process is still far from over, it looks as though the Covered California board will not be short on options when it comes time to award the QHP designation. In October, more than 30 distinct insurance providers issued a “notice of intent to bid” to the board, and most of the state’s major insurance providers have since gone public with their intent to participate in California’s exchange.

The fact that insurance companies appear more than willing to play ball with the exchange, and that Covered California was established as an independent government entity operating outside the control of the Legislature and governor, means that the exchange’s Board of Directors has a considerable amount of power when it comes to shaping California’s post reform heath care landscape.

Protecting Physician Interests

Unfortunately several recent decisions by the exchange board have placed California’s physician community on its heels. The California Medical Association (CMA) has been an active participant in stakeholder hearings and is working to ensure that the interests of physicians and their patients are taken into consideration as the exchange prepares to open for business.

Several of issues of concern arose when the board was working to finalize the benefit standards that interested payors will be required to meet in order to have their products considered for the QHP designation. One major concern for physicians is how the exchange plans to deal with monitoring and ensuring network adequacy among of QHPs.

Throughout the benefit design conversation, exchange staff continued to favor the existing method of network monitoring, which calls for the Department of Managed Health Care (DMHC) and Department of Insurance (DOI) to be responsible for ensuring that plans offered to consumers have enough participating providers. In other words, the status quo. Several stakeholders, including CMA, have noted that those two entities are currently unable to ensure adequate networks among existing plans and would likely be overwhelmed by the added task of monitoring additional exchange products. While CMA asked that the exchange take an active role in monitoring networks beginning in 2014, the DMHC/DOI method remained in the final benefit standards adopted by Covered California’s Board of Directors in August, meaning it could become the norm once the state’s marketplace goes live.

CMA also voiced concern over the exchange’s handling of the “grace period” provision included in the ACA. Under current California law, patients who are delinquent on their premiums are allowed a full 90 days to settle up before their policy is terminated for nonpayment. However, under the ACA’s grace period provisions, exchange plans will be allowed to suspend payment for services rendered if an enrollee is more than one month delinquent. If the patient fails to settle up within the three-month grace period, the plan can then terminate coverage for nonpayment and deny all pending claims for services. In this scenario, physicians could potentially be on the hook for 60 days worth of services with no avenue for recourse.

CMA has repeatedly asked Covered California’s board to reconcile the state and federal policies, but to date an adequate fix has not been presented.

Given the exchange’s accelerated timeline, as well as the exchange board’s tendency to revisit issues that were previously thought to be decided, it remains possible that both of these matters, along with others that have caused concern to physicians, could see some sort of resolution before 2014.

Action Under the Dome

With all of the moving pieces present between the federal government and California’s exchange board, it’s sometimes easy to forget that the state Legislature is also playing a large role in ACA implementation, so large, in fact, that Gov. Jerry Brown saw fit to call for a special session dedicated to health care reform in California.

A total of six bills (three identical proposals being heard in both houses of the Legislature) were introduced during the special session, seeking to address individual market reforms (ABX1-1 and SBX1-1), Medi-Cal expansion (ABX1-2 and SBX1-3) and a proposal to establish a “bridge plan” (ABX1-2 and SBX1-3) that would allow for a seamless transition between Medi-Cal and exchange plans for those individuals whose income may fluctuate past the income thresholds called for in the ACA.

Special sessions usually are reserved for a dire situation in need of immediate legislative action, which makes it somewhat surprising that members of the Legislature allowed the spring recess – their “soft deadline” for special session legislation – to come and go without any major action on these bills. As of early April, the individual market reform and Medi-Cal expansion bills had cleared their houses of origin and were set to be heard in committees within the second house, while the bridge plan proposal had yet to be heard on the floor of either house.

There’s also a considerable amount of activity related to health reform taking place outside of the special session, specifically regarding scope of practice expansions as a way of addressing the access to care issues that will inevitably take place when millions of currently uninsured Californians gain coverage beginning in 2014. Three bills, all authored by Sen. Ed Hernandez (D-West Covina), seek to expand the respective scope of practice for pharmacists, optometrists and nurse practitioners, while a fourth, authored by Sen. Fran Pavley (D-Agoura Hills) would call for a similar expansion for physicians assistants.

The ACA had two major goals: First, to expand access to health coverage to all, and second, to ensure efficient, high quality care. Those who are now invoking the ACA as the sole justification for allowing non-physicians to diagnose and treat California patients and perform complex medical procedures are attempting to achieve the first goal by undermining the second. Allowing non-physicians to practice beyond their training can only lead to inferior outcomes, higher costs and greater fragmentation of care.

CMA will be closely following and fighting these scope bills, working to ensure that California meets the ACA's objectives without eroding quality or jeopardizing patient safety.

To be sure, the next few months will be some of the most important and tumultuous times the medical community has faced in recent memory, but as a CMA member you have the comfort of knowing that your interests are being advocated for in front of all the key players driving the nation’s reform efforts.


Medi-Cal Requiring Re-Enrollment

The California Department of Health Care Services (DHCS) will soon be notifying physicians that they must re-enroll in Medi-Cal as one of the provisions of the Affordable Care Act (ACA). The ACA requires every state Medicaid program (Medi-Cal in California) to re-validate provider enrollment information at least every five years  beginning January 2, 2013.

DHCS is currently working to identify an initial list of all physicians and other providers who will be required to re-validate. Notices of re-validation will be mailed beginning the second week of January 2013. Notices will be sent to business location on file with DHCS. Each notice will include information on which application(s) must be completed. Anyone receiving a notice must complete and return the requested form(s) and required attachments within 35 working days of the date of the notice. Failure to do so may result in payment delays.

Physicians who have re-validated, updated or submitted new applications to the Medicare program within the last 12 months (January 1 through December 31, 2012) will not be required to re-validate at this time. However, your Medicare enrollment information must match the information on file with the Medi-Cal program. If it does not you will receive notice from DHCS requiring you to re-validate.

The California Medical Association (CMA) and DHCS have worked collaboratively over the past year to establish a phased, tightly-controlled re-enrollment process within the confines of current state and federal laws and regulations.

In addition, CMA will host two live webinar training courses with representatives from DHCS to walk attendees through the Medi-Cal enrollment process for both individual providers and groups. Also to be discussed will be program requirements and how to avoid common mistakes that can lead to delays, denials and exclusion from the Medi-Cal program. These extended-length webinars will be held November 15, 2012, and January 16, 2013, from 12:15 to 1:45 pm. These webinars are free and open to everyone.

OCMA/CMA members can contact the CMA reimbursement helpline: (888) 401-5911 or economicservices@cmanet.org


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