Third Supplemental COVID-19 Payment Extended Until June 30, 2023 |
On June 2, the CalOptima Board of Directors approved extending the third temporary 5% supplemental COVID-19 payment increase for certain medically necessary services through June 30, 2023.
Effective July 1, the short-term supplemental payments, totaling up to $58.2 million for providers, hospitals and health networks, are intended to help providers promote and administer COVID-19 vaccinations, cover increased costs for testing and treatment, and help address additional variants of the COVID-19 virus. The payments apply to compliant, directly contracted Medi-Cal providers. They cover services provided to CalOptima Community Network (CCN) and CalOptima Direct (COD) members, including Behavior Health provider services for all CalOptima members.
The Board initiated the supplemental payments in 2020 after recognizing the additional strain put on providers by the pandemic and the potential for interruption in necessary Medi-Cal services for CalOptima members. Since January 2021, the Board has both increased and extended the payments several times. The last supplemental payment extension began January 1, 2022, and was set to expire June 30, 2022. Further, the agency is continuing to protect providers from $6 million in Medicare cuts, maintaining maximum reimbursement in programs serving seniors.
Services excluded from the Medi-Cal supplemental payments include:
- Pharmacy and pharmacy benefit management services, and other contracted administrative service providers for which CalOptima covers the cost of claims
- Nonpharmacy administered drugs
- Long-term care facilities
- Durable Medical Equipment, orthotics and prosthetics, and other medical devices
- Members in CalOptima’s Program for All Inclusive Care for the Elderly (PACE), OneCare and OneCare Connect
- Crossover claims
- Other supplemental or directed payments, such as Proposition 56
- Claims paid by Letter of Agreement (LOA)
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Guidance for Orange County Families With Infants During the Infant Formula Shortage |
A nationwide shortage of infant formula has been ongoing for several months. While a number of measures are being taken at the federal level and through the California Department of Public Health/Women, Infants & Children Program (CDPH/WIC) to increase access to formula, intermittent and sporadic shortages have been reported. Concerns about finding sufficient formula have led to reports of unsafe practices, such as diluting formula or using homemade formula.
Health care providers should support parents and caregivers of infants by:
- Affirming parents’ concerns
- Reinforcing the messages for families and providing the resources below, including printed copies of the page or handouts as needed
- Encouraging and supporting breastfeeding, including helping to arrange for breast pumps and facilitating lactation support, if needed
- Assisting families with selecting alternative formulas and requesting specialty (therapeutic) formulas from the formula manufacturer
- Evaluating mental health needs and making referrals for support as appropriate
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Reporting any suspected or confirmed adverse clinicla outcomes (such as hospital admission that may be a result of inadequate infant nutrition due to the formula shortage to Orange County Health Care Agency at 714-834-8180 or epi@ochca.com
Resources for health care providers:
Resources to share with your patients with infants:
For patients who are breastfeeding or considering breastfeeding:
Instructions on safely preparing formula:
- Infants need a specific balance of nutrients for their growth. Infant formula is strictly regulated by the FDA to not only be as close as possible to human milk, but also safe and free of harmful bacteria.
- Follow the mixing instructions on the label for the formula; do NOT overdilute the formula to stretch the quantity out.
- Avoid making or feeding homemade formula.
- Avoid feeding infants under one year of age cow milk (or other animal milk besides human milk) or other milk substitutes (such as almond or soy beverages).
- Avoid feeding infants toddler formula.
- Avoid using imported formulas from other countries that have not been reviewed by the FDA.
Help your patients find formula:
- Call the vendor (store) ahead of time to see if they have the formula in stock.
- Try another store if the one you usually frequent is out of your formula.
- WIC clients:
- Redeem your WIC benefits as soon as they are redeemable.
- Note that more trips to the store may be required as there may be a limit on how many cans of formula may be purchased at one time.
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Contact your issuing WIC agency if you are unable to locate formula after trying several stores in your area.
- Non-WIC clients: Contact the Health Referral Line at 1-800-564-8448 if you are unable to locate formula after trying several stores in your area.
- Ask a health care provider for guidance on alternative formulas you can use. Babies usually tolerate alternative products except in the case of special therapeutic formula. For babies on therapeutic formula, your health care provider may be able to request limited amounts of formula directly from the manufacturer if there is an urgent health need.
Resources:
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DHCS Releases Unwinding Plan for End of COVID-19 Public Health Emergency |
As the declared PHE for the COVID-19 pandemic was set to expire on July 15, 2022, DHCS released its Medi-Cal COVID-19 PHE Operational Unwinding Plan on May 17. The plan describes how DHCS will approach resuming normal Medi-Cal operations and either unwind or make permanent temporary flexibilities implemented during the PHE.
Since 2020, DHCS implemented more than 100 program flexibilities to minimize strain on the Medi-Cal program, providers and members. Many of these flexibilities will end with the PHE, but those with the most positive impact on Medi-Cal will continue. Additionally, the Families First Coronavirus Response Act requires California to maintain the enrollment of all Medi-Cal enrollees through the end of the month in which the PHE terminates. Afterward, California must conduct a full redetermination of all Medi-Cal members.
The PHE Operational Unwinding Plan also contains information about the DHCS Coverage Ambassadors campaign and links to guidance documents from the Centers for Medicare & Medicaid Services (CMS).
It is likely that the PHE will be extended beyond the July 15 end date. The U.S. Department of Health and Human Services has committed to providing at least a 60-day notice prior to the end of the PHE.
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CalOptima Revises Authorization Request Process for Physician Administered Drugs |
On June 13, CalOptima revised its process for prior authorization (PA) requests for physician administered drugs (PADs). Please submit all faxed PA requests for PADs to our new fax number, 657-900-1649. The Authorization Request Form (ARF) has been updated to reflect this change.
The most efficient process for submitting PA requests to CalOptima is through our secure Provider Portal. To learn more about the CalOptima Provider Portal, please click here.
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July Virtual Learn Meeting to Cover Important Provider Topics |
CalOptima’s Provider Relations team invites all CCN providers to a Virtual Learn Meeting on July 19, 2022, at Noon to learn about important updates.
The one-hour meeting will cover topics such as modifications to prior authorizations and alternative format selections. There will also be a presentation by the Orange County Social Services Agency on the CalFresh monthly food benefit program. Providers, physicians, office managers, back-off billing staff and authorization staff are all invited to attend.
Meeting ID: 872 6327 6535
Password: 241312
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DHCS Adds Requirement for Discharge Hour in PACE Claims |
Under new direction from DHCS, all PACE inpatient claims must include a discharge hour for members starting July 6, 2022.
This change, found in the most recent version of DHCS’ 837 Institutional Encounter Data Transaction companion guide, mandates a discharge hour be included for all Inpatient 8371 encounters when the CL103 Patient Status Code value indicates that a member was discharged. Failure to include a discharge hour will result in an error code and denial message.
For more information and the format for including the discharge hour, see 3.27 in the 8371 Companion Guide here.
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Recent adjustments to the Milliman Care Guidelines (MCG) covers Newborn Intensive Care Unit (NICU) extended stay cases, such as sepsis or severe infections, and affects the following criteria:
In certain cases, California Children’s Services (CCS) criteria supersedes MCG which applies to the following:
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CDC Lowers Threshold for Elevated Lead Levels in Blood Screenings |
The Centers for Disease Control and Prevention (CDC) has announced a change in what is considered an elevated level of lead found during blood screenings for children enrolled in Medi-Cal.
The change lowers the blood lead reference value (BLRV) from 5 micrograms per deciliter (mcg/dL) to 3.5 mcg/dL. The CDC’s Childhood Lead Poisoning Prevention Branch (CLPPB) will update the California Management Guidelines and all required documents with the new threshold level.
For more information, providers can find the CDC’s Recommended Actions Based on Blood Lead Level here, as well as CDPH resources here.
For CCN providers, the blood lead screening quarterly performance report for Q2 will be shared via CalOptima’s Provider Portal on Tuesday, July 12, 2022. Providers must retrieve this report, reconcile it with internal member medical records for accuracy and screen members for lead if they are due.
If providers have any question about blood lead level screenings, please contact CalOptima’s Population Health Management department at QI_Initiatives@caloptima.org.
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DHCS Alternative Format Resources Help Medi-Cal Providers Comply with ADA |
To better help providers comply with the Americans with Disabilities Act (ADA), DHCS has resources for providing written communications in alternative formats to members with visual impairments or other disabilities.
DHCS’ policy, which is in line with Title II of ADA, is that Medi-Cal members must receive the necessary auxiliary aides and services to accommodate disabilities to ensure they benefit equally from government services. This includes providing materials in Braille, audio, large print, data CD or other appropriate formats, depending on a member’s individual situation.
Providers can learn how to request materials in these alternative formats using the Alternative Format Selection Application User Guide found on DHCS’ website.
Providers with questions regarding ADA compliance can call CalOptima’s Provider Relations department at 714-246-8600 or email providerservices@caloptima.org
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OCC Shares Best Practice and Resources for Treating Alzheimer’s and Dementia |
As June is Alzheimer’s & Brain Awareness Month. please note the following best practices and resources for members at risk for dementia and Alzheimer’s:
Providers should also use these codes to document dementia and other cognitive impairments.
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APLs Gives Guidance on Threshold Language Requirements, Non-Emergency Transportation Services and Preventive Health Services |
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On June 1, 2022, DHCS distributed its second annual Preventive Service Report, which describes how managed care plans (MCPs) deliver preventive health services to children.
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Policies and Procedures Monthly Update |
Click on the link below to find an outline of changes made to CalOptima policies and procedures during May 2022. The full description of the policies below is available on CalOptima’s website at www.caloptima.org.
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Health Education: Trainings and Meetings |
Click below for a list of training webinars and links happening in June 2022:
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Based on Medi-Cal Bulletins and NewsFlashes, CalOptima has updated the procedure codes for the subjects listed below:
- Medi-Cal Subscription Service is Coming Back
- Billing Multiple NCCI Modifiers Together and Additional NCCI Webpage Resources
- CHDP Gateway Program 2022 Income Eligibility Guidelines
- CAR-T Cell Therapies Policy Update
- Claims Reimbursement Update for Medical and Incontinence Supplies
- Provider Manual Revisions
- LTC Providers Will Transition to the UB-04 Claim Form
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2022 HPE Income Eligibility Guidelines
- 2022 Income Eligibility Guidelines for PE4PW
- Hepatitis B Vaccine Code 90759 is Now a Medi-Cal Benefit
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- CalOptima Board of Directors: August 4 at 2 p.m.
- CalOptima Provider Advisory Committee: August 11 at 8 a.m.
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Follow CalOptima on Social Media |
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CalOptima regularly posts on social media to engage members with heath tips, community resources, event dates, program updates and other pertinent information. Follow the agency on Facebook, Instagram, Twitter and LinkedIn.
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CalOptima, A Public Agency www.caloptima.org
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