Medi - Cal


Medi-Cal Rural Counties Expansion

The mandatory expansion of Medi-Cal managed care in the eight rural counties with County Organized Health Systems (COHS) is scheduled to begin on September 1, 2013. Beneficiaries in the counties of Del Norte, Humboldt, Lake, Lassen, Modoc, Shasta, Siskiyou, and Trinity will be enrolled into Partnership HealthPlan of California (PHC).

The remaining rural county mandatory expansion is tentatively scheduled for November 1, 2013. This date may be adjusted as the state and health plans are currently working on the final details for beneficiary enrollment. The following 18 counties will use Anthem Blue Cross and California Wellness Plan: Alpine, Amador, Butte, Calaveras, Colusa, El Dorado, Glenn, Inyo, Mariposa, Mono, Nevada, Placer, Plumas, Sierra, Sutter, Tehama, Tuolumne and Yuba. The County of San Benito will use Anthem Blue Cross and the County of Imperial will use California Health and Wellness Plan.

If you have any questions regarding the Medi-Cal managed care transition, please contact CAHSAH`s Director of Policy, Jennifer Gabales at


Department of Health Care Services Makes Changes for Medi-Cal Provider Enrollment

On January 1, 2013, California Senate Bill 1529 (Alquist), which implements the Medicaid provider screening and fraud prevention as required for states under the Affordable Care Act (ACA), will take effect. The law specifies the requirements that the Department of Health Care Services (DHCS) must follow when reviewing provider applications for participation in the Medi-Cal program.

A notice was sent by the DHCS to all providers outlining the new provider screening requirements. All provider applicants will be screened based on a categorical risk level of limited, oderate, or high. Current Home Health and Hospice providers have been identified as moderate risk providers. However, new Home Health and DME providers are listed in the ?high? risk category which requires that they provide background check clearances as part of the clearance process.

All new providers, regardless of the categorical risk level, will be subject to a new application fee of $523 unless the provider has previously paid an application fee as a Medicare provider. If they are a current Medi-Cal provider and they: change location, add a new location or change ownership they will be required to pay the new fee.

All Medi-Cal providers will also be subject to revalidation of their enrollment which will begin in two phases. The first phase will start with the Department sending revalidation notices the 2nd week of January which must be completed and returned by the provider within 35 days or they will risk termination as a Medi-Cal provider. For details on the requirements and links to additional information on the implementation of the ACA please click here.

Final Deadline for Required HIPAA 5010 Compliance

The California Department of Health Care Services (DHCS) has identified December 31, 2012, as the final date that providers can submit Medi-Cal claims in the ASC X12N 4010A1 and NCPDP 5.1/1.1 formats.

Effective on or after January 1, 2013, all 4010/4010A1, NCPDP 5.1 or 1.1 batch transactions submitted will be rejected due to HIPAA non-compliance and will not be processed or paid.

Providers who have not yet converted over to the ASC X12N 5010 and NCPDP D.0/1.2 formats are strongly advised to convert before the December 31, 2012, deadline. Xerox State Healthcare, LLC (Xerox) will mail a letter notifying all providers/submitters who have not yet been certified or converted to ASC X12N 5010 and NCPDP D.0/1.2 formats.

If you have converted to the new format, contact the Computer Media Claims (CMC) Help Desk at 1-800-541-5555, option 4 then option 2, to schedule testing to ensure your batch transactions will be processed for payment.

Additional information can be located on the Medi-Cal website under HIPAA/5010/4010/NCPDP.

Medi-Cal Fee-For-Service Provider Payment Hold

Due to cash flow shortages, the State of California will continue to implement short-term payment delays to Medi-Cal institutional providers. Payments to providers who render services through Medi-Cal funded programs scheduled for the June 28, 2012 checkwrite will be deferred to July 6, 2012. The deferral of the final June checkwrite payments to the following fiscal year will continue on a permanent basis.

The following is a list of programs impacted by this change:

    Medi-Cal (which includes Family PACT [Planning, Access, Care and Treatment])
    Healthy Families
    Child Health and Disability Prevention (CHDP), Medi-Cal funded (Aid Code 8Y)
    State-Only CHDP
    State-Only California Children?s Services (CCS)
    Genetically Handicapped Persons Program (GHPP)
    Payments to the Cancer Detection Programs: Every Woman Counts will be excluded from the last checkwrite hold for warrants dated June 28, 2012.

If you have questions, please contact us at (916) 641-5795.

Source: (DHCS)

Board Forms Managed Care Committee

Seeing increasing problems with the migration of fee for-service care to managed care in Medicare, Medi-Cal and private insurance, the CAHSAH Board of Directors established a Managed Care Committee at its April 11, 2012 meeting. The Committee will consist of approximately ten members appointed from the Board of Directors and the membership. It will inventory the major problems being experienced, analyze the nature of the problems, and meet with Managed Care organizations to seek solutions.

Members interested in being considered to serve on the Managed Care Committee should contact Joe Hafkenschiel at or 916-641-5795, ext. 118.

State Moving Toward Managed Care for Dual Eligibles

California is in the midst of formulating plans to move people eligible for both Medicare and Medi-Cal, known as dual eligibles, into a managed care environment. The state is planning a demonstration for launch at the end of 2012 that will examine the benefits of managed care by enrolling a portion of dual eligibles into this health care delivery model. Through this three-year demonstration targeting four counties (Los Angeles, Orange, San Diego and San Mateo) the state, in partnership with the federal government and California?s counties, aims to test how various models of patient‐centered care delivery can improve beneficiary health and quality of life. CAHSAH is actively involved in stakeholder meetings on the shift into managed care and has advocated on the following concerns:

  • Beneficiaries must be adequately informed of this transition.
  • The state must ensure that there is not a disruption of care to beneficiaries.
  • Beneficiaries should be able to have a choice to maintain their current providers.
  • Providers must be informed about the various managed care contract networks that the state will contract with in each of the pilot counties.

Providers who wish to gain more information on the pilot project may go here and are encouraged to enroll in the various stakeholder work groups. CAHSAH?s Medi-Cal and Medicare Committees will be meeting with state representatives to discuss provider and beneficiary concerns relative to the transition. In addition, a separate meeting is also being proposed by CAHSAH to reach out to the various managed care plans so that they understand the coverage needs and provider concerns relative to the home health benefit.

CAHSAH Requests CMS Intervention to Protect Pediatric Day Health Providers

Last week CAHSAH requested the Center for Medicare and Medicaid Services (CMS) to use its authority to ensure that Pediatric Day Health Centers (PDHC) providers do not have to shoulder the financial burden of a retroactive 10 percent provider reimbursement cut stemming from last year?s state budget. In June of 2011, California proposed and in October received CMS approval for a 10 percent Medi-Cal provider rate reduction which exempted specific provider types based on ?access to care? implications. Among the providers exempted were home health agencies, physician/clinic services for children and distinct part sub-acute facilities. However, PDHC?s were not initially exempted because the California Department of Health Care Services (DHCS) stated that they did not have all the information from PDHC?s about the potential impact of the reductions until after those reductions were implemented (according to a written statement from DHCS spokesperson Norman Williams).

In February of 2012, DHCS realized that the exemption for PDHC?s was warranted. However, DHCS is now stating that PDHC?s must submit a new state amendment plan (SPA) to obtain an approved exemption. Because a SPA cannot be retroactively implemented, restoring the 10 percent provider reimbursement cut cannot occur until April 1, 2012, thus leaving the PDHC providers to cover the 10 percent loss of reimbursement until an approved SPA is granted. Since CMS did not provide approval for a reduction to PDHC?s, it is unreasonable that DHCS is subjecting these providers to cover the period of retroactive cuts until they gain a new SPA. CAHSAH cited the precedent set by the case of Orthopedic Hospital v. Kizer, 1992 which concluded that the Department ?had a judicially enforceable obligation? to consider and make findings each time it modified Medi-Cal reimbursement rates. CAHSAH believes that DHCS had a legal obligation to analyze the impact of implementing such a cut on this specific pediatric population and has asked CMS to step in to provide the necessary authority to ensure that these providers do not incur any reimbursement cut. PDHC?s provide cost neutral services under the Medi-Cal program by enabling Medi-Cal to meet its EPSDT and Olmstead requirements and are an integral part of providing care for severely fragile children.

Home Health Spared from 10% Medi-Cal Reduction!

On Thursday, October 27, 2011, the Director of the California Department of Health Care Services (DHCS) held a conference phone call to announce that the Centers for Medicare and Medicaid Services (CMS) has approved the state?s proposed 10% reduction to Medi-Cal provider reimbursement rates for all provider types except three: physician/clinic services for children, home health services and distinct part subacute facilities. The department stated that they decided to exclude those three provider types based on the analyses and information they were given which demonstrated that the 10% reduction was unadvisable. The department?s full press release can be viewed here.

This is a major victory for both beneficiaries and providers of home health services, as it will save approximately $30 million dollars from being cut, which otherwise would have ensured a crisis to access to care throughout California. CAHSAH thanks all who took the time to respond to our call to action by writing letters to CMS opposing the 10% cut as well as those who came to Sacramento to meet with and provide information to DHCS.

CAHSAH celebrates this victory while also acknowledging the painful result this decision will have on those Medi-Cal providers not spared from the 10% reduction. Californians that depend on Medi-Cal for their well-being will face an even greater challenge in receiving critical care as providers continue to be underpaid by the state, and CAHSAH stands by ready to assist the greater Medi-Cal community however necessary.

Last week's decision comes after a comprehensive advocacy campaign by CAHSAH opposing the 10% reduction that included multiple meetings in Sacramento and a trip to Washington D.C. These efforts are a continuation of CAHSAH?s relentless pursuit of adequate Medi-Cal provider rates for home health providers that includes two lawsuits, grassroots advocacy, and lobbying activity. CAHSAH has spent nearly $1 million on our lawsuits alone; unfortunately we have only collected a fraction of these costs from our membership donations. In light of this news, and to ensure that CAHSAH?s efforts continue, we ask all home health providers to donate to the Medi-Cal Legal Defense Fund by clicking here.

ACS: New Medi-Cal Fiscal Intermediary

CAHSAH?s Medi-Cal Committee met October 19, 2011 at the CAHSAH office. The Committee was introduced to provider representatives, Ajinesh Chand and Theresa Cox from Affiliated Computer Services, Inc. (ACS) the new Medi-Cal fiscal intermediary. A.J. Chand said the HIPAA 5010 implementation for Medi-Cal would be delayed beyond January 1, 2012 because of the fiscal intermediary transition. Providers should watch for Bulletins for updates on the 5010 implementation. Click here to access Medi-Cal Bulletins. There is also an email address for 5010 questions which is

New Medi-Cal Mandatory Enrollment: Seniors and Persons with Disabilities

CAHSAH members are alerted that as a result of California?s Section 1115 Demonstration Waiver approved by the Centers for Medicare and Medicaid Services in November, 2010 and California Senate Bill 208, seniors and persons with disabilities (SPD) are switching from a voluntary to mandatory enrollment in Medi-Cal managed care. Enrollment of these beneficiaries in managed care begins June 1, 2011.

Medi-Cal beneficiaries will receive notification approximately 90 days before their birthday; generally they will have a choice of two managed care plans: a county run plan and a private plan (either Anthem Blue Cross or Health Net). Beneficiaries can also choose to remain in Medi-Cal fee-for-service. If a beneficiary does not choose before the end of their birth month, they will be assigned to a plan.

The following links provide more information and county specific information for the sixteen affected counties. link to the SPD website. This link will take you to where you can select a county and see the various informing letters that went out and the presentation flyers.

Medi-Cal Payments to Be Delayed

The State of California did not enact the fiscal year (FY) 2010-11 budget on June 30, 2010. However, the Department of Health Care Services (DHCS) directed the fiscal intermediary (HP Enterprise Services) to continue to pay Medi-Cal institutional providers through the Medical Providers Interim Payment (MPIP) fund until the loan is exhausted. It is anticipated that the MPIP fund will be exhausted with the August 12, 2010 warrant release date which equates to an Electronic Fund Transfer (EFT) deposit date of August 16, 2010. After this date, Medi-Cal institutional providers (including home health and hospice) will not receive payment until a budget is enacted, except for the institutional provider types listed below:

  • Community Hospital Outpatient Department
  • Community Hospital Inpatient
  • County Hospital Inpatient
  • County Hospital Outpatient
  • Long-Term Care (LTC) Facility
  • Pediatric Subacute Care - LTC

Medi-Cal non-institutional providers as well as hospitals and nursing facilities will continue to be paid per federal mandate.

Medi-Cal Claims Processing Revenue Codes Requirement

The Medi-Cal Fiscal Intermediary recently issued an announcement that outpatient claims submitted on the UB-04 claim form and 837 Version 4010A1 Institutional electronic claim must include valid National Uniform Billing Code (NUBC) revenue codes. Home Health and Hospice fall under outpatient services; however, at this time neither are being required to enter revenue codes but are being cautioned not to enter any data in the revenue code field as this will slow the claims processing down and require a manual review of the claim. Only EAPC claims currently require a revenue code.

Agencies should be aware that they will receive a notification when the codes for home health and hospice have been updated and the effective date to enter revenue codes on claims. For now this article outlines what will occur once the codes are in place.

  • EAPC claims must include the required revenue code in the Revenue Code field (Box 42) and the HCPCS code immediately followed by the appropriate modifier in the HCPCS/Rate field (Box 44) on the UB-04 claim form or Loop 2400, Segment SV201 Institutional Service line on the 837 Version 4010A1 Institutional electronic claim. Claims submitted without all three will be denied. At this time, only EAPC claims require a revenue code.
  • Providers should not enter information in the revenue code field unless it is a valid NUBC revenue code. Revenue codes are listed in the NUBC Official UB-04 Data Specification Manual accessed through the NUBC Web site at
  • Providers should not enter procedure codes in the revenue code field on the UB-04 claim form (box 42).
  • At a future date, claims will deny for invalid revenue codes, therefore provider billing systems should be updated now to accept NUBC revenue codes.
  • Providers should continue to use the (0001) code for the Totals line on the claim form as applicable.
  • Remittance Advice Details (RADs) will be updated in September 2010 to include revenue codes for outpatient claims.

Free eTAR Training Tools Available to Medi-Cal Providers

The Treatment Authorization Requests? (eTAR) training team would like to extend an invitation to access the free learning tools available to all Medi-Cal providers. The eTAR application is an easy, effective, fast and free way to submit TARs. Providers that utilize the eTAR application are generally more successful when submitting TARs. The eTAR webpage ( contains information useful to both new and experienced providers. Web based tutorials are available on this webpage to provide step-by-step instructions on how to submit eTARs and attachments, as well as update and inquire on previously submitted TARs. This newly updated webpage also contains Medical and Pharmacy eTAR training dates, provider bulletins and helpful tips and pointers for both Medical and Pharmacy eTAR providers.

Click here to register for an eTAR class. Regional representatives are also available to provide one-on-one training to assist providers in learning how to use the eTAR application. To request free onsite training from a regional representative, please contact Medi-Cal at 1-800-541-5555.

Medi-Cal EPSDT Changes Address for Submission of TARs

The Early and Periodic Screening, Diagnosis and Treatment (EPSDT) program?s private duty nursing and pediatric day health care (PDHC) services are transitioning from In-Home Operations (IHO), Long Term Care Division, to Medical Case Management (MCM), Systems of Care Division effective October 1. As a result of this transition, EPSDT and PDHC providers must mail TARs directly to the appropriate MCM district office. Electronic submissions will automatically be routed by the TAR system. The initial and reauthorization TAR process for EPSDT nursing and PDHC services will not change. The Department reports that other than the mailing address changes for paper TARs, the transition from IHO to MCM will be transparent to providers. Each MCM regional office covers several counties. Providers should mail completed initial or reauthorization hard copy TARs and supporting documentation to the regional addresses designated for the county in which the Medi-Cal recipient resides.

Click here for further details and to obtain the address to mail your TARs.

Medi-Cal Payment Hold Update

The Department of Health Care Services will delay the March 26th warrant date reimbursement (which means the March 30th payment) for four weeks (paid back April 27th) for Home Health and other Medi-Cal providers. The department could also hold UP TO three more payments in April for four weeks each depending on the state?s cash flow status. (The latest update is posted on the Medi-Cal website, although the language is confusing.)

Beginning the week of March 23, 2009 providers whose held amount is $5,000 or more will receive a Value of Claims (VOC) Letter from the Department of Health Care Services. The letter will specify the amount of their claims payments $5,000 and above being suppressed as a result of the March hold. The purpose of these letters is to assist providers in working with their fiduciary institutions during this payment hold.

CAHSAH and other provider associations are preparing an advocacy campaign against the payment delays if the Governor plans to delay more than two payments. Advocacy efforts have already successfully pushed the payment delays back three weeks.

CAHSAH Claims Another Victory at the 10% Medi-Cal Cut Injunction Hearing

A three-judge panel dismissed many arguments presented by the Attorney General at the February 18th appeal hearing of the 10 percent Medi-Cal cut injunction. The panel also appeared to be leaning toward granting retroactive reimbursement of the cuts back to the implementation date of July 1, 2008. If the retroactive reimbursement is granted, California Home Health providers would be reimbursed the 10 percent cut for services provided between July 1 and November 17, 2008.

Attorney Lynn Carmen, representing CAHSAH, presented compelling arguments against the 10 percent cut, specifically targeting the State's lack of analysis and consideration for how the cuts would impact beneficiaries as required by federal law. Many advocates for the rights of seniors and people with disabilities protested against the cuts outside the U.S. 9th Circuit Court of Appeals.

The three-judge panel of the U.S. 9th Circuit Court of Appeals is expected to make a decision within the next 3 to 12 months. CAHSAH's victorious injunction from November 17 will remain enforced until the panel renders a new decision. CAHSAH won the injunction when Judge Christine Snyder on November 17 ordered the injunction, saving millions of dollars to California's Home Health providers. CAHSAH filed this costly lawsuit seeking an injunction to halt the damaging 10 percent Medi-Cal cut which went into effect on July 1, 2008.

Support the Medi-Cal Legal Defense Fund: CAHSAH has spent over $150,000 in this lawsuit and has spent over $600,000 in our ongoing case seeking adequate rates for Home Health. In October, we began a campaign to raise half of the funds needed for the latest lawsuit, and thanks to our generous donors we have raised $41,000 of the $75,000 goal. Please consider contributing to CAHSAH's Medi-Cal Legal Defense Fund to ensure the viability of Home Health for Med-Cal beneficiaries in California. For information on the lawsuits, to see a list of generous donors, and to make a donation, please Click here

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