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DHCS releases Prop 56 payments to Medi-Cal managed care plans

May 09, 2019
Area(s) of Interest: Payor Issues and Reimbursement Access to Care 


The California Department of Health Care Services (DHCS) has received federal approval of its plan to increase Medi-Cal managed care physician payments for the 2018-2019 fiscal year. While DHCS had already received approval on and began distributing supplemental payments for fee-for-service claims, it had not received approval on the Medi-Cal managed care piece until earlier this year. The supplemental payments – made possible by the Proposition 56 tobacco tax funding – raises payments for a total of 23 CPT codes, including 10 new preventive codes.

DHCS released payment to the Medi-Cal managed care plans in its March capitation payments and is in the final stages of issuing formal guidance to the plans regarding the distribution to physicians.

As was the case with fee-for-service, DHCS increased the supplemental payment amount for the previously eligible CPT codes to 85% of Medicare (a 34% average increase in payments for these eligible codes compared with 2017-2018 payment levels). The 10 newly added preventive CPT codes will be paid at 100% of Medicare.

There is no additional action required by providers who are submitting claims to the managed care plans and are reimbursed on a fee-for-service basis. However, physicians who have a capitated contract with either a Medi-Cal managed care plan or one of its delegated groups for eligible services must submit encounter data to the payor in order to receive the supplemental funds. Without the encounter data, the plan or its delegated entity is unable to determine the services eligible for payment, which will result in non-payment of the supplemental funds. If you are unsure how to submit encounter data, contact the plan or delegated entity for more information.

Plans will have 90 calendar days from receipt of the funds from DHCS to distribute the supplemental payments to eligible physicians. A full list of the eligible CPT codes is listed below.

 

CPT CODE

DESCRIPTION

*2016 FFS
BASE RATE

2018 BASE RATE
W/ PROP 56
SUPP FUNDS

% INCREASE

         

99211

Level 1 Est. Pt Visit

$10.80

$20.80

93%

99212

Level 2 Est. Pt Visit

$16.29

$39.29

141%

99213

Level 3 Est. Pt Visit

$21.60

$65.60

204%

99214

Level 4 Est. Pt Visit

$33.75

$95.75

184%

99215

Level 5 Est. Pt Visit

$51.48

$127.48

148%

99201

Level 1 New Pt Visit

$20.61

$38.61

87%

99202

Level 2 New Pt Visit

$30.87

$65.87

113%

99203

Level 3 New Pt Visit

$51.48

$94.48

84%

99204

Level 4 New Pt Visit

$62.01

$145.01

134%

99205

Level 5 New Pt Visit

$74.43

$181.43

144%

90791

Psych diagnostic eval

$115.27

$150.27

30%

90792

Psych diagnostic eval w/ medical svcs

$92.93

$127.93

38%

90863

Other psych services - pharmacologic mgmt

$20.60

$25.60

24%

99381

Prev. Visit Est. Pt Ages < 1 year

$40.80

$117.80

189%

99382

Prev. Visit Est. Pt Ages 1-4 Years

$42.42

$122.42

189%

99383

Prev. Visit Est. Pt Ages 5-11 Years

$49.35

$126.35

156%

99384

Prev. Visit Est. Pt Ages 12-17 Years

$59.20

$142.20

140%

99385

Prev. Visit Est. Pt Ages 18-39 Years

$102.69

$132.69

29%

99391

Prev. Visit New Pt Ages < 1 Year

$31.22

$106.22

240%

99392

Prev. Visit New Pt Ages 1-4 Years

$33.65

$112.65

235%

99393

Prev. Visit New Pt Ages 5-11 Years

$39.47

$111.47

182%

99394

Prev. Visit New Pt Ages 12-17 Years

$49.35

$121.35

146%

99395

Prev. Visit New Pt Ages 18-39 Years

$92.61

$119.61

29%

 

Physicians with questions can contact Medi-Cal’s Telephone Service Center at (800) 541-5555 or CMA’s Reimbursement Helpline at (888) 401-5911 or email us.

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