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DHCS instructs plans on 2018/19 supplemental Prop 56 managed care payments

July 01, 2019
Area(s) of Interest: Practice Management 


On June 13, 2019, the California Department of Health Care Services (DHCS) issued instructions for Medi-Cal managed care plan distribution of the supplemental payments for FY 2018-2019.  While DHCS released funds to the managed care plans in its March capitation payments, it was not until recently that it provided guidance to the plans on the distribution of funds to physicians.

The supplemental payments – made possible by the Proposition 56 tobacco tax funding – increase payments on 23 CPT codes, including 10 new preventive codes. 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%

 

Medi-Cal managed care plans are required to distribute supplemental payments to physicians within 90 calendar days of receipt of the funds from DHCS. At the request of the California Medical Association (CMA), DHCS clarified that this 90-day requirement includes delegated entities and subcontracts.

The 90-day requirement to distribute payment applies both to the go-forward payments and to the retroactive payment of clean claims or accepted encounter data with dates of service between July 1, 2018, and the date the plan received the Prop. 56 funds.

DHCS issued capitated payments to plans throughout the month of March, so physicians should see their supplemental payments by the end of June or early July (i.e. 90 days after the plans received the money).

How do I know if I’ve been paid correctly?

While some plans continued to make supplemental payments at the FY 17-18 amounts for services provided in FY 18-19, some plans chose to wait until the final guidance was issued before distributing the funds, making reconciliation more difficult. CMA is currently updating its Prop 56 Payment Monitoring Worksheet to help physicians determine whether they have been paid correctly based on the FY 18-19 supplemental payment amounts. (If you would like to be notified when the new worksheet is available, email economicservices@cmadocs.org.)

Is any physician action required to receive the supplemental payments?

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 entities 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 will be 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.

Physician with questions should contact the managed care plan directly. More information on Prop 56 can be found on the DHCS website.

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