The Centers for Medicare & Medicaid Services (CMS) on Monday approved rule changes sought under an 1135 waiver request that will enable the California Department of Health Care Services (DHCS) to more effectively and efficiently deliver care to Californians covered by Medi-Cal during the COVID-19 emergency. The waiver is retroactive to March 1, 2020.

DHCS requested a series of rule waivers under Section 1135 of the Social Security Act used to provide flexibility during national health emergencies. Portions of California’s requests were granted by CMS in a March 23, 2020, letter.

Prior Authorizations: CMS has waived prior authorization requirements in the Medi-Cal fee-for-service (FFS) delivery system and offered extensions for pre-existing prior authorizations in Medi-Cal FFS through the end of the declared public health emergency.

Hearing Requests: CMS has approved allowing enrollees to have an additional 120 days to appeal or request a fair hearing on eligibility or fee for service issues. CMS also approved reducing the time required for managed care plans to resolve beneficiaries appeals to only one day so that they can go straight to a state fair hearing, without having to go through the manage care plan’s appeal process first. 

Out of State Physicians: To grow our supply of providers, the waiver permits California to reimburse out-of-state providers for multiple instances of care to multiple beneficiaries. For providers that are not already enrolled with another state Medicaid agency or Medicare, CMS is waiving certain requirements, such as the fingerprint background check, so that the provider can be temporarily enrolled for the duration of the emergency.

Provider Revalidation: CMS approved California’s request to temporarily cease revalidation of current providers who are located in California or otherwise impacted by the emergency.

Site of Service: To expand the places in which services can be provided, CMS is permitting certain types of licensed facilities, including nursing facilities, to be fully reimbursed for services rendered in an unlicensed facility, provided that the unlicensed facility meets minimum standards.

According to DHCS, CMS is still reviewing a number of California’s remaining 1135 requests. These include requests to 1) waive the “face-to-face encounter” requirement for reimbursement in FQHCs, RHCs, and Tribal 638 Clinics, 2) extend the limitations for elective procedures and informed consent in order to prioritize COVID-19 response activities, and 3) suspend the limitations on the 100-day supply of covered pharmaceuticals, excluding narcotics and opioids.

We will provide additional information on these pending requests when it becomes available.

The full details of the 1135 waiver can be found in this California Medical Association Fact Sheet.