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NEWS & UPDATES
Contract Drugs List (CDL)
October 22, 2021
What is the Contract Drugs List (CDL)?
The CDL is found on the Medi-Cal Rx Web Portal and contains the searchable Medi-Cal Formulary. The CDL displays drugs covered by Medi-Cal without a prior authorization (PA).
How Does It Affect Prescribers?
The searchable CDL allows prescribers to easily identify all covered drugs.
What Should I Do?
Registering for the Medi-Cal Rx Web Portal allows for easy access to the Provider Portal, where the CDL can be found through the Forms & Information link on the left-hand side of the screen.
The CDL may also be found in the Tools & Resources drop-down menu on the Education & Outreach page.
Medi-Cal Rx Pharmacy Providers Electronic Fund Transfer Set Up and Opt Out
Original Published October 12, 2020; Update Published October 11, 2021
The Department of Health Care Services (DHCS) continues to make significant progress and movement toward a full assumption of operations of all pharmacy services on January 1, 2022, to Medi-Cal Rx. To help facilitate a smooth and effective transition for Medi-Cal pharmacy providers, DHCS will be transferring previously established Electronic Fund Transfer (EFT) account information from the existing Medi-Cal fee-for-service (FFS) Fiscal Intermediary to Medi-Cal Rx. However, for those pharmacy providers that do not wish to have their EFT account information transferred over to Medi-Cal Rx for use after the January 1, 2022 assumption of operations, an option to ‘Opt Out’ is available.
Note: Pharmacy providers that submitted their opt out requests during the first and second opportunities in October 2020 and January 2021 need not opt out a third time.
EFT allows pharmacy providers the option of receiving Medi-Cal payments via direct deposit. Through EFT, pharmacy providers may have their payments electronically deposited into their bank accounts and eliminate the need for paper warrants.
For those Medi-Cal pharmacy providers that have an established EFT account with the existing Medi-Cal FFS Fiscal Intermediary, as of October 11, 2021, no action is required if those Medi-Cal pharmacy providers do not Opt Out of the transfer. EFT account information for those providers will be used after assumption of operations for Medi-Cal Rx on January 1, 2022.
Medi-Cal Managed Care All Plan Letter 20-022 Released on COVID-19 Vaccine Administration
August 9, 2021
Consistent with the approach being taken by Medicare through Medicare Advantage Plans, DHCS will carve out the COVID-19 vaccines and associated administration fees from the Medi-Cal managed care delivery system and will reimburse providers under Medi-Cal fee-for-service (FFS) for medical, pharmacy, and outpatient claims. This approach will ease program administration, eliminate challenges with out-of-network provider reimbursements, and keep vaccine administration fee rates consistent for providers regardless of delivery system. […]
Although both the COVID-19 vaccines and associated administration fees will be carved out of the Medi-Cal managed care delivery system to Medi-Cal FFS, including in-home vaccinations, MCPs are reminded that they remain contractually responsible for providing case management and care coordination for their members regardless of whether or not they are financially responsible for the payment of services.
MCPs are encouraged to identify opportunities to use their existing communication pathways to support dissemination of CDPH COVID-19 public health education materials and provider education resources. MCPs should utilize their existing data sources to help identify members who qualify to receive the COVID-19 vaccine in accordance with CDPH guidelines, and attempt outreach to qualifying members and their providers to encourage receipt of the COVID-19 vaccines. MCPs are responsible for coordinating medically necessary care. Care coordination may involve, but is not limited to, assisting members with accessing COVID-19 vaccine administration locations, including non-emergency medical transportation and non-medical transportation as needed, and helping members receive the required number of doses for the COVID-19 vaccines in a timely fashion.
Medi-Cal Rx Implementation Update
August 2, 2021
Medi-Cal Rx is an important initiative for improving health care delivery by standardizing the Medi-Cal pharmacy benefit under one delivery system and improving access to pharmacy services with a network that includes a large majority of the state’s pharmacies. On July 27, 2021, DHCS announced that it accepted a Conflict Avoidance Plan submitted by its Medi-Cal Rx vendor, Magellan Medicaid Administration (MMA), Inc., a subsidiary of Magellan Health, Inc. (Magellan), to mitigate conflicts associated with the proposed acquisition of Magellan by Centene Corporation. As a result of the acceptance of the Conflict Avoidance Plan, DHCS has determined that full Medi-Cal Rx implementation will begin on January 1, 2022. The Conflict Avoidance Plan is posted on the DHCS website.
Click here to read the full DHCS Medi-Cal Rx implementation update and conflict avoidance plan.
Medi-Cal News: Update to Allowable Specialized Services
July 8, 2021
Effective for dates of service on or after July 1, 2021, the list of specialized services that can be billed on an outpatient claim, even when provided on an inpatient basis, is updated. Existing policy currently in place for other allowable specialized services shall remain in place.
Medi-Cal News: Erroneous Payment Corrections for NovoEight Products
May 13, 2021
The article titled “Erroneous Payment Corrections for NovoEight Products” was posted to the Medi-Cal News area of each provider community page on the Medi-Cal Provider website.
If the above link does not take you to the article, then simply copy and paste the following link into your browser.
New Link for Medi-Cal Rx Updates for Rx Pharmacies, Staff and Subscribers
DHCS has released a new link below to get the latest information and to receive updates on Medi-Cal Rx. It is available to all Medi-Cal Rx pharmacies, their staff and to subscribers. Please see this link for more information.
Unwinding of the COVID-19 Public Health Emergency (PHE)
In March 2020, based on the federally declared COVID-19 PHE and Executive Order N-29-20, DHCS directed counties to delay processing of Medi-Cal annual renewals and defer discontinuances and negative actions for Medi-Cal programs to ensure that Californians continued to receive Medi-Cal coverage for the duration of the COVID-19 PHE. In preparation for the resumption of normal Medi-Cal operations after the end of the COVID-19 PHE, DHCS is engaging with the County Welfare Directors Association (CWDA) of California, county Medi-Cal eligibility staff, and Statewide Automated Welfare System (SAWS) representatives to explore ways to address the backlog of renewals and other pending casework resulting from the March 2020 order to suspend these activities. This foundational pre-work is essential to informing the creation of a viable statewide work plan for unwinding the PHE. DHCS will engage with stakeholders in the coming months to communicate the groundwork being established for the work plan, and to solicit feedback that further informs county eligibility operations planning in preparation for the end of the PHE.
Additional COVID-19 updates
CMS Approval of COVID-19 Vaccine Administration Carve-out
Updated: DHCS COVID-19 Vaccine Administration FAQs for Beneficiaries
Updated: DHCS COVID-19 Vaccine Administration FAQs for Providers
Updated: COVID-19 Cases Reported at Licensed or Certified Behavioral Health Facilities
Resubmission of Erroneously Denied Telehealth Claims
January 21, 2021
The Department of Health Care Services (DHCS) identified a claims processing issue affecting some claims billed with HCPCS codes A0000 – Z9999 or CPT codes 00100 – 91298, 91300 – 92017 and 92020 – 99999 with Modifier 95. This issue caused claims to erroneously deny with Remittance Advice Details (RAD) code 0225: This is an incorrect procedure code and/or modifier code for this service. The issue affected claims for dates of service from January 01, 2017, through November 23, 2020.
No action is required. The California Medicaid Management Information System (MMIS) Fiscal Intermediary will resubmit the affected claims. These resubmissions will appear on RAD forms beginning January 7, 2021, with Claim Control Number (CCN) prefix 036455.
If you disagree with any of these resubmissions, you may submit a Claims Inquiry Form (CIF) within six months of the new RAD date or you may submit an Appeal Form within 90 days of the new RAD date. For CIF completion instructions, please refer to the CIF Completion and CIF Special Billing Instructions sections in the appropriate Part 2 manual or on the Medi-Cal website (www.medi-cal.ca.gov).
Click here for the full letter.
Medi-Cal Rx begins January 1st, Are you ready?
October 29, 2021
As of January 1, 2022, all pharmacy benefits will transition away from CA-MMIS and the Medi-Cal managed care plans to Medi-Cal Rx. This transition will create a uniform process for pharmacy providers and prescribers and applies to everyone in Medi-Cal FFS and managed care. All benefits that are billed on a pharmacy claim will be transitioned to Medi-Cal Rx and all Prior Authorizations (PA) will be reviewed by Medi-Cal Rx starting on January 1.
To prepare for Medi-Cal Rx, we encourage you to visit the robust Medi-Cal Rx Education & Outreach page on the Medi-Cal Rx Web Portal to unlock all the training opportunities and informative materials that are currently available. The Medi-Cal Rx YouTube Channel offers training videos, including a video on the transition and the resources that directly impact pharmacy providers and prescribers. We also offer live, instructor-led trainings or join us for an Office Hour Luncheon Session available Monday-Friday, 12 p.m. to 1 p.m. PST (excluding holidays).
California Rolling Out Incentives to Boost Medi-Cal Vaccination Rates
August 6, 2021
SACRAMENTO — The California Department of Health Care Services (DHCS) today announced the availability of $350 million in incentive payments to encourage vaccinations among Medi-Cal’s 14 million beneficiaries. The vaccination incentive program will also encourage significantly expanded outreach in underserved communities. […]
The new program to boost vaccination rates will allow Medi-Cal managed care plans (MCPs) to earn incentive payments for activities that are designed to close vaccination gaps with their members, based upon lessons learned thus far in the pandemic. Funding will incentivize outreach programs and activities by MCPs and their providers, particularly primary care providers and pharmacies, as well as engage with trusted community organizations, such as food banks, advocacy groups, and faith-based organizations. After an initial payment for start-up costs, additional MCP payments will be conditional upon meeting specific vaccination goals. There will also be funding for MCPs to provide direct member incentives, such as grocery store gift cards, to Medi-Cal beneficiaries. […]
The incentive program will run from September 2021 through February 2022. DHCS is using $175 million in state General Funds and an additional $175 million in federal funds. […]
This vaccination incentive program to support local, community-based providers through MCPs can be coupled to the current CalVaxGrant program, which offers up to $55,000 in grant funding to help physician practices vaccinate their communities against COVID-19.Funding for the CalVaxGrant program is awarded on a first-come, first-served basis, so early application submissions are encouraged. Applications will be accepted until September 10, 2021.
California Advancing and Innovating Medi-Cal (CalAIM) Behavioral Health Timeline
August 2, 2021
Based on stakeholder feedback and internal analysis, DHCS will stagger certain CalAIM behavioral health implementation dates. This delay will allow DHCS to continue discussions with stakeholders and allow time for counties to implement and test the policies prior to the official go-live dates. The table below reflects the new go-live dates:
Lisa Murawski Appointed Chief of the Benefits Division at Department of Health Care Services
July 8, 2021
Now announcing the appointment of Lisa Murawski, Chief, Benefits Division (BD), effective July 8, 2021.
Ms. Murawski has worked for the California State Assembly, Appropriations Committee for over 10 years, most recently as Principal Consultant. In this capacity, Ms. Murawski was responsible for analyzing costs and benefits of health-related legislation, working collaboratively with administrative staff and a wide range of health advocates and stakeholders, and supporting members and staff to further legislative priorities while reducing costs and improving operational efficiency. Prior to this, Ms. Murawski served as a Fiscal and Policy Analyst with the Legislative Analyst’s Office. In this capacity, Ms. Murawski was responsible for analyzing programmatic activities and budgets for a variety of state health programs. She also analyzed health care program eligibility, benefits and costs, and produced fiscal estimates.
Ms. Murawski earned a Bachelor’s Degree in Industrial Engineering from the State University of New York at Buffalo, and a Master’s Degree in Geography from the University of California, Santa Barbara. She lives in South Land Park with her husband and two sons, and enjoys family fun time, bike commuting, nature, writing, and good food.
Medi-Cal News: In-Person Signature Requirement for Delivered Medications
June 21, 2021
In an April 28, 2020 article titled, “Temporary Suspension of In-Person Signature Requirement for Delivered Medications,” the Welfare and Institutions Code, Section 14043.341 requirement that “providers who dispense controlled drugs, dangerous drugs or dangerous devices to a Medi-Cal beneficiary to maintain a record of the signature of the person receiving the drug or device” was waived pursuant to Executive Order (EO) N-55-20 in response to the coronavirus disease 2019 (COVID-19) public health emergency.
EO N-55-20 will expire on June 30, 2021 per Governor Newsom’s most recent EO N-08-21 (issued June 11, 2021) to lift specific COVID-19-related executive orders that were put in place since March 2020. The Department of Health Care Services will end this policy change effective July 1, 2021 for all programs. Beneficiaries and clients, or their representatives, will need to sign for medications in person from their home or sign onsite at their provider location.
State of California Accelerates Health Coverage for Medi-Cal Applicants
From CalMatters’ Barbara Feder Ostrov
Californians who sign up for Medi-Cal will now receive immediate health coverage instead of remaining uninsured for months while waiting for their applications to be approved, according to the terms of a settlement finalized Monday.
Medi-Cal Rx Resources
December 31, 2020
You can find some helpful information relative to the Medi-Cal Rx website and email inbox, as well as various external-facing supporting documents, policies, and procedures at the links below. Please note: The following are subject to revision.
The Resources and Reference Materials section contains links to helpful information:
- Medi-Cal Rx Frequently Asked Questions (FAQs)
- Medi-Cal Rx Pharmacy Transition Policy
- Medi-Cal Rx Complaints and Grievances
- Medi-Cal Rx Website and Pharmacy Portal Policy
- Medi-Cal Rx Clinical Liaison Policy
- Medi-Cal Rx Scope
- Medi-Cal Rx Beneficiary Notice
Medi-Cal Rx Website: https://medi-calrx.dhcs.ca.gov/home/
For questions and/or comments regarding Medi-Cal Rx, please email RxCarveOut@dhcs.ca.gov
DHCS Released Numbered Letters 05-1020 and 07-1120 Regarding CCS and GHPP
December 31, 2020
You can find policy updates on the coverage of experimental and
investigational drugs, biological products, and devices under the California Children’s Services (CCS) Program and the Genetically Handicapped Persons Program (GHPP) in NL 05-1020.
In NL 07-1120 you will see updates to policy regarding the authorization of restricted treatment products/drugs for the following specific congenital or acquired bleeding disorders and acquired inhibitor antibodies:
• Hemophilia A (Factor VIII deficiency) with and without inhibitors
• Hemophilia B (Factor IX deficiency) with and without inhibitors
• Von Willebrand Disease (VWD) with and without inhibitors
• Factor VII deficiency
• Acquired Factor XIII deficiency
• Factor X deficiency
Click here to read N.L.: 05-1020 and N.L.: 07-1120
Patient Services Inc. Creates COVID-19 Emergency Assistance Fund
(Midlothian, VA – April 14, 2020)
Patient Services Inc. (PSI), a non-profit 503(c)(3) patient assistance program, has created an emergency assistance fund in response to COVID-19 to help patients navigate uncharted territory. To support PSI patients and their families affected by the virus, we have introduced the PSI Emergency Assistance Program, to assist active PSI patients in getting over the financial hurdle that may have been created due to the pandemic.
About the Health Care Access Forums
HCC hosts quarterly Health Care Access Forums each year, connecting stakeholders to discuss and address solutions to potential threats and significant changes to public and private health insurance, state programs, therapies and services, and provider relationships that affect quality of care for people with bleeding disorders. HCC’s Health Care Access Forums help solve patient access issues and improve collaboration among healthcare providers, pharmacies, and state health care departments.
2021 Health Care Access Forum Dates
Thursday, December 2 (online)
Annual membership for the quarterly Health Care Access Forum is $1,500 for the year, open to industry professionals and stakeholders, and includes two seats at the quarterly forums held either virtually or in Sacramento, access to HCC’s team for help with bleeding disorder patient healthcare access support, and regular updates on legislation and administrative issues affecting patients. Additional tickets are $250 per person per Forum, and multiple memberships are available.
To request an invoice, pay via check, or for any other questions regarding membership, please email email@example.com.
For purchasing additional tickets, enter your information below. Extra tickets are only available to current forum members.