Health Care Access Forum
Health Care Access Forum – Thursday, December 8th
Forum Schedule:
9:15 AM – 10 AM Networking Breakout Rooms
10 AM – Noon Forum
Location: Virtual via Zoom ONLY
This is a members-only event.
Need help registering? Please email Andrea at apalladino@hemophiliaca.org
Are you a member who needs extra tickets?
We have options for membership or to purchase extra tickets.
Questions? Email Andrea at apalladino@hemophiliaca.org.
Now Active – Physician Administered
Drug Policy Updates
September 16, 2022
What is Happening?
The Physician Administered Drug (PAD) policy is updated as follows:
Pharmacy claims for PADs not typically approved for and dispensed by pharmacy providers will deny with Reject Code 816 – Pharmacy Drug Benefit Exclusion. An exception for pharmacy benefit approval may be considered via prior authorization request and may be covered as a pharmacy benefit.
Next Steps
- Pharmacy providers and prescribers are encouraged to assess their business processes and workflows to account for the PAD policy update.
- Refer to the Medi-Cal Rx Bulletins & News and Medi-Cal Rx Forms & Information pages of the Medi-Cal Rx Web Portal to stay up to date.
- Providers can learn more by consulting the Medi-Cal Rx Pharmacy Reimbursable Physician Administered Drugs list.
Continuing Medi-Cal Coverage for Young Adults
August 22, 2022
In an effort to maintain continuity of coverage for individuals who turn age 26 until the Medi-Cal expansion of people ages 26-49 takes effect on January 1, 2024, the Department of Health Care Services (DHCS) will continue existing state-funded full-scope Medi-Cal coverage for this group, even after the COVID-19 public health emergency (PHE) ends.
When the COVID-19 PHE ends, many individuals included in the young adult expansion will age, or would have already aged, out of coverage when they turn 26—which for some, may be months before their state-funded full-scope Medi-Cal coverage will begin again under the 26-49 expansion. DHCS will resolve that by continuing to provide them with state-funded full-scope Medi-Cal coverage before the expansion occurs. This will be done by instructing counties to deprioritize their annual redetermination after the end of the PHE and before the 26-49 expansion policy begins. This is critical in preventing a reduction of benefits for these individuals due to age and immigration status if their post-PHE renewal occurs before the 26-49 expansion policy is implemented. DHCS updated the Medi-Cal COVID-19 PHE Operational Unwinding Plan to reflect changes to the policy for this population.
As enacted by Senate Bill 184 (Chapter 47, Statutes of 2022), California will implement state-funded full-scope Medi-Cal to individuals age 26 through 49, regardless of immigration status, if otherwise eligible, beginning on January 1, 2024. This Medi-Cal expansion is another important step to help close health equity gaps in California, and will improve access to care for some of the state’s most vulnerable populations.
As part of the federal continuous coverage requirements under the COVID-19 PHE, DHCS maintained ongoing Medi-Cal coverage for young adults who were provided state-only full-scope Medi-Cal under the young adult expansion, and who would have otherwise lost their Medi-Cal eligibility due to aging out at 26. The current COVID-19 PHE ends on October 13, 2022. However, since states have not received the 60-day advance notice in mid-August, it is anticipated that the COVID-19 PHE would be extended until at least January 2023 by the federal government.
Once the COVID-19 PHE ends, federal requirements outlined by the Centers for Medicare & Medicaid Services require Medicaid agencies to redetermine eligibility for all individuals enrolled in the program. In accordance with Medi-Cal policy, this population would most likely be determined ineligible for continuing state-funded full-scope Medi-Cal due to their age and immigration status at their scheduled annual renewal if the renewal occurs prior to the 26 -49 expansion taking effect. Federal guidance for the COVID-19 PHE unwinding allows states to prioritize populations as part of their PHE unwinding annual redetermination strategy, so long as it is completed within 14 months.
Para leer “Cobertura continua de Medi-Cal para adultos jóvenes” haga clic aquí.
Reinstatement of Reject Code 88 Begins July 22nd
July 15, 2022
What is happening?
Effective July 22, 2022, Drug Utilization Review (DUR) claim edits will be reinstated. Specifically, claims will reject for National Council for Prescription Drug Programs (NCPDP) Reject Code 88 – Drug Utilization Review Reject Error for DUR alerts such as drug-drug interactions, high dose, early refill, etc.
Next Steps
To prepare for reinstatement of DUR claim edits, providers are encouraged to:
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- Share this information with vendors, business partners, and staff who need to know about the upcoming change.
- Assess business processes and workflows to ensure successful submission of claims.
- Review Medi-Cal Rx billing guidelines in the NCPDP Reject Code 88 DUR Reference Guide to avoid or resolve claim rejections.
Update: Postponement of Implementation of NCPDP Reject Code 80
July 12, 2022
What is happening?
The Department of Health Care Services (DHCS) has elected to postpone implementation of the National Council for Prescription Drug Programs (NCPDP) Reject Code 80 – Diagnosis Code Submitted Does Not Meet Drug Coverage Criteria.
Claims submitted to Medi-Cal Rx will NOT be edited for a diagnosis code as planned to begin July 22, 2022. However, providers are reminded of their obligation to document the meeting of Code 1 restrictions and to keep that information readily available.
Feedback from stakeholder engagements has been critical to the design of the reinstatement plan for claim edits and prior authorizations (PAs) for Medi-Cal Rx. DHCS and Magellan Medicaid Administration acknowledge that implementation of Reject Code 80 could require submission of PAs prior to the timeframe targeted for PA reinstatement.
The decision to postpone application of a diagnosis code edit at this time aligns with our commitment to continue the dialogue with our stakeholder community and ensure the delivery of timely and safe pharmacy services to Medi-Cal beneficiaries and providers across California. Medi-Cal Rx will undertake a robust communication and education plan before Reject Code 80 is executed.
Please note: Claim edits for Drug Utilization Review (DUR) requirements will be reinstated, as planned, effective July 22, 2022.
Medi-Cal Rx Coverage of Over-the-Counter COVID-19 Antigen Test Kits
January 26, 2022
Effective February 1, 2022, Over-the-Counter (OTC) Emergency Use of Authorization (EUA) U.S.
Federal Drug Administration (FDA)-authorized, self-administered COVID-19 antigen test kits can be billed and reimbursed as a pharmacy-billed medical supply benefit through Medi-Cal Rx in accordance with current Centers for Disease Control and Prevention (CDC) recommendations.
Coverage is restricted to specific 1-test-per-kit or 2-tests-per-kit OTC EUA COVID-19 FDAauthorized, self-administered COVID-19 antigen tests listed in the List of Covered Emergency Use Authorization (EUA) COVID-19 Antigen Tests, which can be found on the Medi-Cal Rx Web Portal under “Forms and Information,” and require dispensing from a pharmacy, written (or electronic equivalent) on a prescription pad signed by a licensed prescriber or a pharmacist. Packages/kits cannot be broken or sold as individual tests.
The following coverage criteria applies:
- Restricted to EUA for the diagnostic condition of suspected COVID-19 (Code I Restriction).
- Restricted to up to 8 tests (4 kits for 2 tests/kit) per 30 days per beneficiary.
- No refills allowed; the beneficiary would need to obtain a new prescription for each
dispensing
Centene Corporation’s Acquisition of Magellan Health
December 30, 2021
On December 30, the California Department of Managed Health Care (DMHC) announced the approval of Centene Corporation’s acquisition of Magellan Health, Inc., with conditions to ensure the merger does not adversely impact enrollees or the stability of California’s health care delivery system.
Magellan is DHCS’ Medi-Cal Rx vendor. DHCS had previously identified two areas of conflict if Centene were to acquire Magellan in relation to Medi-Cal Rx. At DHCS’ direction, Centene developed a conflict avoidance plan to address these issues, and DHCS determined that Centene’s plan addressed such concerns.
Medi-Cal Rx launches on January 1, 2022, and will standardize the Medi-Cal pharmacy benefit under one statewide delivery system.
Medi-Cal Managed Care All Plan Letter 20-022 Released on COVID-19 Vaccine Administration
August 9, 2021
DHCS Release of CalAIM Community Supports Services
January 1, 2022
On January 1, 2022, Medi-Cal managed care plans (MCPs) will begin implementing CalAIM Community Supports services in select counties. Subject to approval by DHCS, MCPs may add Community Supports at defined six-month intervals. DHCS will post the elected Community Supports offerings by county and MCP to the DHCS CalAIM Enhanced Care Management (ECM) and Community Supports webpage.
Community Supports are medically appropriate and cost-effective alternatives to services covered under the State Plan; are optional services for Medi-Cal MCPs to provide. The 14 pre-approved Community Supports comprehensively address the needs of members, including those with the most complex challenges affecting health, such as homelessness, unstable and unsafe housing, food insecurity, and/or other social needs.
The CalAIM Community Supports elections table identifies (by county and MCP) the 14 Community Supports offerings by MCP in the counties they operate, and specifies the date of implementation for each Community Supports service.
The table, which will be posted to the DHCS CalAIM ECM and Community Supports webpage, will be updated as needed with new and revised elections approved by DHCS. For more information, please email CalAIMECMILOS@dhcs.ca.gov.
Now Active – Reinstatement of Limited Prior Authorization Requirements for 11 Drug Classes
September 16, 2022
What is Happening?
On September 16, 2022, prior authorization (PA) requirements were reinstated for 11 drug classes for new start medications for beneficiaries 22 years of age and older.
- “New start” is defined as either a new therapy or the first time the beneficiary has been prescribed the drug. Medi-Cal Rx will review claim date of service up to 15 months to determine if the beneficiary is new to therapy.
- New start prescriptions for children and youth 21 years of age and under within these 11 drug classes will not be subject to PA reinstatement.
Click here to read the Phase I, Wave III Drug Classes and Next Steps.
Retirement Announcements for Harry Hendrix and Mike Wofford at DHCS Pharmacy Benefits Division
August 24, 2022
After more 22 years with the State of California – including over 20 with DHCS and 10-plus as the Chief for the Pharmacy Benefits Division (PBD) – Harry Hendrix is retiring from state service at the end of this year. Harry started his career with the state in May 2000, at what was then the Department of Health Services. He became the acting Chief of PBD in December 2011, and was appointed to the position in June 2012 by then Director Toby Douglas. For two years prior to that, he was Chief for the Drug Rebate Branch in PBD, and before that he spent over eight years in what was then the Medi-Cal Managed Care Division (MMCD) where he started as a Staff Services Analyst/Contract Manager and worked his way up to a Staff Services Manager I for the Policy Unit. During his time in MMCD, Harry took an 18-month sabbatical to work at the California Department of Transportation, but returned to MMCD and has been with DHCS ever since. Harry’s approach to leadership has always focused on building relationships based on trust and honesty with his team and coworkers. It is an approach that has served him as a leader and DHCS well, and he will be missed greatly when he retires.
Harry’s last day of work will be December 30, 2022.
After 23 years with the Department of Health Care Services, the last 12 as Policy Chief, Pharmacy Benefits Division (PBD), Mike Wofford has made the decision to retire from state service at the end of this year. Mike started his career with the state in June, 1999 at what was then the Department of Health Services. He became the Policy Chief, PBD, in 2010. Prior to that Mike was Chief, Medical Supplies Branch in PBD for 5 years, a Pharmacy Consultant (PC) II (Specialist) in the PBD Policy and Contracting Branch for 5 years, and before that a PC I Treatment Authorization Request (TAR) adjudicator in the Stockton Field Office. Mike is not only regarded as one of the most knowledgeable Medi-Cal pharmacy policy experts in the Department, but also a fierce advocate for the expansion of pharmacy benefits to those served by our program. Mike’s kindness, patience, and ability to remain calm on the outside when all else around him is in chaos are but a few of the many exceptional qualities that will be missed when he retires.
Mike’s last day of work will be December 30, 2022.
The Department is conducting robust recruitment efforts to fill both of these upcoming vacancies. The foundations that have been built over the years will continue to be developed and strengthened as the Medi-Cal Pharmacy Benefits Division moves forward. Mike and Harry will be doing all they can to ensure smooth transitions to their successors in support of their respective teams.
COVID-19 Public Health Emergency Extension
July 15, 2022
On July 15th, Health and Human Services Secretary Becerra renewed the COVID-19 Public Health Emergency (PHE) effective July 15, 2022 for up to 90 days. This means the PHE is extended to October 13th unless it receives another extension. The official declaration of this renewal can be accessed here: https://aspr.hhs.gov/legal/
Please contact the DHCS COVID inbox at MCED.COVID@dhcs.ca.gov or Theresa Hasbrouck (Theresa.Hasbrouck@dhcs.ca.gov
Medi-Cal Rx Operational Updates
May 5, 2022
Since February 2022, Medi-Cal Rx has stabilized the Medi-Cal Rx Customer Service Center (CSC) and prior authorization (PA) operations. The Department of Health Care Services (DHCS)
and Magellan Medicaid Administration, Inc. (MMA) have also engaged in an intensive planning process for phased reinstatement of claim edits and PA requirements. As previously communicated, claim edits originally proposed to be reinstated May 1, 2022, will not occur until the education and outreach efforts have been completed. DHCS and MMA are evaluating the appropriate time to terminate this transition policy and will provide detailed information in the coming weeks. Stakeholders will be notified 90 days prior to the retirement of the 180-day transition policy. Utilizing feedback from various stakeholders, Medi-Cal Rx has created a Special Populations Clinical Liaison (SPCL) Team within the (CSC) that has been trained to serve the specific needs of populations enrolled in California Children’s Services, the Genetically Handicapped Persons Program, and those who have specialty behavioral health conditions. This team is comprised of pharmacy technicians and pharmacists.
Requirements for Medi-Cal Rx Claims
January 6, 2022
What do Pharmacies Need to Fill Prescriptions?
Important changes for dispensing prescriptions to Medi-Cal Rx beneficiaries include the following:
Pharmacies must have the beneficiary’s Benefits Identification Card (BIC), Client Index Number (CIN), or Health Access Program (HAP) card number to successfully bill for the medication. See the following examples:
- Beneficiaries will NOT be able to utilize their Managed Care Plan (MCP) ID card
- If beneficiaries do not currently have a BIC or CIN, they can obtain a new card by contacting their local county office.
- Providers can look up beneficiary eligibility by logging in to the secured Medi-Cal Rx
Pharmacy Claims Denial Issue
January 3, 2022
Medi-Cal Rx has identified a Pharmacy claims denial related to beneficiary eligibility and is working to resolve the problem.
If you are a pharmacy provider and received Reject Code 65, please see below for next steps:
1. Verify beneficiary eligibility through the following:
a. Log in to Transaction Services via the Medi-Cal Web Portal at:
https://www.medical.ca.gov/
Refer to the following for available services:
https://files.medi-cal.ca.gov/
b. A valid Provider Identification Number (PIN) is needed for access. The PIN is issued when providers enroll in Medi-Cal. In the instance when a provider does not remember their PIN, the Medi-Cal Telephone Service Center (TSC) technical help desk agents are authorized to release the existing PIN once caller validation protocols have been completed. The Medi-Cal TSC phone number is 1-800-541-5555; follow the prompts for the Technical Help Desk.
c. Look up the beneficiary and review the response.
2. If the beneficiary is eligible, retain a screenshot of the eligibility verification results as documentation for later use.
CCS Whole Child Model Numbered Letter and All Plan Updates
December 9 & 10, 2021
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.
A one page summary of the issues you present during your legislative office visit that you can leave with or email to the legislator/staffer.
A one page summary of the issues for your reference during your office visit with the legislator/staffer.
A quick elevator speech to explain what are hemophilia / bleeding disorders and how people with bleeding disorders receive health care.
Some tips for constructing your personal bleeding disorders story.
A few lobbying do’s & don’ts adapted from NHF’s Washington Days.
A sample thank you letter to send as a follow up to your legislative office visit thanking the legislator/staffer for their time and reminding them of the key issues.
A more in depth description of what are hemophilia / bleeding disorders and how people with bleeding disorders receive health care.
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.
2022 Health Care Access Forum Dates
Thursday, February 17 (online)
Thursday, June 9 (HYBRID)
Thursday, September 8 (HYBRID! – In person Sacramento OR via Zoom)
Thursday, December 8 (online)
Don’t forget to get your 2022 Health Care Access Forum Membership! You can find the different options below-
To request an invoice, pay via check, or for any other questions regarding membership, please email apalladino@hemophiliaca.org.
For purchasing additional tickets, enter your information below. Extra tickets are only available to current forum members.