CCUIH Policy Updates and Timelines

Below are critical State Plan Amendments (SPA) and Waivers in California, with descriptions and important dates about each one.

Please contact CCUIH if you have any questions.

2012

SPA 12-002: Amendments to Medi-Cal Tribal and Designee Advisory Process - IN INDIAN CONSULTATION PERIOD

SPA 12-002 (released in February 2012) loosens the requirements for DHCS to notify tribes and urban programs of Medi-Cal changes that may affect them. This includes changes to meeting notification requirements, webinars, and allows for a shortened notification process.

DHCS is proposing that the effective date of the SPA will be January 1, 2012, which would affect all SPAs issued this year.

SPA 12-004: Provider-Preventable Conditions (PPC) - IN INDIAN CONSULTATION PERIOD

SPA 12-004 (released February 2012) puts California in line with new federal regulations that prohibit payment for Provider-Payment Conditions (PPCs), which are defined as conditions that did not exist before the provider treated the patient. Providers will also be required to report to DHCS when PPCs have occurred in any Medi-Cal patient.

2011

SPA 11-009: 10% Outpatient Rates Reduction - APPROVED, CURRENTLY ON HOLD PENDING LITIGATION

SPA 11-009 (released in May 2011) reduces Medi-Cal payment for outpatient services by up to 10% to non-FQHC Medi-Cal providers. It was approved by CMS in October 2011, but has currently been halted pending litigation in federal court since January 2012.

SPA 11-013: Limit the Total Number of Physician Office and Clinic Visits to Seven Per Fiscal Year - PENDING

SPA 11-013 limits the number of reimbursable office and clinic visits to seven per fiscal year. However, due to exemptions in the bill and DHCS's subsequent interpretation, this bill would only apply to new patient visits without a "chief complaint" and preventable care visits. The SPA was submitted to CMS in the fall of 2011 but is pending at CMS due to questions regarding the implementation and tracking visits. If approved, the SPA would be effective 60 days from approval of the SPA.

California Bridge to Reform Demonstration 1115 Waiver Amendment (Copayments) - DENIED

In August 2011, DHCS requested a Bridge to Reform Demonstration Waiver to CMS which would have allowed the state to impose mandatory copayments on Medi-Cal beneficiaries. The copayments would have applied to all beneficiaries, including AIANs, despite the provision in the American Reinvestment and Recovery Act preventing cost sharing for AIANs.

The waiver was denied in February 2012.

2009

Optional Benefits Elimination - APPROVED

In May 2009, DHCS announced the elimination of optional benefits for Medi-Cal recipients including adult dental, podiatry and chiropractic services, effective July 2009. On October 18, 2010, the federal court ordered California to resume reimbursements for adult dental, podiatry and chiropractic services until the state received formal approval from CMS to officially eliminate optional services. On May 23, 2011, the optional benefits elimination was approved by CMS.

In August 2011, DHCS notified Medi-Cal providers that payments would be recouped from FQHCs and RHCs for non-exempt adult dental, podiatry, chiropractic and other services provided between October 18, 2010 and May 23, 2011.

Currently, DHCS is still seeking recoupment of payment for services provided between October 18, 2010 and May 23, 2011. However, at this point there has been no formal communication from DHCS as to the method of repayment or how the determination of the amount of repayment for each clinic will be made.

The following SPAs/Waivers have been released in Fiscal Year 2011-2013 for Indian Health Program Notifications

Please click on the title of the SPA or Waiver for more information.

Please contact CCUIH if you have any questions.

State Plan Amendments

2013

Outpatient Drug Coverage for Persons with Medicare and Medi-Cal - SPA 13-001: RELEASED

Payments to Primary Care Physicians - SPA 13-003: RELEASED

Optional Targeted Low-Income Children (TLIC) - SPA 13-005: RELEASED

2012

Amendment to Medi-Cal Tribal Advisory Process - SPA 12-002: RELEASED

Two Visit Limit per Month - SPA 12-003: RELEASED

Provider Preventable Conditions - SPA 12-004: RELEASED