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CMS Approves Flexibilities for Medi-Cal

Updated: Nov 20, 2020

On March 23, 2020, the Centers for Medicare & Medicaid Services (“CMS”) approved additional flexibilities to California’s Medi-Cal program to prepare for the COVID-19 pandemic. Specifically, the Secretary of the U.S. Department of Health and Human Services invoked his authority under section 1135 of the Social Security Act to waive or modify certain requirements of the Medicaid Act to ensure that health care items and services are available to meet the needs of Medicaid beneficiaries and to ensure that health care providers may be reimbursed for such items and services.

Illustration from California State Flag

Effective March 1, 2020, and until the termination of the public health emergency, CMS approved the following waivers:

  • Temporary suspension of Medicaid fee-for-service prior authorization requirements. During the waiver period, DHCS intends for providers to submit manual claims for services that typically require prior authorization to Conduent. It expects that Conduent will process the claims without regard to prior authorization requirements or documentation of medical necessity.

  • Extension of pre-existing authorizations received prior to the emergency period through the end of the public health emergency. For example, pre-existing authorizations for medications or long term care will not have to be re-authorized.

  • Extension to delay Medicaid state fair hearings and issuance of state fair hearing decisions. Medi-Cal enrollees will have more than 90 days and up to an additional 120 days to submit a request for a state fair hearing. Medi-Cal managed care enrollees will still have to submit appeals to the plan’s internal process, but those will be deemed denied after a period set by the State of at least one day. Then, the enrollee will be permitted to request a state fair hearing within 240 days of the plan’s denial.

  • Provider enrollment flexibilities

o California may reimburse payable claims for services rendered to Medi-Cal

enrollees performed by out-of-state providers enrolled in either Medicare or in another Medicaid program, subject to specified conditions.

o California may also temporarily enroll out-of-state providers for the duration of the public health emergency.

o CMS will waive screening requirements for providers not already enrolled in

Medicare or another state Medicaid program, including (1) payment of the application fee, criminal background checks, site visits, and in-state/territory licensure requirements.

o California may cease revalidation of providers who are located in California or otherwise directly impacted by the emergency.

  • Provision of services in alternative settings. CMS will allow facilities, such as nursing facilities, intermediate care facilities for individuals with intellectual and developmental disabilities, psychiatric residential treatment facilities, and hospital distinct-part nursing facilities, to be reimbursed for rendering services to an unlicensed facility. For example, a skilled nursing facility that needs to relocate residents due to an outbreak may be reimbursed if it continues to provide skilled nursing services to those residents when relocated to an unlicensed location. The State must make a reasonable assessment to ensure the health, safety and comfort of the residents and staff.

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