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DHCS Issues Resource for CalAIM Transitional Care Services Care

What’s happening: The Department of Health Care Services (DHCS) has issued a new technical assistance resource to support Medi-Cal managed care plans (MCPs) and others in implementing  transitional care services (TCS) for Medi-Cal members who need long-term services and supports (LTSS) needs.  

What else to know: Under the CalAIM population health management program, MCPs are responsible for delivering TCS to enrollees before, during, and after their transition from one care setting to another.  

CMS Issues Updated Medicare Advantage Complaint Form

What’s happening: As previously reported, the Centers for Medicare & Medicaid Services (CMS) has developed a process that allows providers to submit questions and complaints related to Medicare Advantage (MA) plan appeals or claims payment issues. 

What else to know: The form serves as a mechanism for Medicare providers seeking CMS assistance to resolve specific MA claims issues; CMS will enter complete complaint forms into the complaints tracking module and direct the MA to investigate the case.   

CMS Issues Annual Data Submission Requirements for MA Plans

What’s happening: The Centers for Medicare & Medicaid Services (CMS) has issued detailed information about data collection and audit procedures for Medicare Advantage (MA) (Part C) plans. 

What else to know: The information will allow CMS to conduct a comprehensive review of plan compliance with utilization management requirements, including new requirements on development, appropriateness, and public accessibility of internal coverage criteria.   

DMHC Penalizes Blue Cross for Delayed Payments

What’s happening: The California Department of Managed Health Care (DMHC) has taken enforcement actions, including a total of $8.5 million in fines, against Blue Cross of California Partnership Plan and Anthem Blue Cross for their failure to address payment disputes with health care providers in a timely manner.  

What else to know: In addition to paying the fines, the plans must improve response times by removing barriers that create delays, monitoring provider disputes more regularly, and adding staff to handle provider disputes. Per two letters of agreement, Blue Cross is expected to complete the corrective actions before Dec. 31.      

Update: Court Determines CHA Lawsuit Against Anthem is a “Complex Case”

What’s happening: A Los Angeles Superior Court Judge has designated a lawsuit brought by CHA against Anthem Blue Cross a “complex case,” requiring exceptional judicial management.  

What else to know: CHA’s suit challenges Anthem’s failure to authorize and arrange for access to timely and appropriate post-hospital health care services for its members. The next activity in the case will be an initial status conference on Oct. 3.  

New Provider Complaint Process Aims to Increase Federal Oversight of Medicare Advantage Plans

What’s happening: The Centers for Medicare & Medicaid Services (CMS) has implemented a new process allowing providers to submit questions and complaints related to Medicare Advantage (MA) plan appeals or claims payment issues. 

What else to know: CHA welcomes these first steps in establishing greater CMS oversight for MA plans. The MA final rule, which took effect on Jan. 1, codified important new policies and expectations for MA plans, directed toward greater alignment between traditional Medicare and MA.   

CHA Comments on DMHC Network Adequacy Standards

What’s happening: CHA continues its work to hold insurance companies accountable for providing timely, comprehensive patient care. Last week, CHA submitted a letter to the Department of Managed Health Care urging it to expand network adequacy standards to reflect patients’ current health care needs and hold plans accountable for making those life-changing, lifesaving services available.  […]

Office of Inspector General to Examine Medicare Advantage Use of Prior Authorization for Post-Acute Care

What’s happening: The U.S. Health and Human Services Agency has announced that the Office of Inspector General (OIG) will investigate the use of prior authorization for post-acute care services by Medicare Advantage (MA) plans.   

What else to know: CHA members have reported that they encounter significant challenges in obtaining authorizations from MA plans for access to the most appropriate level of post-acute care (PAC).  

DMHC Provides Additional Guidance Regarding Post-Stabilization Care Requests

What’s happening: The Department of Managed Health Care (DMHC) has issued All Plan Letter (APL) 24-012, which reminds plans that they may not require a hospital to make more than one telephone call to request authorization to provide post-stabilization care to plan members.   

What else to know: The APL reiterates the requirements of Health & Safety Code 1371.4, which states that plans must provide hospitals with one telephone number to serve as the point of contact for 24-hour access for post-stabilization authorization requests. Plans may not require a hospital to contact the plan in any way other than the plan’s designated phone number.