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New Federal Electronic Prior Authorization Requirements Finalized

This post has been archived and contains information that may be out of date.

What’s happening: The Centers for Medicare & Medicaid Services (CMS) has finalized policies to advance interoperability and streamline prior authorization processes by using application programming interfaces (API) technology.  

What else to know: The final rule also requires payers to provide a specific reason for denied prior authorization decisions and publicly report certain prior authorization metrics.  

CHA Comments on Proposed Changes to Medicare Advantage Plans

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What’s happening: CHA submitted comments on the proposed technical changes to Medicare Advantage plans for contract year 2025. 

What else to know: Comments were due to the Centers for Medicare & Medicaid Services on Jan. 5. 

Managed Care Plans to Face Sanctions from DHCS for Poor Performance

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What’s happening: Medi-Cal managed care plans (MCPs) will face sanctions from the Department of Health Care Services (DHCS) for failing to meet quality performance standards. 

What else to know: DHCS has issued All Plan Letter (APL) 23-012, which updates and clarifies the policy on the imposition of administrative and monetary sanctions to plans that fail to meet minimum performance for required quality performance measures. 

New Managed Care Plan Changes in January Help Advance Health Equity, Access, and Accountability

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What’s happening: Effective Jan. 1, 2024, Medi-Cal managed care plans (MCPs) will operate under a new and revamped contract intended to better advance quality, access, accountability, health equity, and transparency.   

What else to know: Also effective Jan. 1, 2024, MCPs available for enrollment in certain counties will change due to county-elected model changes, the awarding of new commercial MCP contracts, and/or the expansion of direct contracts with Kaiser Permanente.   

Children’s Behavioral Health Services Lack Timely Access

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What’s happening: The California State Auditor recently investigated children’s access to Medi-Cal-covered behavioral health services.  

What else to know: The auditor concluded that many Medi-Cal health plans were out of compliance with state requirements for timely care and that the Department of Health Care Services (DHCS) is not adequately disciplining health plans.

Updated Guide on Final Rule Implementation Now Available

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What’s happening: A members-only guide from the American Hospital Association to support hospitals in the implementation of the Medicare Advantage (MA) final rule is now available for calendar year 2024.  

What else to know: The document provides a summary of key provisions of the final rule, which seeks to align MA coverage with traditional Medicare more clearly and to increase oversight of MA plans.  

Growing Discharge Delays Leading to Hospital Overcrowding, Other Problems

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California hospital patients are experiencing frequent, lengthy, and costly delays in care transitions. That’s the finding of a new CHA member survey investigating the extent and impact of discharge delays in three key hospital settings: emergency departments (EDs), general acute care, and inpatient psychiatric care.   

DHCS Issues Updated 2024 Medi-Cal Managed Care Plan Transition Policy Guide

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On Sept. 29, the Department of Health Care Services (DHCS) released an updated 2024 Medi-Cal Managed Care Plan (MCP) Transition Policy Guide. It includes the new MCP Transition Monitoring and Oversight Policy and new transition-related requirements for incentive programs, as well as updates to all other sections of the policy guide. It also contains DHCS policy and related MCP requirements related to member transitions among Medi-Cal MCPs that take effect on Jan. 1, 2024. 

Progress on Stopping Unfair Payment Practices

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Late last week, the state regulatory agency that oversees health plans issued a sweeping letter to every plan in California making it clear that unfair payment practices must cease.