News

Reimbursement for American Indian Health Service Programs

Date: 03/08/18

As communicated in the Department of Health Care Services (DHCS) All Plan Letter 17-020, released on December 15, 2017, DHCS has changed its policy regarding reimbursement of American Indian Health Service Programs providing services to Medi-Cal members, for dates of service on or after January 1, 2018.

OVERVIEW
Under federal law, California must ensure that American Indian Health Service Program providers are paid the applicable Office of Management and Budget (OMB) encounter rates published annually in the Federal Register by the Indian Health Service. If there is any difference between the amount paid by a managed care plan (MCP) and the applicable OMB encounter rate, the state is required to make a supplemental payment pursuant to Title 42 of the United States Code (USC) Section 1396u-2(h)(2)(C)(ii) and Title 42 of the Code of Federal Regulations (CFR) Sections 438.14(c)(2) and (3).

Effective January 1, 2018, California Health & Wellness (CHWP) is required to reimburse American Indian Health Service Program providers for eligible services provided on or after January 1, 2018, at the applicable OMB encounter rate.

INDIAN HEALTH SERVICE OMB REIMBURSEMENT RATES
The OMB all-inclusive rates are published annually and are effective on a calendar year basis. The comprehensive list of Indian Health Service OMB reimbursement rates for 2018 is published in Federal Register Vol. 83, No.4, January 5, 2018, on page 682, available online here.

Where the OMB rate applies, CHWP will reimburse Indian Health Service Program providers as follows:

• For CHWP Medi-Cal members who do not have Medicare coverage or have Medicare Part A coverage only, reimbursement for providers identified by DHCS will be at the outpatient encounter rate of $427 for eligible services received on or after January 1, 2018.
• For CHWP Medi-Cal members who have full Medicare coverage or have Medicare Part B only, reimbursement to providers identified by DHCS will be at the outpatient encounter rate of $282.72 for eligible services received on or after January 1, 2018.
• CHWP ensures any retroactive outpatient per-visit rates are appropriately reimbursed to program providers.

CLAIMS INSTRUCTIONS
Medi-Cal claims must be submitted within 180 days from the last day of the month of the date of service. For claims submitted for services after January 1, 2018, CHWP will reimburse providers for the original claims payment, and will make any retroactive adjustment necessary to ensure the provider has been reimbursed the total OMB rate.

CHWP Participating American Indian Health Service Program Providers
CHWP participating American Indian Health Service Program providers should continue to submit claims to CHWP via the standard process and in accordance with the terms of the CHWP Provider Participation Agreement (PPA).

Additional information on claims submission and reimbursement is available online in the Provider Resources section of our website.

Nonparticipating American Indian Health Service Program Providers
Nonparticipating American Indian Health Service Program providers should refer to the Provider Resources section of our website. to learn more about claims procedures and how to submit claims to CHWP.

ADDITIONAL INFORMATION
Providers are encouraged to access CHWP’s provider portal for real-time information, including eligibility verification, claims status, prior authorization status, plan summaries, and more.

If you have questions regarding the information contained in this update, contact your Provider Relations representative or call 1-877-658-0305.