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Proposition 56
Starting 2019, the Legislature and Department of Health Care Services (DHCS) will use Prop. 56 funding for loan repayment for physicians and dentists, Value Based Payment Program (VBPP), Developmental Screening and ACEs screening, Family Planning Incentives, and Behavioral Health Integration grants.
Change to Prop 56 add-on payment process beginning 4/1/2023
Prop56 add-on payment process update
In November 2016, California voters passed Proposition 56, also known as the California Healthcare Research and Prevention Tobacco Tax Act. The proposition allocated money for many things, but a large percentage was earmarked to support Medi-Cal providers. The program provides supplemental payments for certain eligible medical and screening services provided to Medi-Cal beneficiaries. More information on the program can be found here:
https://www.dhcs.ca.gov/provgovpart/Prop-56/Pages/default.aspx
What Is Changing?
- Beginning in April 2023, claims received and paid, where Prop 56 Supplemental Add-On payments are due, will no longer be reflected on the individual claims, but instead will be reimbursed monthly by separate check from CenCal Health.
- Providers will now see an explain code applied to these service lines explaining that a separate payment to reimburse the Prop 56 Supplemental Add-On payment will be made separately. The explain code will be used through June 2023 to remind providers of the transition. The explain code which will be used during this time is:
- HT- PROP 56 SUPPLEMENTAL PAYMENT PAID SEPARATELY
- These payments will be made by the 15th of the following month after the claim with the Prop 56 service was paid.
- A new Itemized report will be available in our secure Provider Portal soon!
Please contact the Claims Department at (805) 562-1083 if you have additional questions.
Proposition 56 All Plan Letter (APL)
The purpose of this All Plan Letter (APL) is to provide Medi-Cal managed care health plans (MCPs) with guidance on directed payments, funded by the California Healthcare, Research and Prevention Tobacco Tax Act of 2016 (Proposition 56).
Developmental Screening APL19-016
DHCS Webinar: Prop 56 New Incentive Payments for Quality
Behavioral Health Integration (BHI)
Program Update: DHCS has notified CenCal Health and alike Managed Care Plans (MCP) that an implementation date will be discussed following additional information provided by the MCP and its providers. CenCal Health will continue to update providers who applied for the BHI program as updates from DHCS are received.
If you have any questions, please reach out to DHCS-BHIIPA@dhcs.ca.gov or email BHIprogram@cencalhealth.org or for further details, please reference DHCS BHI Incentive Program Webpage
The Department of Health Care Services (DHCS) Behavioral Health Integration (BHI) Incentive Program goals are to incentivize improvement through Prop 56 funding for physical & behavioral health outcomes and deliver efficient care and patient experience. DHCS is providing this funding to incentivize Medi-Cal providers and health plans to partner together to promote BHI in their practice.
Click here for CenCal Health’s Integration Overview & BHI Project Examples
Integration Program Details:
- Three (3) Year Program: April 1, 2020 – December 31, 2022
- $93 million statewide financial allocation plus additional Federal funds
- Funding per MCP will be 5% of capitation currently paid by DHCS
- Funding is an incentive for providers and does not count toward PPS calculation
Eligible Providers
Eligible providers contracted with CenCal Health or contracted with the Holman Group include: Federally Qualified Health Centers (FQHC), Rural Health Clinics (RHC), Hospital Information Systems (HIS) clinics, hospitals, medical groups, individual providers, mental health and substance use providers, county mental health, and substance use providers.
Reference our recorded webinar or CenCal Health’s presentation for additional project details.
Online DHCS Application
Contracted Providers are required to submit an application to CenCal Health to operate one (1), or more, of six (6) BHI projects. A separate application is required for each project. Please fill out DHCS’s statewide application, and reference program process guides, and more FAQ’s.
Submit Application
Submit your application directly to CenCal Health via email at BHIprogram@cencalhealth.org.
Adverse Childhood Experiences (ACEs)
The ACEs Aware initiative is first-in-the-nation! It’s a statewide effort to screen children/adults in primary care settings, and to treat the impacts of toxic stress with trauma-informed care. ACEs Aware is built on the consensus of scientific evidence demonstrating that early detection and evidence-based intervention improves outcomes. The goal is to reduce ACEs and toxic stress by half (in one generation), and to launch a national movement to ensure everyone is ACEs Aware.
To learn more, reference our Adverse Childhood Experiences (ACEs) Aware Resource
Provider Training
DHCS is offering provider training on trauma and trauma-informed care at ACEsAware.org. Reimbursement will continue effective July 1, 2020 only to providers that have completed the required two (2) hour training available on the ACES Aware website.
Providers will have to self-attest after taking the two (2) hour course directly through DHCS’s online Trauma Screening Training Attestation form. Please make a copy of your email confirmation, and email a copy of your training certificate to CenCal Health Provider Services Department at psrgroup@cencalhealth.org.
Screening Tools
Standardized screening tools include Pediatric ACEs and Related Life-Events Screener (PEARLS), and the ACEs Assessment Tool for adults. The screening tool surveys the member’s history of exposure to 10 categories of ACEs by age 18. Note that the score is the total number of ACE categories experienced, and not the severity or frequency of any specific experience. The total score ranges from 0 to 10.
Clinical Practice
The ACEs Screening Clinical Algorithm helps a provider assess whether a patient is at low, intermediate, or high risk of a toxic stress pathology.
Billing
Effective July 1, 2020, CenCal Health providers must complete the certified ACEs Aware Training and must attest prior to receiving payment. Billing requires that the appropriate screening tool was used, the results were reviewed, interpreted, and documented, discussed with the member and/or family, and any clinically appropriate actions were documented. Effective January 1, 2020, CenCal Health will reimburse for annual ACEs screening for members under age 21, and once per lifetime for members ages 21 to 65. The rate is $29 per screening for all providers.
The Healthcare Common Procedure System (HCPCS) billing codes used are:
- G9919: ACE score of 4 or greater, at high risk for toxic stress
- G9920: ACE score of 0 – 3, at lower risk for toxic stress
Additional Resources:
For more information on this service, or for help improving your clinical care, please email CenCal Health’s Quality Improvement Department at qualityimprovement@cencalhealth.org.
Developmental Screenings
Developmental screenings identify areas in which a child’s development differs from same-age norms. Due to development being dynamic in nature, and surveillance and screenings having limitations, periodic screening with a validated instrument are recommended to detect a problem not detected by surveillance. Repeated and regular screening is necessary to ensure timely identification of problems and early intervention, especially in later-developing skills such as language.
Billing
Effective January 1, 2020, through June 30, 2021 DHCS approved reimbursement for Developmental Screening Services. CenCal Health will reimburse (dual members are excluded) all contracted providers $59.90 when billing with CPT code 96110 without KX modifier.
Screening Tools
CenCal Health Contracted Providers are eligible for this payment and screening must be in accordance with the Bright Futures/AAP periodicity schedule and guidelines for 9 months, 18 months and 30 months of age and when medically necessary based on developmental surveillance.
Value Based Payment (VBP) Program
CenCal Health is pleased to partner with our providers on the Department of Health Care Services’ (DHCS) Value Based Payments Program. The Value Based Payment (VBP) Program has been established and funded by DHCS utilizing funding generated from The California Healthcare, Research & Prevention Tobacco Tax Act of 2016 (Proposition 56). The VBP Program provides supplemental payments to providers for meeting specific measures aimed at improving care for some of the most vulnerable members of the communities we serve.
Click here to watch our DHCS VBP Training video or print a copy of the slides.
There are a total of four (4) domains and seventeen (17) measures under which payments will be based. Measures of immunization timeliness will be computed with supplemental data from the California Immunization Registry (CAIR).
The domain categories are:
- Prenatal/Post-Partum Care
- Early Childhood Preventive Care
- Chronic Disease Management
- Behavioral Health Integration
The list of measures is available by clicking here
Payment
CenCal Health began the payment process in December 2020 and will continue to run payments on a monthly basis for VBP eligible claims data received for dates of service on or after July 1, 2019.
If you have elected to receive payments via EFT process, you will receive your VBP supplemental payments in this manner.
Per guidance outlined in the Department of Health Care Services All Plan Letter (APL) 20-014, the payments must be made to the rendering provider. In consideration that our contract is or may be with a group, payment will be made at the group level. However, the California Department of Health Care Services and CenCal Health require that the incentive payments be passed through to the rendering provider.
Exclusions
- Encounters occurring at Federally Qualified Health Centers (FQHCs), Rural Health Clinics, American Indian Health Clinics, or Cost Based Reimbursement Clinics will be excluded from payment in addition to
- Encounters for members with Medicare Part B
- Claims for VBP program services received by CenCal Health more than one year after the date of service
Payment details and reports will be made available via the Provider Portal. Please log in to view payment details in the Payment History Tool and to view a report for each unique provider site and payment amounts owed to the rendering provider under this program. Member-level detail information can be accessed under the Downloads tab. Any contracted provider not enrolled to receive funds electronically via EFT will receive their payments and corresponding reports via mail.
File a Grievance
Providers can file a grievance by filing a dispute as described in the Claims section of the CenCal Health website.
If you have any questions about the VBP Program please contact our CenCal Health Provider Relations team at psrgroup@cencalhealth.org or for more information about the VBP incentive program, please visit the DHCS website.
Family PACT Planning Program
The Family Planning, Access, Care, and Treatment (Family PACT) Program will continue to provide time-limited supplemental payments to Family PACT providers for Evaluation and Management (E&M) office visits rendered for comprehensive family planning services for the period of July 1, 2019 through December 31, 2021.
This directed payment program is intended to enhance the quality of patient care by ensuring that Providers in California who offer family planning services receive enhanced payment for their delivery of effective, efficient, and affordable health care services. Timely access to vital family planning services is a critical component of beneficiary and population health.
In particular, this program is focused on the following categories of family planning services:
- Long-acting contraceptives
- Other contraceptives (other than oral contraceptives) when provided as a medical benefit
- Emergency contraceptives when provided as a medical benefit
- Pregnancy testing
- Sterilization procedures (for females and males)
For more information on Prop 56 and Family PACT, access the DHCS website here