1. Session 1 Wednesday, March 28, 2012 9:30 A.M. to 11:30 A.M Session 3 Thursday, March 29, 2012 9:30 A.M. to 11:30 A.M. Session 2 Wednesday, March 28, 2012 1:30 P.M. to 3:30 P.M.

2. New Federal Requirements for State Medicaid Agencies  42 CFR 455 Subpart E - Provider Screening and Enrollment o State Medicaid agencies must comply with the process for screening providers under sections 1902(a)(39), 1902(a)(77) and 1902(kk) of the Affordable Care Act and 42 CFR Section 455.400 et seq.

3. New Federal Requirements for State Medicaid Agencies  Where did they come from? o March 2010 ─The Patient Protection and Affordable Care Act (ACA) was passed by Congress and signed by the President o September 2010 ─Proposed Rule published o October/November 2010 ─States’ Comment Period o February 2, 2011 ─Final Rule published in the Federal Register o March 25, 2011 ─Changes to the Code of Federal Regulations (CFR) became effective

4. Steps Towards Implementation  Legislation – SB 1529 (Alquist) o Introduced February 24, 2012 o Statutes would become effective January 1, 2013 o Only “minimum necessary” changes will be made  State Plan Amendment (SPA) o Due to CMS – April 1, 2012 o Required for most of the CFR provisions  Provider/Regulatory Bulletin(s) o Regulatory and informational  January 1, 2013 o Target date for full implementation of new requirements

5. Steps Towards Implementation  Coordinating with other Divisions and Departments  Stakeholder Meetings  Making necessary changes to current policy and procedures  Developing and updating forms in order to collect the required provider information

6. SESSION 1: Wednesday, March 28, 2012 9:30 A.M. to 11:30 A.M. SCREENING LEVELS FOR MEDICAID PROVIDERS 42 CFR § 455.450 CRIMINAL BACKGROUND CHECKS INCLUDING FINGERPRINTING 42 CFR § 455.434 TERMINATION OR DENIAL OF ENROLLMENT AND REPORTING 42 CFR § 455.416

7. Screening Levels for Medicaid Providers 42 CFR § 455.450  42 CFR § 455.450 requires states to screen providers according to limited, moderate and high risk categories.  Federal law designates specific provider types within the three categories at 42 CFR § 424.518.  The State Medicaid agency must screen providers in accordance with the federal designations.

8. Screening Levels for Medicaid Providers 42 CFR § 455.450  42 CFR § 424.518: Provider types designated as limited categorical risk include: o Physicians o Nonphysician practitioners o Ambulatory surgical centers o Federally qualified health centers (FQHC) o Hospitals, including critical access hospitals, Department of Veterans Affairs hospitals, and other federally owned hospital facilities o Health programs operated by an Indian Health Program o Pharmacies o Rural health clinics o Skilled nursing facilities

9. Screening Levels for Medicaid Providers 42 CFR § 455.450  42 CFR § 424.518: Provider types designated as moderate categorical risk include: o Ambulance service suppliers o Community mental health centers o Comprehensive outpatient rehabilitation facilities o Hospice organizations o Independent clinical laboratories o Independent diagnostic testing facilities o Physical therapists (individual & groups) o Portable x-ray suppliers o Revalidating home health agencies o Revalidating DME suppliers

10. Screening Levels for Medicaid Providers 42 CFR § 455.450  42 CFR § 424.518: Provider types designated as high categorical risk include: o Prospective (newly enrolling) home health agencies o Prospective (newly enrolling) DME suppliers

11. Screening Levels for Medicaid Providers 42 CFR § 455.450  Screening procedures required of the categorical risk levels: o Limited ─Requires license verifications (§ 455.412) ─Database checks (§ 455.436) o Moderate ─Requires onsite inspections (§ 455.432) ─All screening procedures required of the Limited risk level o High ─Requires fingerprinting/criminal background checks (§ 455.434) ─All screening procedures required of the Limited and Moderate risk levels

12. Screening Levels for Medicaid Providers 42 CFR § 455.450  All providers, regardless of provider type, must be screened at the high categorical risk level if any of four conditions exist: o Payment suspension that is based on a credible allegation of fraud, waste or abuse o Existing Medicaid overpayment o Excluded by OIG or another State’s Medicaid program within the previous 10 years o A Moratorium was lifted within previous six months prior to applying and the provider would have been prevented from enrolling due to the moratorium

13. Criminal Background Checks Including Fingerprinting 42 CFR § 455.434  42 CFR § 455.434: o Requires all providers designated as high categorical risk to submit fingerprints o Defines providers as any person or entity that holds 5% or more ownership or control interest o Requires providers to submit a set of fingerprints in the “form and manner” determined by the State Medicaid agency o Requires fingerprints to be submitted within 30 days of a request from CMS or the Medicaid agency

14. Termination or Denial of Enrollment and Reporting 42 CFR § 455.416  42 CFR § 455.416 specifies causes for the denial and/or termination of enrollment of providers.  This section broadens the State’s current authority to deny and/or deactivate the enrollment of providers.  States have discretion in some situations when denial or termination can be documented as “not in the best interest of the Medi-Cal program.”

15. Termination or Denial of Enrollment and Reporting 42 CFR § 455.416  New denial/termination causes: o Provider is terminated on or after January 1, 2011, under Medicare, Medicaid or CHIP of any other State o Provider, or agent or managing employee fails to submit timely and accurate information & doesn’t cooperate with required screening procedures o Provider fails to submit fingerprints within 30 days of a CMS or a State Medicaid request o Provider fails to permit access to provider locations for any site visits o Provider falsifies any information on an application or their identity cannot be verified

16. Termination or Denial of Enrollment and Reporting 42 CFR § 455.416  Reporting provider terminations o California is required to report terminated providers on the Medicaid and Children’s Health Insurance Program State Information Sharing System (MCSIS) so that other States and Medicare can determine which providers have been terminated by California.  42 CFR § 455.101 states that a Medicaid or CHIP provider is terminated when: o The State has taken action to revoke billing privileges o The provider has exhausted all applicable State appeal rights o The revocation is not temporary o The provider must re-enroll (and be re-screened per Section 455.420) to establish billing privileges

17. Department of Health Care Services | Provider Enrollment Division PEDACA@dhcs.ca.gov

18. SESSION 2: Wednesday, March 28, 2012 1:30 P.M. to 3:30P.M. ORDERING AND REFERRING PROVIDERS 42 CFR § 455.410 TEMPORARY MORATORIA 42 CFR § 455.470

19. Ordering and Referring Providers 42 CFR § 455.410  42 CFR § 455.410 requires all providers, including ordering or referring physicians or other professionals providing services under the State plan or under a waiver of the plan to be enrolled as participating providers.  42 CFR § 455.440 requires all claims for items and services ordered or referred to contain the National Provider Identifier (NPI) of the ordering or referring provider.  States are permitted to rely on the results of provider screening performed by any Medicare contractor or Medicaid agency or CHIP of other States when enrolling ordering and referring providers.

20. Ordering and Referring Providers 42 CFR § 455.410  Provider Types that may be required to enroll as ordering/referring providers include: o Doctors of Medicine or Osteopathy o Doctors of Dental Surgery and Dental Medicine o Doctors of Podiatric Medicine o Doctors of Optometry o Physician Assistants o Certified Clinical Nurse Specialists o Nurse Practitioners o Clinical Psychologist o Certified Nurse Midwives o Clinical Social Workers o Doctors of Chiropractic Medicine o Audiologists and Hearing Aid Dispensers

21. Ordering and Referring Providers 42 CFR § 455.410  Physicians and nonphysician practitioners who will be required to enroll in Medi-Cal solely for the purpose of ordering and referring may be: o Department of Veterans Affairs employees o Public Health Service employees o Department of Defense Tricare employees o IHS or tribal organization employees o Federally Qualified Health Centers, Rural Health Clinics or Critical Access Hospital employees o Community Clinic or Free Clinic employees o Licensed Medical Residents or Fellows

22. Ordering and Referring Providers 42 CFR § 455.410  Medicare began implementing the enrollment of ordering and referring providers in Fall 2011 with a new form, CMS-8550.  As of today, Medicare has not turned on the automated edits that would deny claims for items and services ordered or referred by providers not yet enrolled in Medicare.  Once the automated edits are turned on: o Claims from the “filling providers” (i.e. pharmacies) will be denied if the ordering or referring provider’s name and NPI listed on the claim is not enrolled. o Patients may not receive needed items or services (i.e. medication) if the “filling providers or suppliers” refuse to accept orders or referrals from providers that are not enrolled.

23. Temporary Moratoria 42 CFR § 455.470  CMS may establish Medicaid wide temporary moratoria on the enrollment of new providers or provider types: o The State Medicaid agency must impose moratoria established by CMS unless it would create an access to care issue ─The State must then notify CMS in writing  The State Medicaid agency may otherwise impose moratoria, numerical caps, or other limits on the enrollment of new providers: o When fraud, waste or abuse is identified in the Medicaid program and CMS has identified the provider type as being at high risk for fraud, waste and abuse o The State must notify CMS and obtain concurrence with the imposition of the moratoria

24. Department of Health Care Services | Provider Enrollment Division PEDACA@dhcs.ca.gov

25. SESSION 3: Thursday, March 29, 2012 9:30 A.M. to 11:30 A.M. APPLICATION FEE 42 CFR § 455.460 REVALIDATION 42 CFR § 455.414

26. Application Fee 42 CFR § 455.460  42 CFR § 455.460 requires States to collect an application fee from all prospective or re- enrolling providers EXCLUDING the following: o Individual physicians or non-physician practitioners o Providers already enrolled with Medicare o Providers already enrolled in any State’s Medicaid or CHIP o Providers who have already paid an application fee to either a Medicare contractor or another State’s Medicaid or CHIP program

27. Application Fee 42 CFR § 455.460  CMS calculates the application fee for each Calendar Year.  The fee is adjusted annually by the percentage change in the consumer price index for all urban consumers. o 2010 ~ $500.00 o 2011 ~ $505.00 o 2012 ~ $523.00  If the fees collected by the State exceed the application screening costs, the State must return the remainder to the Federal Government.

28. Application Fee 42 CFR § 455.460  To request a waiver of the application fee: o Individual providers may submit a request to CMS for a hardship exception in the form of a letter that describes the hardship and explains why it justifies an exception. o The State may submit a request to CMS for a fee waiver applicable to a group or category of providers by demonstrating that the fee will have a negative impact on beneficiary access to care.

29. Revalidation 42 CFR § 455.414  42 CFR § 455.414 requires revalidation of enrollment for all provider types at least every 5 years.  Federal regulation also allows States to rely on the results of the provider screening performed by Medicare contractors and Medicaid or CHIP programs of any State to fulfill this requirement.  California regulations already contain requirements for re-enrolling and re-certifying providers, but the “every five years” revalidation requirement is new.

30. Department of Health Care Services | Provider Enrollment Division PEDACA@dhcs.ca.gov