DHCS issued two all-plan letters about billing for inpatient services at both designated public hospitals (DPH) and private or non-designated public hospitals for CCS-eligible conditions of managed care Medi-Cal beneficiaries. Generally, CCS services are paid through fee-for-service Medi-Cal, and most CCS services are carved out of managed care plans. However, some plans carve in these services.
For services provided to a Medi-Cal beneficiary with a CCS-eligible condition enrolled in a managed care plan with a CCS carve out:
- A hospital stay for a CCS-eligible condition must be billed entirely to Medi-Cal FFS (DPH will get a per diem, while other hospitals will get a single payment based on the diagnosis related group), with no billing to the managed care plan.
- A hospital stay for a non-CCS eligible condition with subsequent services during the stay for a CCS-eligible condition is billed entirely to Medi-Cal FFS (again with applicable per diem or DRG), with no billing to the managed care plan.
- A stay that includes delivery and well-baby coverage is billed entirely to the health plan. If the baby develops a CCS-eligible condition, the baby’s entire stay will be billed to Medi-Cal FFS and not the health plan.
For services and hospital stays for a Medi-Cal beneficiary with a CCS-eligible condition enrolled in a managed care plan that covers CCS services, a beneficiary hospital stay (regardless of reasons) must be billed entirely to the managed care plan.
DHCS APL 16-007, DHCS APL 16-008 (7/18/16)