Provider Alerts

As part of the California Advancing and Innovating Medi-Cal (CalAIM) initiative, including the mandatory transition of beneficiaries to managed care, Health Plan of San Joaquin (HPSJ) will be responsible for the LTC benefit effective January 1, 2023.

While Medi-Cal managed care is available statewide, the benefits vary among counties depending on the managed care plan model. These variations include coverage of the skilled nursing facility (SNF) benefit under the institutional LTC services. To further CalAIM’s goals to standardize and reduce complexity across the state and reduce county to county differences, the Department of Health Care Services (DHCS) will require most non-dual and dual LTC members (including those with Share of Cost) to enroll in a managed care plan.

Beginning January 1, 2023, HPSJ will authorize and cover medically necessary services provided in SNF facilities (including a distinct part or unit of a hospital) for LTC members residing in or obtaining care in a SNF. This means that members who are admitted into a SNF and would otherwise have been disenrolled from HPSJ will remain enrolled.

Services covered by HPSJ include facility services, professional services, ancillary services, and all care coordination and Complex Care Management (CCM) services. HPSJ will help coordinate benefits for members with other health coverage (OHC) programs, recognizing OHC as primary, as the Medi-Cal program is the payer of last resort.

For coverage of Medi-Cal pharmacy benefits, these will vary according to the following:

• Drugs covered by HPSJ for services provided by a SNF will remain HPSJ’s responsibility.
• Medi-Cal pharmacy services billed on a medical or institutional claim by a pharmacy, or any other provider, must be billed to HPSJ.
• Prescription drugs provided by a SNF and not part of the bundled rate for services, the financial responsibility for those drugs is determined by the claim type on which they are billed.
  1. If the drugs are dispensed by a pharmacy, and billed on a pharmacy claim, then they are carved out and paid by Medi-Cal Rx.
  2. If the drugs are furnished by the SNF and billed on a medical or institutional claim, HPSJ is the payer.

The remaining LTC members receiving the Subacute LTC benefit and Intermediate Care Facility for the Developmentally Disabled (ICF-DD) LTC will be enrolled in a managed care plan effective July 1, 2023. More information specific to the Subacute LTC benefit and ICF-DD LTC benefit will be provided at a later date.

If you have any further questions, please contact your Provider Services Representative, or call our Customer Service Department at 1-888-936-PLAN (7526). You may also visit https://www.hpsj.com/alerts/ for online access to the documents shared.