Home care billing in California

Both. In CMS's 2024 state tables the County Organized Health System, Two-Plan, Geographic Managed Care and Single-Plan models carry the program type of an MCO with managed long-term services and supports (MLTSS), under 1915(b) authority for the first three and 1115(a) with 1915(b) for the Single-Plan model, while the Regional model is an MCO program without MLTSS. Fee-for-service Medi-Cal remains for members outside those plans.⁴ The CMS plan-level dataset cited below lists the plans by model, among them L.A. Care Health Plan, Health Net Community Solutions, Anthem Blue Cross Partnership Plan, Kaiser Permanente, Molina Healthcare of California Partner Plan, Inland Empire Health Plan, CalOptima and Partnership HealthPlan of California. For CBAS and MSSP the CalEVV page, cited above, names the Jurisdictional Entities that authorize and pay providers as managed care plans and MSSP sites.

CalEVV, the state's free system, implemented for personal care services on January 1, 2022 and home health care services on January 1, 2023 under the 21st Century Cures Act, with Sandata as the CalEVV solutions partner. A provider may instead use a third-party EVV system, but that vendor must be certified to meet the California standard and follow the alternate EVV specifications. Providers of PCS or HHCS are required to register in the Provider Self-Registration Portal.¹ The Department of Aging describes CalEVV as a means of achieving Cures Act compliant claims matching for EVV, and it publishes forms for Jurisdictional Entities covering EVV policy and procedures, technical assistance logs and sanction requests, so an unverified visit can reach you as a sanction from the plan or MSSP site as well as a denial.

Services under EVV¹

• Personal Care Services (PCS), under CalEVV since January 1, 2022
• Home Health Care Services (HHCS), under CalEVV since January 1, 2023
• Community-Based Adult Services (CBAS) core and additional services, for the Medi-Cal provider types and procedure codes listed in the state's Provider Types and Codes document
• Multipurpose Senior Services Program (MSSP) services listed in the same document

For MSSP, a team of health and social service professionals gives each participant a complete health and psychosocial assessment to determine needed services, and MSSP care management then coordinates care, links the participant to community resources and purchases services that are not otherwise available.² For CBAS, the center's health professionals assess each potential participant and plan the services needed, as the CBAS page cited below states, and the managed care plan or MSSP site, as Jurisdictional Entity, authorizes and pays the provider under the CalEVV page cited above. Medi-Cal fee-for-service home health authorization rules sit in the Medi-Cal provider manuals, which could not be reached at review, so they are not described here.

Claims follow the authorizing Jurisdictional Entity: managed care plans and MSSP sites are the local organizations that authorize and pay providers and vendors and oversee day-to-day service delivery, and CalEVV exists to support Cures Act compliant claims matching against those claims. There is no single state EVV claims gateway in the Department of Aging's description.¹ Each Medi-Cal plan applies its own claims policy; San Francisco Health Plan's policy, cited below, sets six months following the month of service for original claims, with reduced payment after that. Medi-Cal fee-for-service claim submission is set by the Medi-Cal provider manuals, which were not reachable at review.

National Government Services, Inc., the A/B MAC for Jurisdiction 6, processes Medicare home health and hospice claims for California, together with Alaska, American Samoa, Arizona, Guam, Hawaii, Idaho, Michigan, Minnesota, Nevada, New Jersey, New York, the Northern Mariana Islands, Oregon, Puerto Rico, the US Virgin Islands, Washington and Wisconsin.⁵ The California Department of Public Health certifies home health aides under Health and Safety Code sections 1725 to 1742 and Title 22, Division 5 of the California Code of Regulations, listing 42 CFR Part 484 as the federal requirement; an aide completes a CDPH-approved 40-hour program while holding an active Certified Nursing Assistant certificate or a 120-hour program, and renews with 24 hours of in-service training within each two-year certification period. CDPH's agency licensure pages could not be reached at review, so home health agency licensure is not described here.