Navigating 2024 targeted rate increases

• California Department of Health Care Services (DHCS) introduced targeted rate increases (TRI) for specific health services effective January 1, 2024.
• Primary Medical Groups/Independent Physician Associations must adhere to the new TRI fee schedule for 2024 claims.
• Various professionals, including physicians and therapists, are eligible for this rate increase.

On June 20, 2024, the California Department of Health Care Services (DHCS) published targeted rate increases (TRI) in APL 24-007 for professional primary care, obstetric care, and non-specialty mental health services retroactive to January 1, 2024. Anthem is working diligently to update its claims payment operations to comply with a requirement to reimburse the TRI fee schedule rate for clean claims received on/after December 31, 2024.

Professional services defined as the financial risk of the Primary Medical Group (PMG)/Independent Physician Associations (IPA) must also adhere to the requirements outlined in APL 24-007 and reimburse network providers at no less than the TRI fee schedule rate for clean claims received after December 31, 2024, for dates of service on or after January 1, 2024.

List of provider types defined by DHCS as eligible for TRI (based on primary taxonomy code):

• Physicians
• Physician assistants
• Nurse practitioners
• Podiatrists
• Certified nurse midwives
• Licensed midwives
• Doula providers
• Psychologists
• Licensed professional clinical counselor
• Licensed clinical social workers
• Marriage and family therapists

PMG/IPA must pay all claims for dates of service from January 1, 2024, to December 31, 2024, to pay in-scope services at the TRI fee schedule rate by December 31, 2024, in addition to paying a clean claim received after December 31, 2024, at the TRI fee schedule rate.

Please reference the TRI Supplemental Data Request (SDR) for additional details regarding the TRI guidance provided by DHCS.

Federally qualified health centers (FQHCs), rural health clinics (RHCs), and American Indian Health Service Programs, as well as cost-based reimbursement clinics are not eligible for TRI fee schedule rates.

Services rendered to a dual-eligible member (a beneficiary with Medicaid and Medicare eligibility) are not in scope for reimbursement at the TRI fee schedule rate.

The current payment methodology allows Anthem to reimburse the supervising physician for services rendered by a nurse practitioner or physician assistant. As outlined in APL 24-007, it is a requirement for qualifying services rendered by a nurse practitioner or physician assistant to be reimbursed at no less than the TRI fee schedule rate. It is the responsibility of the supervising physician who holds a contractual agreement with the nurse practitioner or physician assistant to ensure the rendering provider is receiving reimbursement for services at no less than the TRI fee schedule rate.

Prop 56 Physician Services Update

All procedure codes included in the Proposition 56 Physician Services program (APL 23-019) are found on the TRI fee schedule effective January 1, 2024. The TRI fee schedule rates are defined by the DHCS as being inclusive of the Proposition 56 Physician Services directed payment amount. The Prop 56 Physician Services program under APL 23-019 was effectively terminated as of December 31, 2023.