MedicaidMay 5, 2023
Proposition 56 Value-Based Payment Program update
Background
The California Healthcare, Research and Prevention Tobacco Tax Act of 2016(Proposition 56) increased the excise tax rate on tobacco products to fund specified expenditures, including existing programs administered by the Department of Health Care Services (DHCS). Assembly Bill 74 appropriates Proposition 56 funds 2019 to 2020, 2020 to 2021, and 2021 to 2022state fiscal year for specified DHCS directed payment expenditures.
DHCS released the Value-Based Payment (VBP) Program specifications outlining the measures and payment triggers for each domain on the Value-Based Payment Program webpage on the DHCS website. The specifications provide an explanation for each VBP program measure, the source for each measure, the appropriate diagnosis/procedure codes, and exclusion criteria, etc.
Update
The Proposition 56 Value-Based Payment Program is in effect from June 1, 2019, to June 30, 2022. Services performed after June 30, 2022, are not eligible to receive VBP enhanced payments.
Visit the DHCS Value-Based Payment Program webpage for details at https://dhcs.ca.gov/provgovpart/Pages/VBP_Measures_19.aspx.
The domains and measures eligible for directed payments and the corresponding amounts for qualifying services are:
Domain | Measure | Add-on amount for non-at-risk members | Add-on amount for at-risk members* |
Prenatal/postpartum care bundle | Prenatal pertussis (whooping cough) Vaccine | $25.00 | $37.50 |
Prenatal care visit | $70.00 | $105.00 | |
Postpartum care visits | $70.00 | $105.00 | |
Postpartum birth control | $25.00 | $37.50 | |
Early childhood bundle | Well-child visits in first 15 months of life | $70.00 | $105.00 |
Well-child visits in 3rd – 6th years of life | $70.00 | $105.00 | |
All childhood vaccines for 2-year-olds | $25.00 | $37.50 | |
Blood lead screening | $25.00 | $37.50 | |
Dental fluoride varnish | $25.00 | $37.50 | |
Control of persistent asthma | $40.00 | $60.00 | |
Tobacco use screening | $25.00 | $37.50 | |
Chronic disease management bundle | Controlling high blood pressure | $40.00 | $60.00 |
Diabetes care | $80.00 | $120.00 | |
Control of persistent asthma | $40.00 | $60.00 | |
Tobacco use screening | $25.00 | $37.50 | |
Adult influenza (flu) vaccine | $25.00 | $37.50 | |
Behavioral health integration bundle | Screening for clinical depression | $50.00 | $75.00 |
Management of depression medication | $40.00 | $60.00 | |
Screening for unhealthy alcohol use | $50.00 | $75.00 |
* At-risk members: members diagnosed with a substance use disorder, a serious mental illness, or who are homeless or have inadequate housing
How will we process payments?
Providers will receive monthly checks via mail along with remittance advice.
How will we determine the responsible payer?
To qualify for payment, providers must be contracted providers, must be practicing within their practice scope, and must have an individual (Type 1) NPI. Payments cannot be made if an individual (Type 1) NPI is not found on the claim, or the W-9 (Request for Taxpayer Identification Number and Certification form) information is not available.
If you believe you qualify for the VBP payment, email your W-9 form and the table below with your NPI/TAXID/Name/Billing address information to prop56@anthem.com and include Prop56VBP-W9 in the subject line.
Individual Type 1 NPI | W9 business tax ID | W9 business name | Billing address | Billing city | Billing state | Billing ZIP |
How will I receive my payment?
Providers will receive payments directly via a direct-to-provider payment process from Anthem Blue Cross (Anthem). Independent physician associations will not receive supplemental payments. If you would like to receive line-level detail for the payments, send an email to prop56@anthem.com, and we will send you a secure detail file within two weeks of receipt of your email.
Please provide the following information:
- Billing tax ID(s)
- Provider name
- Check number
- Contact name
- Contact phone number
- Secure email address
Whom may I contact with questions or concerns?
Anthem has set up an email address specifically for Proposition 56-related questions at prop56@anthem.com. Include VBP in the subject line.
How do I file a provider grievance?
Providers may file grievances up to 180 calendar days from the date the provider becomes aware of the issue by:
- Calling the Medi-Cal Customer Care Center at 800-407-4627 (outside L.A. County) and 888-285-7801 (inside L.A. County).
- Visiting the provider website at https://mediproviders.anthem.com/ca/pages/forms.aspx.
- Faxing to the Grievance and Appeals department at 866-387-2968.
- Mailing to
Anthem Blue Cross
Grievance and Appeals Department
P.O. Box 60007
Los Angeles, CA 90060-0007
CABC-CD-022086-23
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