Targeted Rate Increase Frequently Asked Questions

March 7, 2024
24-221a

1. What is the Medi-Cal targeted rate increase (TRI)?
   
   To improve access to care, quality and equity, the California Department of Health Care Services (DHCS) is increasing rates to 87.5% of Medicare for certain Medi-Cal services. The state is adding additional funding to health plan premiums to pass this funding to providers. The amount of funding for health plans is still being determined. TRI applies to all professional provider types.
2. Which contracted providers will receive the TRI?
   
   
   • 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
   Only eligible contracted providers [defined in All Plan Letter 19-001 (PDF)] will receive the TRI. Non-contracted providers will continue to be reimbursed at the existing Medi-Cal rate for procedure codes identified as Primary/General Care.
3. What CPT codes apply?
   
   Refer to CY 2024 TRI Fee Schedule v1.06.01082024 (XLSX) for rate information.
4. When will fee-for-service claims that are processed by Health Net be paid at TRI rates?
   
   TRI rates are effective January 1, 2024. Plans have until July 31, 2024, to start paying at TRI rates for any new claims. Additionally, plans have until October 31, 2024, to retroactively implement the rate increases for fee-for-service claims.
5. When will Health Net's capitation rates to our delegates include TRI rates?
   
   Capitation rates need to be updated no later than December 31, 2024, to include TRI rates. We are working to finalize rates as soon as possible.
6. When will our delegates have to include TRI rates in their fee-for-service claims to their downstream providers?
   
   TRI rates are effective January 1, 2024. Delegates have until July 31, 2024, to start paying at TRI rates for any new claims. We are working to finalize payment rates for delegates as soon as possible.
7. When will delegates' capitation rates to their downstream providers need to include TRI rates?
   
   Delegates capitation rates need to be updated as soon as possible and no later than December 31, 2024, to include TRI rates.
8. Will Health Net be amending fee-for-service contracts to include TRI rates?
   
   We do not anticipate amending fee-for-service contracts but will notify fee-for-service providers in advance of making this change.
9. Will Health Net be amending capitated contracts to include TRI rates?
   
   Yes. Capitated agreements will be amended to indicate the additional payment amounts beyond the base capitation rates.
10. Do delegates have to pay their downstream providers at TRI rates?
    
    Yes. Delegates will be required to attest to payments to downstream providers.
11. Do Managed Care Organizations (MCOs) have to pay their downstream providers at TRI rates?
    
    Yes. MCOs are required to attest to payments to downstream providers.
12. Are Prop 56 physicians' services payments included in the TRI calculation?
    
    Yes. Prop 56 is incorporated into the TRI fee schedule. The provider will get the contracted rate plus the Prop 56 or TRI fee schedule, whichever is greater. The Assembly Bill 97 reduction does not apply to TRI codes.
13. Are incentive, bonus and profit share payments excluded from the TRI calculations?
    
    Yes.