Targeted Rate Increase Frequently Asked Questions
Updated November 20, 2024
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- 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 for certain Medi-Cal services to 87.5% of Medicare. The DHCS will add funding to health plan premiums, which will then be passed on to eligible contracted providers. - What makes a provider eligible?
Only contracted providers, as defined by DHCS, providing qualifying services are eligible to receive the TRI. The TRI is not applicable to services rendered pursuant to Single Case Agreements (SCAs) or Letters of Agreement (LOAs). If you are not contracted with the payor you are billing, you will not get paid the TRI adjustment. - What services are eligible?
TRI category Eligible provider types Eligible claim forms Contract status Primary/general care - Physician
- Physician Assistants
- Nurse Practitioners
- Podiatrists
- Certified Nurse Midwives
- Licensed Midwives
- Doula Providers
- Psychologists
- Licensed Professional Clinical Counselor
- Licensed Clinical Social Workers
- Licensed Marriage and Family Therapists
CMS 1500 Contracted Network Provider
(Does not include Single Case Agreements (SCAs) or Letters of Agreement (LOAs))Obstetric Any/all CMS 1500 (professional)/UB04 (facility)/nonstandard invoice Contracted Network Provider
(Does not include SCA, LOA)Non-Specialty Mental Health Services Any/all CMS 1500 (professional)/UB04 (facility)/nonstandard invoice Contracted Network Provider
(Does not include SCA, LOA) - What CPT codes apply?
Refer to CY 2024 TRI Fee Schedule v1.06.01082024 (XLSX) for rate information. - What do I need to know about Proposition 56 Physician Services Payments (APL 23-019 [PDF])?
Medi-Cal TRI incorporates Prop 56 Physician Services payments. All other Prop 56 programs (dental, family planning, sensitive services) will remain unchanged in 2024. - Do health plans have to pay their downstream providers at TRI rates?
Yes. Health plans are required to attest to payments to contracted and eligible downstream providers. - Are Prop 56 Physician Services payments included in the TRI calculation?
Yes. Prop 56 Physician Services payments are incorporated into the TRI fee schedule. See item 1 under Fee-for-service providers below. - Are incentive, bonus, and profit share payments excluded from the TRI calculations?
Yes. - Are providers who are on Single Case Agreements (SCAs) or Letters of Agreements (LOAs) eligible for TRI payments?
No. Only network providers, as defined in DHCS All Plan Letter (APL) 19-001 are eligible to receive the TRI. SCAs or LOAs do not meet the requirements of APL 19-001. Providers who are presently on SCA or LOA and wish to be eligible for TRI payments would need to contract with Health Net according to the requirements of APL 19-001. - Updated October 31, 2024 – Are Federally qualified health clinics (FQHCs) and Rrural health clinics (RHCs) eligible to receive TRI?
No. FQHC and RHC services do not qualify for reimbursement under the TRI Fee Schedule in the FFS delivery system. Pursuant to W&I section 14087.325(d), health plans must reimburse contracted FQHCs and RHCs in a manner that is no less than the level and amount of payment that the health plan would make for the same scope of services if the services were furnished by another provider type that is not an FQHC or RHC. While FQHC and RHC are excluded from TRI please note that we will be paying parity payments to comply with the requirements of Provision 3.3.7 of Exhibit A, Attachment III, of the State Medi-Cal Contract.
The health plan boilerplate Medi-Cal Contract is available at DHCS.
- Updated October 31, 2024 – How is the fee-for-service (FFS) TRI payment methodology calculated?
Fee-for-service (FFS) TRI Payment Calculation Step 1:
Calculate current contract + Prop 56 Physician Services payment amountStep 2:
Determine the TRI fee schedule amountStep 3:
Pay using the greater amount from steps 1 and 2, and apply final "Lesser of Charges"Billed $80, contract $40
Lesser of = $40
Prop 56 Physician Services payment = $30
Total = $70Greater than the TRI fee schedule
TRI $50Health Net pays the current contracted rate + Prop 56 Physician Services payments
Payment = $70Billed $80, contract $60
Lesser of = $40
Prop 56 Physician Services payment = $30
Total = $70Less than the TRI fee schedule
TRI $100Payment is based on the TRI fee schedule price, but the final "Lesser of" will affect payment
Payment "Lesser of" = $100
Payment after "Lesser of": -$80 - Updated November 20, 2024 – When will FFS claims processed by Health Net be paid at TRI rates?
TRI rates are effective January 1, 2024. Health plans have until December 31, 2024, to start paying at TRI rates for any new claims for dates of service on or after December 31, 2024. Health Net will start paying TRI rates for new day claims by December 31, 2024. Health plans have until December 31, 2024, to retroactively implement rate increases for FFS claims for dates of service on or after January 1, 2024. On October 22, 2024, Health Net started making retroactive adjustments going back to January 1, 2024. Health Net will pay Prop 56 Physician Services payments until our systems are configured to start paying TRI, at which point Prop 56 Physician services payment will be built into the TRI logic. - Does my FFS contract have to indicate that I will be paid at TRI rates?
No. TRI is a pass-through funding program and is a separate fee schedule from the Medi-Cal fee or any contractual schedule. Contractual rates cover all services within the scope of the contract. TRI fee schedule only covers specifically eligible services as indicated in the TRI fee schedule. TRI does not modify contractual fee schedules. Instead, our claims system will automatically apply the additional TRI payments for eligible services and providers during the claim adjudication process. Health Net is updating our claims systems to include TRI by December 31, 2024, as required by DHCS. Furthermore, TRI is a DCHS requirement, and our Medi-Cal contracts automatically incorporate DHCS requirements. - Will Health Net be amending FFS contracts to include TRI rates?
No. Health Net will not amend FFS provider contracts because the fee schedule in the contracts is not changing. Instead, the TRI fee schedule, which is the same for all providers, is applied in addition to the fee schedule in the contract, as described above. - Updated September 20, 2024 – Do the standard adjustments (late filing, etc.) apply to TRI?
Yes, late filling and other standard adjustments will apply for TRI payments. - Updated September 20, 2024 – If a code has a modifier that affects payment or utilizes a different schedule (i.e., 26, TC, 51, 50, 62, AS, 80, SL, UA, UB, etc.), would TRI be paid on this claim line?
No, the claim line would be processed using the standard Medi-Cal fee schedule methodology. - Do FFS providers need to re-submit claims for backpay?
No, eligible providers do not need to re-submit claims. Health Net will adjust all eligible claims by December 31, 2024. - Updated November 20, 2024 – When will Health Net start incorporating the TRI fee schedule on a prospective basis?
For FFS claims, Health Net plans to reimburse TRI rate-eligible claims on a prospective basis starting December 2024. - Added September 20, 2024 – Will the TRI fee schedule be shown on the explanation of payments (EOPs)?
No, the TRI fee schedule will not appear separately on the EOPs. - Added September 20, 2024 – How will Health Net handle retrospective payments for FFS claims? Will claims be reprocessed, or will a lump sum be issued?
Health Net will reprocess the eligible TRI FFS claims. - Added September 20, 2024 – If claims are reprocessed, will the EOP indicate it is due to the TRI fee schedule?
Yes, the EOP will include a note stating that the additional payment is part of the TRI remediation. - Added September 20, 2024 – If payment is issued as a lump sum, will Health Net provide detailed information on which accounts were adjusted and the amount adjusted per claim?
No, payments will not be issued as a lump sum. - Added September 20, 2024 – What should providers do if they disagree with the retrospective payment amounts?
The dispute process remains unchanged. Providers should follow the Provider Dispute procedures detailed in the operations manual.
- When will Health Net's capitation rates to PPGs 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. Health Net will continue to pay Prop 56 Physicians Services payment directly to providers for 2024 dates of service. By December 31, 2024, Health Net will make retroactive TRI add-on capitated payments to PPGs. These retroactive TRI add-on capitated payments will not include the value of Prop 56 Physicians Services. Health Net will share the Prop 56 Physicians Services payment data for 2024 with PPGs. Health Net will make prospective TRI add-on capitated payments effective January 1, 2025. The prospective add-on capitation payments will include the value of Prop 56 Physicians Services payment. - What do PPGs need to do to obtain the applicable TRI rates owed to them?
To calculate TRI rates owed to PPGs, Health Net needs PPGs to submit their capitated encounters and FFS claims to Health Net through the secure file transfer protocol (SFTP) site, Health Net Data Request - DHCS Medi-Cal TRI (Targeted Rate Increase) template (XLSX). To submit encounters please:- Assign a designated individual, on behalf of your PPG, to submit the requested data to Health Net.
- Submit the designated individual's contact information, including their name, email and phone to the regulatory and legislative implementation intake team.
- Your designated individual will be emailed and given a temporary password to log in to the SFTP site. Once logged in, they can change the temporary password.
- Prior to June 30, 2024, your designated individual must submit the data to the SFTP site using Health Net Data Request - DHCS Medi-Cal TRI (Targeted Rate Increase) template (XLSX).
- Once the TRI rate amount due to a PPG is calculated, Health Net will send a proposed amendment to your contract. Health Net will target to send proposed PPG amendments inclusive of the TRI capitation rate increases in August 2024, assuming timely data submission by PPGs in Step 4 above.
- Why is this data submission needed?
PPGs already submit encounter data to Health Net, but the following two elements are missing from existing encounter submissions and necessary to calculate the appropriate TRI rates:- FFS Claims: Accurate paid amounts for all TRI-eligible services.
- Sub-capitation: Sub-capitation payments, and encounter detail of all sub-capitation services.
- Updated October 31, 2024 – Once the PPGs submit their capitated encounters and FFS claims, how will Health Net process the information to determine TRI capitation rate due to the PPG?
- For FFS encounters, the exact TRI add-on is calculated using the paid amount. For capitation, the capitated encounters will be analyzed to determine how much additional capitation is needed to support TRI.
- The 2024 TRI capitation per member per month equals the total add-on from the FFS encounters plus the total capitated encounters, minus Prop 56 Physicians' Services payments.
Note: Health Net will pay Prop 56 Physician Services payment in 2024. As a result, you will receive two sets of capitated amounts:- 2024 TRI capitation rates: which do not include the value of Prop 56 Physicians' Services payments.
- 2025 TRI capitation rates: which will include the value of Prop 56 Physicians' Services payments.
Fee-for-service (FFS) TRI Payment Calculation - Example for 2024 payment Step 1:
Calculate current contract + Prop 56 Physician Services payment amountStep 2:
Determine the TRI fee schedule amountStep 3:
Pay using the greater amount from steps 1 and 2, and apply final "Lesser of Charges"Billed $80, contract $40
Lesser of = $40
Prop 56 Physician Services payment = $30
Total = $70Greater than the TRI fee schedule
TRI $50PPG pays the current contracted rate = $40
Health Net pays Prop 56 Physician Services payment = $30
Total Payment = $70Billed $80, contract $40
Lesser of = $40
Prop 56 Physician Services payment = $30
Total = $70Less than the TRI fee schedule
TRI $100Payment is based on the TRI fee schedule price, but the final “Lesser of” will affect payment.
Before final "Lesser of", PPG pays TRI fee schedule minus Prop 56 Physician Services payment = $70
Health Net pays Prop 56 Physician Services payment = $30
After final "Lesser of", PPG pays TRI fee schedule minus Prop 56 Physician Services payment = $50
Health Net pays Prop 56 Physician Services payment = $30
Health Net will stop paying Prop 56 Physicians Services payments starting with 2025 dates of service and will communicate to all physicians to work directly with PPGs for the full payment, inclusive of Prop 56 Physicians Services payment. We will continue paying all other P56 programs as we do today until we get direction to pay differently from the DHCS.
Fee-for-service (FFS) TRI Payment Calculation - Example for 2025 payment Step 1:
Calculate current contract + Prop 56 Physician Services payment amountStep 2:
Determine the TRI fee schedule amountStep 3:
Pay using the greater amount from steps 1 and 2, and apply final "Lesser of Charges"Billed $80, contract $40
Lesser of = $40
Prop 56 Physician Services payment = $30
Total = $70Greater than the TRI fee schedule
TRI $50PPG pays the current contracted rate + Prop 56 Physician Services payment
Payment = $70Billed $80, contract $40
Lesser of = $40
Prop 56 Physician Services payment = $30
Total = $70Less than the TRI fee schedule
TRI $100Payment is based on the TRI fee schedule price, but the final "Lesser of" will affect payment.
Payment before "Lesser of" = $100
Payment after "Lesser of" = $80
- Do PPGs have to pay their downstream providers at TRI rates?
Yes. PPGs will be required to attest to appropriate reimbursement to downstream providers. - Updated September 20, 2024 – When will PPGs have to include TRI rates in their fee-for-service claims to their downstream providers?
TRI rates are effective January 1, 2024. PPGs must correctly process all 2024 applicable claims using the TRI logic by December 31, 2024. - When will PPGs' capitation rates to their downstream providers need to include TRI rates?
As soon as possible, but no later than December 31, 2024. - What are the attestation requirements to ensure PPGs have paid their downstream providers?
DHCS requires health plans to attest that rendering providers are being paid in a manner that is compliant with the TRI APL. As such, Health Net will also require PPGs to attest to complying with TRI requirements, including confirmation that rendering providers are paid in accordance with the TRI APL. Health Net will implement an attestation process that includes an attestation form. Attestation forms must be signed by the PPG's finance executive and include the accounting documentation that TRI funds received from Health Net were distributed to PPGs' downstream providers. - Will Health Net be amending capitated contracts to include TRI rates?
Yes. Capitated agreements must be amended to reflect the additional payment amounts beyond the base capitation rates. The amendments will include TRI capitation rates for 2024, and separately for 2025. Amended contracts will also include language related to compliance with TRI requirements. - If PCP capitation is more than TRI, will there be a negative adjustment?
No, there will not be a negative adjustment. TRI is meant to set a minimum payment level such that providers receiving more than TRI will continue receiving more than TRI. - For FFS claims paid by the PPG, which contract status is used to determine eligibility for TRI?
The contract status between the provider and the PPG is used to determine the provider’s eligibility for TRI. - Added September 20, 2024 – What is Health Net's process to educate the delegated entities, so they comply with the TRI fee schedule?
Health Net employed a comprehensive approach to ensure our delegates understand and comply with the TRI fee schedule:- Multiple Communications: We have sent numerous communications to our delegates, all accessible in the Communications section on this page.
- Live Webinars: We conduct live webinars to provide real-time guidance and answer any questions.
- Direct Meetings: We have held direct meetings with most of our delegates to discuss compliance in detail.
- Trained Provider-Facing Teams: Our provider-facing teams have received specialized training to answer or escalate inquiries effectively.
- Offer further instructions and support for our delegates.
- Require delegates to confirm that they are on track with TRI requirements.
- Obtain attestations by December 31, 2024, ensuring compliance with TRI requirements.