1 From: Bui, Tiffany@DHCS <[email protected]>
Sent: Friday, November 18, 2022 8:15 AM
To: Gelein, Teresa@DHCS; Bryan Johnson; Katrin Bandhauer; Elsa Chow; Heidi Lee Cc: Delis, Jesse@DHCS; Landry, Lina@DHCS; Geisen, Katie@DHCS; Brandt, Tyler@DHCS; Tamai, Michelle@DHCS; Kung, Serina@DHCS
Subject: RE: PP-GEMT IGT Net Benefit - City of Orange
Follow Up Flag: Follow up
Flag Status: Flagged
Good morning City of Orange,
Thank you for your patience. Please see additional details pertaining to Fee-For-Service (FFS) IGT amount and net benefit.
The PP-GEMT IGT Program consists of two (2) different delivery systems, Managed Care and Fee-For-Service (FFS). The LOI includes one collection figure, which is a combined MC and FFS IGT amount. Therefore, I can only speak to the FFS portion of those collection dollars and associated revenue.
In the Fee-For-Service (FFS) delivery system, the Intergovernmental Transfer (IGT) amount is calculated by using the following components:
o Total historical FFS trips across all public providers This includes dual Medicare/Medi-Cal (Medi-Medi) Emergency Transports, which account for approximately 2.6% of all public provider transports o Total estimated non-federal share of PP-GEMT IGT expenditure anticipated to be paid to all FFS public providers, based upon projected GEMT utilization in CY 2023, and o The proportional share of FFS trips by providers that intend to contribute IGT in support of the program.
To help illustrate the process described above, we are providing FFS details pertaining to your specific data:
City of Orange estimated FFS Net Benefits for CY 2023 are as follows:
Total Projected Fee-For-Service Net Benefit: $162,161.94 Projected Fee-For-Service Net Benefit per Trip: $664.60 For more specific information regarding City of Orange Fee-For-Service IGT Calculation, please see detail information listed below.
For NPI 1922004555, the estimated number of FFS trips in CY 2023 is 244, which was projected based on your CY 2021 FFS paid claims data. When 244 is divided by all participating FFS public provider trips (39,690 trips at the time of calculation), your provider’s proportional percentage of trips is 0.61%. This percentage is then applied to the estimated aggregate FFS non-federal share of $14.5 million, which yields an annual IGT collection
2 amount of $88,843.03. The above estimates are based upon available data at the time of your IGT calculation and may be subject to change.
Based on this information, City of Orange estimated FFS Net Benefits for CY 2023 calculation is as follows:
o Estimated number of FFS trips in CY 2023: 244
o Base reimbursement rate per transport: $118.20
To simplify the illustration, base reimbursement is $118.20 per transport, which is the fee schedule rate for 4 of the 5 procedure codes (A0427, A0429, A0433, A0434) that are eligible for the PP-GEMT IGT add-on. The fifth procedure code (A0225) eligible for the PP-GEMT IGT add-on has a fee schedule rate of $179.92, so base reimbursement will likely be higher than estimated in this illustration.
o PP-GEMT IGT Add-On amount per transport: $946.92
o Estimated annual FFS IGT collection amount: $88,843.03 o 10 percent administrative fee for participating in PP-GEMT IGT: $8,884.30 Estimated base reimbursement for CY 2023: 244 x 118.20 = $28,840.80 Estimated reimbursement from the PP-GEMT IGT Add-On for CY 2023: 244 x 946.92 = $231,048.48
Estimated total reimbursement for CY 2023: $28,840.80 + $231,048.48 = $259,889.28 Estimated net benefit: $259,889.28 - $88,843.03 - $8,884.30 = $162,161.94 o Net Benefit = Total Reimbursement – IGT – admin fee
Please note that the figures above are offered for illustrative purposes and the PP-GEMT IGT collection amount is subject to change depending on changes in provider participation.
If you have any additional questions regarding the program please do not hesitate to reach out.
Best Regards,
Tiffany Bui
Associate Governmental Program Analyst| Provider Rates Section – Unit A Fee for Service Rates Development Division
California Department of Health Care Services
1501 Capitol Ave, Sacramento, CA 95814
[email protected]
From: Gelein, Teresa@DHCS <[email protected]>
Sent: Friday, November 18, 2022 8:01 AM
To: [email protected]; [email protected]; [email protected]; [email protected] Cc: Delis, Jesse@DHCS <[email protected]>; Landry, Lina@DHCS <[email protected]>; Geisen, Katie@DHCS <[email protected]>; Brandt, Tyler@DHCS <[email protected]>; Bui, Tiffany@DHCS <[email protected]>; Tamai, Michelle@DHCS <[email protected]>; Kung, Serina@DHCS <[email protected]>
Subject: PP-GEMT IGT Net Benefit - City of Orange
Hello City of Orange,
3 As a follow up to Letter of Intent (LOI) distributions, the Managed Care (MC) team is providing you with your estimated MC CY 2023 net benefit for the PP-GEMT IGT Program. This estimated net benefit is a calculation is based off today’s level of assumed provider participation. We are providing these projections for informational purposes and caveat that figures are subject to change. As stated, projected revenue is specific to MC, thus it does not include the Fee-For-Service (FFS) net benefit. We have CC’dour FFS counterparts on this communication so they can speak to their revenue allowing you to budget your total estimated net benefit across both delivery systems. Total Projected Managed Care Net Benefit: $1,311,206.00, which equates to the below, Projected Managed Care Net Benefit per Trip: $539.45
The primary function of this information is to clarify how the annualized trip counts from Jul 2020 – Dec 2021 and the CY 2023 DRAFT non-federal share cost impact provider revenue, requested IGT, and the estimated CY 2023 net benefit within MC. This estimate leverages the current CY 2023 fee schedule rate plus Add-on and includes aggregate trend factors and assumptions in order to provide an estimated CY 2023 net benefit within managed care. The trips in scope include beneficiaries with and without Medicare Part B. This calculated benefit does not account for the 10% administrative fee, however you can subtract 10% of what you see on your LOI from both the MC and FFS net benefit.
Again, FFS will follow up separately with their estimated return. For the avoidance of doubt, we reiterate that the actual net benefit in CY 2023 will vary based on a number of factors including, but not limited to, actual 2023 trip counts and Final CY 2023 rates/non-federal share.
Please “Reply All” to this email if you have any questions.
Thank you,
Teresa Gelein
Capitated Rates Development Division (CRDD)
California Department of Health Care Services
Email: [email protected]
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