Medi-Cal Fee for Service Comparative Payment Rate Analysis
Background
On May 10, 2024, Centers for Medicare & Medicaid Services (CMS) issued the Ensuring Access to Medicaid Services Final Rule, 89 FR 40542 (2024 Access Final Rule). The rule introduces measures to increase transparency and accountability, standardize data and monitoring, and create opportunities for States to promote active beneficiary engagement, with the overarching goal of improving access to care.
The 2024 Access Final Rule requires the Department of Health Care Services (DHCS) to publish a comparative payment rate analysis (CPRA) applicable to the Medi-Cal Fee-For-Service (FFS) delivery system for primary care services, obstetrical and gynecological services, and outpatient mental health and substance use disorder services. The initial analysis will be published by July 1, 2026, and every two years thereafter to ensure Medi‑Cal FFS rates remain transparent, comparable to Medicare, and publicly accessible. This page will serve as a centralized hub for the Medi-Cal Fee-For-Service CPRA.
CPRA
The CPRA includes Medi‑Cal’s comparative payment analysis for primary care services, obstetrical and gynecological services, and outpatient mental health and substance use disorder services, pursuant to 42 CFR § 447.203(b)(2). The CPRA is based on the Centers for Medicare and Medicaid Services’ published code list of Evaluation and Management Current Procedural Terminology/ Healthcare Common Procedure Coding System (CPT/HCPCS). The CPRA includes the Medi‑Cal FFS base rate displayed as a percentage of the Medicare rate, the number of Medicaid‑paid claims, and the number of beneficiaries who received each service within the calendar year of the applicable analysis.
Resources
§ 447.203 Documentation of access to care and service payment rates