Clinical Laboratory Services Rate Methodology
May 2021 Update:
In accordance with section 105(a) of the Further Consolidated Appropriations Act 2020 (FCAA) and section 3718 of the Coronavirus Aid, Relief, and Economic Security (CARES) Act, the Centers for Medicare & Medicaid Services (CMS) did not change their clinical laboratory fee schedule for 2021. As a result of the Medi-Cal rate review, no fee for service (FFS) Medi-Cal clinical laboratory rates require a rate adjustment at this time, and, thus DHCS did not submit proposed State Plan Amendment (SPA) 21-0008 as noticed on December 31, 2020.
December 2020 Update:
The Department of Health Care Services (DHCS) has calculated the Clinical Laboratory rates, effective July 1, 2020 in compliance with California Welfare and Institutions Code section 14105.22.
On December 16, 2020, the CMS approved SPA 20-0010. The procedure codes with rates adjusted in accordance with SPA 20-0010 are listed below. The new rates are effective retroactively to July 1, 2020.
|Procedure Codes||Code Description|
July 1, 2020 Rate
|80305||DRUG TEST PRSMV DIR OPT OBS || $9.98 |
|82120||AMINES VAGINAL FLUID QUAL|| $3.22 |
|82172||ASSAY OF APOLIPOPROTEIN|| $12.96 |
|82270||OCCULT BLOOD FECES|| $2.48 |
|82962||GLUCOSE BLOOD TEST|| $1.57 |
|83020||HEMOGLOBIN ELECTROPHORESIS|| $9.57 |
|83050||BLOOD METHEMOGLOBIN ASSAY|| $6.17 |
|83789||MASS SPECTROMETRY QUANT|| $16.28 |
|85046||RETICYTE/HGB CONCENTRATE|| $3.81|
|86677||HELICOBACTER PYLORI ANTIBODY|| $12.42|
|87653||STREP B DNA AMP PROBE|| $24.68 |
|87806||HIV ANTIGEN W/HIV ANTIBODIES || $21.85|
|88108||CYTOPATH CONCENTRATE TECH|| $22.07 |
|88112||CYTOPATH CELL ENHANCE TECH|| $60.14 |
|88189||FLOWCYTOMETRY/READ 16 & >|| $69.16|
|88350||IMMUNOFLUOR ANTB ADDL STAIN || $61.30|
|G0482||DRUG TEST DEF 15-21 CLASSES || $126.22 |
|G0483||DRUG TEST DEF 22+ CLASSES || $160.47 |
In accordance with Assembly Bill (AB) 1494 (Committee on Budget), the DHCS is required to:
Implement a 10 percent payment reduction, excluding services under the Family Planning, Access, Care and Treatment (FPACT) program and outpatient hospital services, effective July 1, 2012 through June 30, 2015, for clinical laboratory and laboratory services until a new rate setting methodology is approved by the Centers for Medicaid & Medicare Services (CMS).
As required by statute, the AB 97 payment reduction is also applied to the new payment methodology.
Data Collection Process
DHCS underwent a significant stakeholder process to develop the data collection tool to be used for the development of the new methodology and to determine the new rates under that methodology.
Beginning in 2012, DHCS conducted meetings with clinical laboratory stakeholders to develop a data collection methodology that was operationally feasible and consistent with the intent of the legislation.
DHCS requested third-party payer rate and utilization data from providers and limited the use of data to codes that met either of the following two thresholds based on the prior year's Medi-Cal paid claims data:
Medi-Cal paid claims volume equal to or greater than 1,000
Total Medi-Cal paid amount equal to or greater than $500,000
The thresholds for choosing providers required to submit utilization data are:
Medi-Cal paid claims volume equal to or greater than 5,000
Total Medi-Cal paid amount equal to or greater than $100,000
Reimbursement for clinical laboratory or laboratory services shall not exceed the lowest of the following:
(1) the amount billed,
(2) the charge to the general public,
(3) 80% of the lowest maximum allowance established by the federal Medicare Clinical Laboratory fee schedule and Medicare Physician fee schedule for the same or similar services,
(4) and every three years, beginning on July 1, 2020, an amount calculated based on a weighted average of the lowest amount that third-party payers are paying for the same or similar services, excluding all rates paid over 150 percent of the Medicare maximum allowance for California.
Triennially, DHCS utilizes the data collected to develop the clinical laboratory reimbursement rates. The following represents the steps taken in the determination of the average of the lowest rate.
DHCS uses the range of rates that fall between zero and one-hundred fifty percent of the calculated California specific Medicare rate.
These rates are then weighted based on the units billed to create an average.
The methodology is individually applied to each code meeting threshold requirements, excluding codes for which no third-party rate and/or utilization data was submitted, or if the services under that code were terminated or no longer a Medi-Cal benefit.
To ensure that requirements of the provisions of statute continue to be met, DHCS will collect third-party payer rate and utilization data every three years, beginning in 2019, from clinical laboratory or laboratory services providers. Beginning on July 1, 2020, and every years thereafter, rates are required to be calculated based on the prior year’s data and application of the methodology will be limited to those codes meeting either of the two thresholds. DHCS will continue to monitor the thresholds and methodology and make changes as necessary to comply with the law, access requirements, and account for other operational or programmatic issues.