All Plan Letters

APL

Relevant Provider Takeaways

The purpose of this All Plan Letter (APL) is to inform Managed Care Plans (MCPs) of the requirements for quality and health improvement. CenCal Health aligns our internal quality and health equity efforts with the Department of Health Care Services (DHCS’s) Comprehensive Quality Strategy Report. CenCal Health is required to complete a minimum of two Performance Improvement Projects (PIPs). CenCal Health will implement and annually report a Quality Improvement and Health Equity plan that addresses clinical quality of physical, behavioral health,  access and engagement of Providers, continuity and coordination across setting and all levels of care and Member experience.

CenCal Health will participate in an annual performance measure validation audit. DHCS will conduct an annual satisfaction survey of CenCal Health Members and CenCal Health will cooperate in conducting these surveys.

The purpose of this All Plan Letter (APL) is to provide information regarding timely access to abortion services. CenCal Health will ensure Members have timely access to abortion services by the following: notifying Members when they enroll that some hospitals, clinics or Providers may refuse to provide abortion services and if that is the case, CenCal Health will assist the Member to find another Provider for the needed service.

CenCal Health will cover abortion services, as well as the medical services and supplies (incidental or preliminary) to an abortion, consistent with the requirements outlined in the Medi-Cal Provider Manual. All Providers are prohibited from requiring a medical justification, or imposing any utilization management or Utilization Review requirements, including Prior Authorization and annual or lifetime limits, on the coverage of outpatient abortion services. Non-emergency inpatient hospitalization for the performance of an abortion may require a Prior Authorization under the same criteria as other medical procedures.

The purpose of this All Plan Letter (APL) is to summarize and clarify existing federal and state protections and alternative health coverage options for American Indian Members enrolled in Medi-Cal managed care plans (MCPs). Additionally, this APL consolidates various MCP requirements pertaining to protections for Indian Health Care Providers (IHCPs), including requirements related to contracting with IHCPs and reimbursing claims from IHCPs in a timely and expeditious manner. This APL also provides guidance regarding MCP tribal liaison requirements and expectations in relation to their role and responsibilities.

Effective January 1, 2024, MCPs are required to have an identified tribal liaison dedicated to working with each contracted and non-contracted IHCP in its service area. The tribal liaison is responsible for coordinating referrals and payment for services provided to American Indian MCP Members who are qualified to receive services from an IHCP.

To learn more, please contact the Provider Relations Supervisor at dlopez@cencalhealth.org or Lia Noland lnoland@cencalhealth.org phone (321) 349-4071.

Street medicine directly aligns with California Advancing and Innovating Medi-Cal’s (CalAIM) primary goal to identify and manage comprehensive needs through whole person care approaches and social drivers of health. Street medicine offers an opportunity to provide needed services to individuals who are experiencing unsheltered homelessness by meeting them where they are and utilizing a whole person, patient centered approach to provide Medically Necessary health care services, as well as address social drivers of health that impede health care access.  The Department of Health Care Services (DHCS) considers street medicine to be a harm reduction tool and integral to avoiding an emergency department visit or hospitalization, providing access to Medically Necessary health care services, and connecting MCP Members to Community Supports that they may not otherwise access.

The purpose of this APL is to provide Medi-Cal MCPs with guidance on the incentive payments provided by the Student Behavioral Health Incentive Program (SBHIP).​  SBHIP is a part of California’s Children and Youth Behavioral Health Initiative (CYBHI) and is being implemented by the Department of Health Care Services (DHCS).  Participating MCPs must comply with the policy requirements outlined throughout this APL to earn incentive payments for submitting deliverables and meeting predefined goals and metrics.​  Incentive payments provided through SBHIP must supplement and not supplant existing payments to MCPs. ​

MCP Eligibility and Participation​: MCP participation in this incentive program is voluntary, but strongly encouraged. ​To earn incentive payments, MCPs that elect to participate will be required to engage with County Offices of Education (COEs) and/or partner with Local Educational Agencies (LEAs) to submit required deliverables, Memorandum of Understanding (MOUs) and to meet predefined goals and metrics. ​MCPs are also encouraged, but not required, to partner with County Behavioral Health Departments.

The purpose of this All Plan Letter (APL) is to provide guidance to CenCal Health regarding participation in the California Children’s Services (CCS) Whole Child Model (WCM) program. CenCal Health will refer a Member to the County for a CCS eligibility determination if the Member demonstrates a CCS condition(s) as outlined in the CCS Medical Eligibility Guide. CenCal Health will refer all Members as soon as possible to the County for eligibility determination and not wait for the annual redetermination period.

CenCal Health will provide services to CCS-eligible Members with other health coverage, with full scope Medi-Cal as the payor of last resort. CenCal Health will provide screening, diagnostic and treatment services in accordance to APL 23-005 or any superseding APL, to identify potential CCS-eligible Members. CenCal Health will provide case management and care coordination, including referrals to subspecialists, if not previously referred by the Primary Care Provider, and service authorizations for CCS eligible Members and their families.

CenCal Health must meet specific Network certification requirements while participating in the WCM Program, which includes having an adequate Network of CCS-paneled Providers to serve the CCS-eligible population including, physicians, specialist, allied professionals, SCCs, hospitals, home health agencies, and specialized and customizable DME providers.

The purpose of this All Plan Letter (APL) is to provide Medi-Cal managed care health plans (MCPs) with the 2024-2025 Medi-Cal Eligibility Data System (MEDS)/834 cutoff and processing schedule. The MEDS/834 cutoff and processing schedule covers the period of December 2023 through January 2025. These cutoff dates and timelines are established by the Department of Health Care Services (DHCS), Enterprise Technology Services Division and are critical to ensuring timely processing of eligibility files and data. When applicable, it is important for DHCS to receive all enrollments and disenrollments on a daily basis. MCPs must adhere to the enclosed cutoff dates and timelines to allow adequate processing time and to ensure timely payments. In addition to the MEDS/834 cutoff and processing schedule, enclosed is the updated outline of MCP 834 responsibilities and the Health Care Options (HCO) Secure Data Exchange Services (SDES) file posting schedule for 2024.

The Department of Health Care Services (DHCS) released its California Advancing and Innovating Medi-Cal (CalAIM) proposal on October 29, 2019, in anticipation of the expiration of its Medi-Cal 2020 1115 Demonstration and 1915(b) Specialty Mental Health Services Waiver authorities. DHCS postponed the planned implementation of the CalAIM initiative, which was originally scheduled for January 1, 2021, due to the COVID-19 public health emergency, and released a revised CalAIM proposal on January 8, 2021. DHCS also submitted its CalAIM Section 1115 Demonstration and 1915(b) Waiver applications to the Centers for Medicare and Medicaid Services on June 30, 2021.1 DHCS obtained statutory authority to establish the CalAIM initiative to support the stated goals of identifying and managing the risks and needs of Medi-Cal beneficiaries, transitioning and transforming the Medi-Cal program to a more consistent and seamless system, and improving quality outcomes.

Effective upon the DHCS determined ECM implementation date for each MCP in its respective county of operation, the MCP must administer ECM and provide the following seven core ECM services to eligible Members in applicable ECM Populations of Focus: 1) Outreach and Engagement; 2) Comprehensive Assessment and Care Management Plan; 3) Enhanced Coordination of Care; 4) Health Promotion; 5) Comprehensive Transitional Care; 6) Member and Family Supports; and 7) Coordination of and Referral to Community and Social Support Services.

The purpose of this APL is to provide CenCal Health with guidance on the Age 26-49 Adult Expansion to ensure individuals transitioning from restricted scope Medi-Cal or are otherwise uninsured to full-scope Medi-Cal maintain their existing PCP assignments to the maximum extent possible to minimize disruptions in services.  CenCal Health will coordinate with county uninsured programs and public health care systems to share data for the Adult Expansion Population ad use that data to effectuate PCP assignment.

The goal of the demonstration’s Medi-Cal Justice-Involved Reentry Initiative, is to build a bridge to community-based care for justice-involved Medi-Cal members, offering them services up to 90 days prior to their release to stabilize their health conditions and establish a plan for their community-based care (collectively referred to as “pre-release services”).

The Guide is intended to delineate for implementing stakeholders – correctional facilities (CFs), county behavioral health agencies, providers, CBOs, County Social Services Departments (SSD) and Medi-Cal managed care plans (MCPs), among others – the policy design and operational processes that will serve as the foundation for implementing this important initiative.

Effective 1/1/2024 ECM Population of Focus (POF) 4 continues to go live, however the Pre-Release Enrollment policy for POF 4 will go live 10/1/2024.

The MCP Contract requires CenCal Health to build partnerships with the following Third Party Entities: local health departments; local educational and governmental agencies, such as county behavioral health departments for specialty mental health care and Substance Use Disorder (SUD) services; other local programs and services, including social services; child welfare departments; Continuum of Care programs; First 5 programs and providers; Regional Centers; Area Agencies on Aging; Caregiver Resource Centers; Women, Infants and Children Supplemental Nutrition Programs (WIC); Home and Community-Based Services (HCBS) waiver agencies and providers; and justice departments to ensure Member care is coordinated and Members have access to community-based resources in order to support whole-person care.  The MOUs are intended to be effective vehicles to clarify roles and responsibilities among parties, support local engagement, and facilitate care coordination and the exchange of information necessary to enable care coordination and improve the referral processes between the parties. The MOUs are also intended to improve transparency and accountability by setting forth certain existing requirements for each party as it relates to service or care delivery and coordination so that the parties are aware of each other’s obligations.

This APL describes the requirements for CenCal Health to cover intravenous (IV) moderate sedation and deep sedation/general anesthesia services provided by a physician in conjunction with dental services for Members in hospitals, ambulatory surgical settings, or dental offices. This APL identifies information that MCPs must review and consider during the prior authorization process as described and detailed in the attached guidelines for IV moderate sedation and deep sedation/general anesthesia for dental procedures.

Within this APL, CenCal Health must determine Medically Necessity consistent with definitions in 22 Code of California Regulations (CCR) sections 51124.5 and 51124.6, Welfare and Institutions Code section 14132.25, and the Medi-Cal Manual of Criteria.

Effective January 1, 2024 CenCal Health will ensure that Members in need of adult or pediatric subacute are services are placed in a health care facility that provides the level of care most appropriate to the Member’s medical needs.  In addition to if a Member needs adult or pediatric subacute care services, they are placed in a health care facility that is under contract for subacute care with DHCS’s Subacute Contracting Unit (SCU) or is actively in the process of applying for a contract with DHCS’ SCU.

This APL supersedes APL 19-012 Federal Drug Utilization Review Requirements Designed to Reduce Opioid Related Fraud, Misuse and Abuse.  CenCal Health is required to operate a DUR program that complies with the Medicaid-related DUR provisions contained in section 1004 of the SUPPORT Act.  Describe the opioid related prospective safety edits, as well as the automated process for retrospective claims review that CenCal Health has in place to address duplicate fill, early fill, and quantity limits. CenCal Health will describe the prospective safety edits for the maximum morphine milligram equivalents (MEE)/daily that can be prescribed to CenCal Health members enrolled for treatment in of chronic pain, not to exceed 500 MME/daily dose limitation.  Will monitor and manage appropriate use of all psychiatric drugs to include antipsychotics, mood stabilizers and anti-depressant medications for all children under 18 years of age and all foster children.

For additional resources visit CenCal Health’s Drug Utilization Review section of the website

DHCS has provided guidance regarding the Diversity, Equity, and Inclusion (DEI) training program requirements for our contracted Provider Network and all CenCal Health Staff.

This APL supersedes APL 99-005: Cultural Competency in Health Care Meeting Needs of a Culturally and Linguistically Diverse Population.

In December 2023, CenCal Health will develop a DEI training program that encompasses sensitivity, diversity, culturally competency and cultural humility, and health equity trainings, for all CenCal Health staff and Network Providers regardless of their cultural or professional training and background.  CenCal Health will develop a way to monitor DEI training completion, deficiencies, and record maintenance.  In addition to annually inform the Quality Improvement and Health Equity Committee of the DEI training program with reports.

The DEI training applies to newly onboarded CenCal Health staff, Subcontractors, Downstream Subcontractors, and Network Providers service CenCal Health Members within 90 days of start date in addition to implementing ongoing DEI training to such groups during times of re-credentialing or contract renewals.

To learn more please reference Section B of the CenCal Health’s Provider Manual.

The focus for this service is to provide guidance regarding the qualifications for providing Doula services, effective for dates of service on or after January 1, 2023.

CenCal Health must provide Doula services for prenatal, perinatal, and postpartum Members, and provide Doulas with all necessary, initial, and ongoing training and resources regarding relevant MCP services and processes, including any available service through the MCP for prenatal, perinatal, and postpartum Members.

Also, provide technical support in the administration of doula services, ensuring accountability for all service requirements while ensuring doulas document the dates, time, and duration of services provided to CenCal Health Members.

To learn more about the Doula Service Benefit, please reference Section E of the CenCal Health’s Provider Manual.

DHCS has provided requirements to all MCPs including CenCal Health for the Long-Term Care (LTC) ICF/DD services provisions of the CalAIM benefit standardization initiative.

This APL contains requirements related to ICF/DD Homes, ICF/DD-H Homes, and ICF/DD-N Homes.  This Benefit requirement provides all Medically Necessary Covered Services for Members residing in or obtaining care in an ICF/DD home.  The benefit also provides the appropriate level of care coordination in adherence to the PHM Policy Guide, authorize, and cover Medically Necessary ICF/DD Home services consistent with the Medi-Cal Provider Manual definitions.

To learn more, please reference CenCal Health’s Provider Manual.

This All-Plan Letter (APL) provides guidance on Continuity of Care for beneficiaries who are mandatorily transitioning from Medi-Cal Fee-For-Service (FFS) to enroll as Members in Medi-Cal managed care. This APL applies to both Medi-Cal only beneficiaries and those dually eligible for Medicare and Medi-Cal, for their Medi-Cal Providers. This APL also describes other types of transitions into Medi-Cal managed care for specific Medi-Cal Member populations.

CenCal Health will demonstrate that we are meaningfully responding to community needs as well as provide other updates on the PHM Program to inform DHCS’ monitoring efforts.  In addition, CenCal Health will continue to report on existing metrics related to any Continuity of Care provisions outlined in state law and regulations, or other state guidance documents.

This APL provides guidance on the modified Population Needs Assessment (PNA) and new Population Health Management (PHM) Strategy requirements for CenCal Health.

DHCS now requires CenCal Health to demonstrate that we are meaningfully responding to community needs as well as provide other updates on the PHM Program to inform DHCS’ monitoring efforts.  In addition, CenCal Health is no longer required to submit an annual PNA Action Plan. In addition, the PHM Policy Guide will be updated with details on the modified PNA and future submissions of the PHM Strategy deliverable due in 2024.

DHCS would like Managed Care Plans to remind our provider network of the responsibilities to pay all claims within contractually mandated statutory timeframes and in accordance with the timely payment standards.  CenCal Health will maintain sufficient claims processing/tracking/payment system capabilities to comply with HSC section 1371 through 1371.36, which govern Provider compensation and to pay clean claims within 30 calendar days of receipt (pay interest of untimely payments).

To learn more, please reference the Claims and Billing Guidelines Section of our Provider Manual.

This requires Managed Care Plans (MCP) to make uniform and fixed dollar add-on payments to eligible individual Providers rendering specified service with the date of service.  CenCal Health must ensure these directed payments are received by the individual rendering Providers that are eligible Network Providers and to not pay any amount for any services or items, other than Emergency Services, to Provider that are suspended, excluded, or terminated from the Medi-Cal Program.

CenCal Health will include an itemization of payments made with each payment to the Network Provider and will follow the Prop 56 Directed Payments Expenditures File Technical Guidance for reporting requirements, and ensure the payments required are made in accordance with the timely payment standards.

To learn more, please visit cencalhealth.org/providers/proposition-56/ for more resources.

Beginning January 1, 2024 CenCal Health will be subject to new requirements to advance health equity, access, accountability and transparency to improve the Medi-Cal health care delivery system. The policy guide contains DHCS policy and related Managed Care Plan requirements related to member transitions among Medi-Cal Managed Care Plans.

The Budget Act of 2021 changed the source of the nonfederal share of the supplemental payments for trauma screenings to the state General Fund.  In accordance with the State Plan Amendment (SPA) 21-0045,5 effective July 1, 2022, the ACEs program will become a benefit, and it will no longer be funded by Proposition 56. The ACEs Aware program must continue to be utilized to provide informational resources for ACE screening services.

ACEs Aware Trainings: The “Becoming ACEs Aware in California” Core Training is a free, two-hour training for which clinicians and clinical team members will receive 2.0 Continuing Medical Education and/or 2.0 Maintenance of Certification credits upon completion. Please find the training here: https://www.acesaware.org/learn-about-screening/training/

Providers must complete this training and the DHCS ACEs Provider Training Attestation form to qualify for payment for completing ACE Screenings.

More information about training is available at https://www.acesaware.org/learn-about-screening/training/.

Allowed ACE Screening Tools: For Children and Adolescents: The Pediatric ACEs and Related Life-Events Screener (PEARLS) is used to screen children and adolescents ages 0-19 for ACEs.

Three versions of the tool are available, based on age and reporter:

• PEARLS child tool, for ages 0-11, to be completed by a parent/caregiver;
• PEARLS adolescent, for ages 12-19, to be completed by a parent/caregiver; and
• PEARLS for adolescent self-report tool, for ages 12-19, to be completed by the adolescent

For Adults: The ACE questionnaire may be used for adults (ages 18 years and older).

Members who are dually eligible for Medi-Cal and Medicare Part B will not qualify for reimbursement (regardless of enrollment in Medicare part A or Part D).

Details pertaining to ACEs Aware Certification, Eligibility, Provider Requirements, ACE Screening Implementation, HCPCS Codes, Descriptions, Directed Payment, and notes can be found in the APL.

The Budget Act of 2021 changed the source of the nonfederal share of these payments to the state General Fund.

The CPT Code, description and Directed Payment amount can be found on page 4 of the APL.

More information can be found on the DHCS Directed payments – Proposition 56 website .

DHCS intends to continue this directed payment arrangement on an annual basis for the duration of the program.

Please refer to the APL for Procedure Codes, Descriptions, Minimum Fee Schedule amounts, and Dates of services from July 1, 2017 to “Ongoing” which means the directed payment is in effect, subject to future budgetary authorization and appropriation by the California Legislature, until discontinued by DHCS via an amendment to this APL.

The funding that was approved through June 2022 will be distributed following timely payment standards in the Contract for Clean Claims or accepted encounters that were received no later than one year after the date of service up to June 30, 2022.

Please see Appendix A of this APL to understand the Domain, Measure and Add-on Amounts from Dates of service between July 1, 2019 and June 30, 2022.

Services performed after June 30, 2022, are not eligible for VBP directed payments.

Mandatory Signatories to the California Health and Human Services Agency Data Exchange Framework

Enforcement Actions: Administrative and Monetary Sanctions (Supersedes APL 22-015)

Provides guidance and clarification regarding federal and state legal requirements for recovery of all Overpayments to Providers.  All network Providers are to report to CenCal Health when they have received an overpayment and to return the overpayment to CenCal Health within 60 calendar days, in addition to a notification in writing of the reason of the overpayment.

Provides guidance about the provision of Medically Necessary Behavioral Health Treatment (BHT) services for Members under the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit in accordance with mental health parity requirements.

Clarifies responsibility of coordination with other entities, and ensures all of a Member’s needs for Medically Necessary BHT services are met across environments, including on-site at school or during virtual school sessions.

Clarifies contractual obligations for authorizing post-stabilization care services.

The funding that was approved through June 2022 will be distributed following timely payment standards in the Contract for Clean Claims or accepted encounters that were received no later than one year after the date of service.

DHCS requested approval from CMS for this directed payment arrangement for CY 2022 and CY 2023.

Subject to future appropriation of funds by the California Legislature and the necessary federal approvals of the directed payment arrangement, DHCS intends to continue this directed payment arrangement on an annual basis for the duration of the program. The requirements of this APL may change if necessary to obtain CMS approvals applicable to this directed payment arrangement or to comport with future state legislation.

This directed payment program is intended to enhance the quality of patient care by ensuring that Providers in California who offer family planning services receive enhanced payment for their delivery of family planning services. Timely access to vital family planning services is a critical component of Member and population health

In particular, this program is focused on the following categories of family planning services:

• Long-acting contraceptives
• Other contraceptives (other than oral contraceptives) when provided as a medical benefit
• Emergency contraceptives when provided as a medical benefit
• Pregnancy testing
• Sterilization procedures (for females and males)

As technology continues to advance, the healthcare industry has embraced telehealth as a valuable modality for delivering services. In the state of California, providers and practitioners offering telehealth services to members must adhere to specific guidelines and requirements.

Providers offering Covered Services via Telehealth in California must be licensed in the state and enrolled as a Medi-Cal Provider or affiliated with a Medi-Cal Provider group. If the provider is located outside of California, they need to be associated with a Medi-Cal enrolled Provider group in California or a border community.

While telehealth can be a convenient and effective means of providing Covered Services, certain services are not suitable for remote delivery. Procedures requiring the in-person presence of a member, direct visualization or instrumentation of bodily structures, or sampling of tissues or medical device insertion/removal cannot be appropriately delivered via Telehealth.

With the exception of Federally Qualified Health Centers (FQHCs), Rural Health Clinics (RHCs), and Tribal Health Providers (THPs), all providers can be reimbursed for consultations offered via Telehealth. It’s important to note that e-consults can only be initiated by the provider and not the member. Additionally, providers, including FQHCs, RHCs, and THPs, are eligible for reimbursement for brief virtual communication with members who are not physically present.

Starting January 1, 2024, providers offering applicable Covered Services through audio-only synchronous interactions must also offer the same service via video synchronous interactions. This change aims to preserve the member choice and ensure access to comprehensive telehealth services.

To safeguard a member’s right to in-person care, providers delivering services through video or audio-only synchronous interactions must take the following steps:

1. Offer the same services through in-person, face to face contact; OR
2. Facilitate a referral for in-person care, ensuring members do not need to independently contact another provider.

Prior to initiating Covered Services via Telehealth, providers must inform members about the use of this modality and obtain their verbal or written consent. It is crucial to document this consent in the member’s medical record, as it may be requested for review by the Department of Health Care Services

During the consent process, providers must explain the following to members:

1. The member’s right to access Covered Services in person if desired.
2. The voluntary nature of Telehealth and the ability to withdraw consent at any time.
3. The availability of Non-Medical Transportation for in-person visits.
4. The potential limitations or risks associated with receiving Covered Services through Telehealth compared to an in-person visit.

Telehealth offers providers and practitioners the opportunity to provide Covered Services remotely, expanding access to care for patients.

Please reference the July Provider Pulse E-Newsletter for more information.

Delegation and Subcontractor Network Certification (Supersedes APL 17-004)

• Attachment A:Subcontractor Network Certification Instruction Manual
• Attachment B:Subcontractor Network Exemptions Request
• Attachment C: Network Adequacy and Access Assurances Report

Requirements For Coverage of Early and Periodic Screening, Diagnostic, and Treatment Services for Medi-Cal Members Under the Age of 21 (Supersedes APL 19-010)​

Provides requirements on the Skilled Nursing Facility (SNF) Long Term Care (LTC) benefit standardization provisions of the California Advancing and Innovating Medi-Cal (CalAIM) initiative, including the mandatory transition of beneficiaries to managed care plans such as CenCal Health.

California Advancing and Innovating Medi-Cal Incentive Payment Program (Supersedes APL 21-016)

2023-2024 Medi-Cal Managed Care Health Plan MEDS/834 Cutoff and Processing Schedule

Network Certification Requirements (Supersedes APL 21-006)

• Attachment A: Network Adequacy Standards (PDF)
• Attachment B: Annual Network Certification Instruction Manual (PDF)
• Attachment C: Alternative Access Standard (AAS) Request Template (.xls)