All Plan Letters

Dental Services – Intravenous Moderate Sedation and Deep Sedation/General Anesthesia Coverage (Supersedes APL 15-012)

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 guidelines for IV moderate sedation and deep sedation/general anesthesia for dental procedures.

Subacute Care Facilities – Long Term Care Benefit Standardization and Transition of Members to Managed Care

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.

Federal Drug Utilization Review Requirements Designed to Reduce Opioid Related Fraud, Misuse & Abuse

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 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

Diversity, Equity, and Inclusion Training Program Requirements

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.

Doula Services (Supersedes APL 22-031)

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.

Intermediate Care Facilities for Individuals With Developmental Disabilities– Long Term Care Benefit Standardization and Transition of Members to Managed Care

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, to 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.

Continuity of Care for Medi-Cal Beneficiaries who newly enroll in Medi-Cal Managed Care from Medi-Cal Fee-For-Service, and for Medical Members who transition into a new Medi-Cal Managed Care Health Plan on or after January 1, 2023 (Supersedes APL 22-032)

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.

Population Health  Needs Assessment and Population Health Management Strategy (Supersedes APL 19-011)

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.

Requirements for Timely Payment of Claims

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.

Prop 56 Directed Payment for Physician Services (Supersedes APL 19-015)

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.

Managed Care Health Plan Transition Policy

APL 23-018 announces the release of DHCS’s 2024 Managed Care Plan Transition Policy Guide. This Guide contains DHCS operational requirements and guidelines specific to Member transitions prompted by county-driven MCP model changes, changes to commercial MCP contracting, and a new direct contract with Kaiser Permanente.

Directed Payments for Adverse Childhood Experiences Screening Services

Date: June 13, 2023 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.

Directed Payments for Developmental Screening Services

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 .

Proposition 56 Directed Payments for Private Services

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.

Proposition 56 Value-Based Payment (VBP) Program Directed Payments

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

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

Proposition 56 Directed Payments for Family Planning 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)

Telehealth Services Policy

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 CertificationDelegation 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

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

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)