From time to time, the Department of Health Care Services (DHCS) posts All Plan Letters (APLs) informing managed care plans (MCPs) of new guidelines and standards required by the state of California for Medi-Cal services. 

Blue Shield of California Promise Health Plan provides APL summaries to help our network Medi-Cal providers stay informed of the latest requirements.

View the full text of all managed care APLs on the DHCS website
 

APL 21-012 

Enhanced Care Management requirements

As part of the CalAIM program, outlines requirements for administering the Enhanced Care Management benefit to support the needs of high-cost, high-need managed care members.

APL 21-011 

Grievance and appeals requirements, notice and “Your Rights” templates

Updates guidance regarding federal and state grievance and appeals requirements and includes templates for member notifications and the attachments that are sent with them.

APL 21-010 

Medi-Cal COVID-19 Vaccination Incentive Program

Offers incentives for MCPs to develop and implement a Vaccination Response Plan to encourage Medi-Cal members to be vaccinated against the COVID-19 virus.

View COVID-19 APL updates

APL 21-009 

Collecting social determinants of health data

Designates 18 codes from the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) list to be prioritized in the collection of social determinants of health data and encourages MCPs to use them to help support population health management.

APL 21-008 

Tribal Federally Qualified Health Center providers

Explains reimbursement requirements for Tribal Federally Qualified Health Centers, a new clinic provider type that Centers for Medicare and Medicaid Services allows to participate in Medi-Cal.

View APL 21-008 summary (PDF, 91 KB)
 

APL 21-007 

Third party tort liability reporting requirements

Updates the process MCPs must follow when submitting information and copies of paid invoices or claims for covered services related to third party liability torts to DHCS.

View APL 21-007 summary (PDF, 91 KB)
 

APL 21-006 

Network certification requirements

Informs managed care providers about the annual network certification requirements for the contract year. 

View APL 21-006 summary (PDF, 88 KB)
 

APL 21-005 

California Children’s Services Whole Child Model program

Provides guidance to MCPs that participate in the Whole Child Model program, including requirements for continuity of care, oversight of network adequacy standards, quality performance of providers, and routine grievance and appeal processes.

APL 21-004 

Standards for determining threshold languages, nondiscrimination requirements, and language assistance services

Identifies in which languages MCPs must provide written translated member information, based on established thresholds and concentrations of language speakers, and sets standards for nondiscrimination requirements and language assistance services.

View APL 21-004 summary (PDF, 87 KB)
 

APL 21-003 

Medi-Cal network provider and subcontractor terminations

Outlines required procedures that must be followed when a provider or subcontractor’s contract is terminated, including notification, reporting, transition planning and continuity of care requirements.

View APL 21-003 summary (PDF, 81 KB)
 

APL 21-002 

Cost avoidance and post-payment recovery for other health coverage

Because state law requires that Medi-Cal be the payer of last resort, this APL provides requirements with regards to cost avoidance measures and post-payment recovery for members who have access to health coverage other than Medi-Cal.

View APL 21-002 summary (PDF, 110 KB)
 

APL 20-022 

COVID-19 vaccine administration

Outlines how COVID-19 vaccines will be delivered at no cost to all Medi-Cal beneficiaries and administered by DHCS and managed care plans. Includes instructions for Medi-Cal providers to bill DHCS directly for administrative-only costs, for fee-for-service reimbursement. The vaccine is provided by the government at no cost.

View COVID-19 APL updates

APL 20-021 

Acute hospital care at home

Explains requirements for the Acute Hospital Care at Home program. Hospitals that apply for and receive waiver approval from Centers for Medicare and Medicaid Services (CMS) may provide approved acute care inpatient services to eligible members at home.

View COVID-19 APL updates

APL 20-020 

Governor’s executive order N-01-19, regarding transitioning Medi-Cal pharmacy benefits from managed care to Medi-Cal Rx

Provides guidance on the planned transition of Medi-Cal pharmacy benefits management to a state-run program called Medi-Cal Rx.

Although the APL states the program will launch on January 1, 2021, DHCS has since announced that Medi-Cal Rx will begin implementation on April 1, 2021.

APL 20-018 

Ensuring access to transgender services​

Reminds managed care plans of their obligations to provide transgender services to members, including services deemed “medically necessary to treat gender dysphoria” or which “meets the statutory criteria of reconstructive surgery.”

APL 20-017 

Requirements for reporting managed care program data​

Requires managed care plans to report monthly program data to DHCS using standardized JavaScript Object Notation (JSON) reporting formats.

APL 20-016

Blood lead screening of young children ​

Managed care plans must ensure that their network providers who perform periodic health assessments on children between the ages of six months and six years (i.e., 72 months) comply with federal and state laws and industry guidelines related to blood lead anticipatory guidance and screening.

View APL 20-016 summary (PDF, 126 KB)
 

APL 20-015 

State non-discrimination and language assistance requirements

Regardless of changes in federal law, California state law requires that managed care plans (MCPs) must not unlawfully discriminate, exclude people, or treat them differently because of sex, race, color, religion, ancestry, national origin, ethnic group identification, age, mental disability, physical disability, medical condition, genetic information, marital status, gender, gender identity, or sexual orientation.

In addition, MCPs must continue to provide notice of their nondiscrimination policies and grievance procedures in English, and must continue to provide taglines notifying members of the availability of free language assistance services in English and in the top 16 languages spoken by individuals in California with limited English proficiency.

APL 20-014

Proposition 56 value-based payment program directed payments

Provides guidance on payment amounts and processes for applying funds from the California Healthcare, Research and Prevention Tobacco Tax Act of 2016 (Proposition 56) to value-based directed payments. These payments are to be made for specified services in the domains of prenatal and postpartum care, early childhood prevention, chronic disease management, and behavioral health care.

Learn more about Proposition 56 payments
 

APL 20-013

Proposition 56 directed payment program directed payments

Specified family planning services, with dates of service on or after July 1, 2019, are designated to receive directed payments funded by the California Healthcare, Research and Prevention Tobacco Tax Act of 2016 (Proposition 56)

Learn more about Proposition 56 payments
 

APL 20-012 

Private duty nursing case management responsibilities for Medi-Cal eligible members under the age of 21

Clarifies that managed care plans (MCPs) must provide case management services to Medi-Cal members under the age of 21 who are receiving private duty nursing care, even for carved out services that the MCP does not cover.

View APL 20-012 summary (PDF, 78 KB)
 

APL 20-011

Governor’s executive order N-55-20 in response to COVID-19

Provides DHCS with various flexibilities in support of COVID-19 mitigation efforts. Site reviews and subcontractor monitoring may be virtual, or have deadlines extended. Annual medical audits are suspended. Deadlines for Health Risk Assessments are extended.

The revision posted June 12, 2020 adds that this order also suspends all requirements outlined in APL 20-006 during the COVID-19 emergency and for an additional six months following.

The revision posted July 8, 2021 terminates the flexibilities previously extended in APL 20-011.

View COVID-19 APL updates
 

APL 20-010 

Retracted by DHCS

 

APL 20-009

Preventing isolation of and supporting older and other at-risk individuals to stay home and stay healthy during COVID-19 efforts

Reminds providers of the need to support older and other at-risk individuals who may be isolated during the state’s COVID-19 stay-at-home campaign. Lists available public resources for food, aging and adult services, isolation, wellness checks, fraud, and Alzheimer’s support and encourages providers to share them with patients who qualify.

View COVID-19 APL updates
 

APL 20-008

Mitigating health impacts of secondary stress due to the COVID-19 emergency

In consideration of the negative health outcomes the stress of the COVID-19 crisis could cause, advises MCPs to support continuity and integration of medical and behavioral health services via telehealth and other adaptations; share information with providers about disaster-responsive, trauma-informed care; and ensure providers are aware of the published signs of, and assess for, stress-related morbidity, and create responsive treatment plans. Also provides links to additional resources.

View COVID-19 APL updates

 

APL 20-007

Policy guidance for community-based adult services in response to COVID-19 public health emergency

Advises community-based adult services (CBAS) providers that congregate services inside centers are not allowed during the COVID-19 public health emergency. Essential services may be provided to individuals in the center or in the home, so long as they meet safety and infection control precautions. CBAS centers are granted flexibility to reduce day-center activities and to provide CBAS temporarily alternative services telephonically, via telehealth, live virtual video conferencing, or in the home. The APL also lists specific requirements for services, staffing, authorization and reimbursement, and documentation and reporting..

View COVID-19 APL updates
Read the summary shared with our CBAS providers (PDF, 104 KB)
 

APL 20-006 

Site reviews: Facility site review and medical record review

Informs Medi-Cal managed care health plans about new criteria and scoring for facility site reviews and medical record reviews. These criteria must be met by July 1, 2020.
 

APL 20-004

Emergency guidance for Medi-Cal managed care health plans in response to COVID-19

Outlines temporary changes to federal requirements for managed care plans (MCPs), including extended timeframe for State Fair Hearings; flexibilities for provider Medi-Cal screening and enrollment; waiving prior authorization for COVID-19 services, including screening and testing; reimbursement for COVID-19 testing; provision of care in alternative settings, hospital capacity and blanket waivers; pharmacy guidance.

Providers are advised to refer to the DHCS COVID-19 response web page for the most up-to-date information.

Additional guidance added on April 27, 2020, reminds MCPs “that they must adhere to existing contractual requirements and state and federal laws requiring MCPs to ensure their members are able to access medically necessary services in a timely manner.”

The June 8, 2020 revision adds guidelines related to well child visits and member eligibility, temporarily reinstates acetaminophen and cough/cold medicines as covered benefits, and temporarily adds coverage for services provided by Associate Clinical Social Workers and Associate Marriage and Family Therapists at Federally Qualified Health Centers and Rural Health Clinics.

View COVID-19 APL updates
 

APL 20-003 

Network certification requirements

Informs managed care providers about the annual network certification requirements for the contract year.
 

APL 20-002

Non-Contract Ground Emergency Medical Transport (GEMT) payment obligations

Specifies that the GEMT Quality Assurance Fee program, legislated by the state of California, requires that a reimbursement add-on amount be paid for GEMT services provided beginning July 1, 2019.

Learn more about non-contract GEMT payments