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.
Electronic Visit Verification implementation requirements
Provides MCPs with directions for implementing Electronic Visit Verification, a federally mandated telephone and computer-based application that electronically verifies in-home service visits.
Provider credentialing/re-credentialing and screening/enrollment
Addresses MCP responsibilities for screening and enrolling providers in the Medi-Cal Program, along with obligations for credentialing and re-credentialing providers.
Governor’s Executive Order N-01-19, regarding transitioning Medi-Cal pharmacy benefits from managed care to Medi-Cal Rx
Clarifies changes to the administration of Medi-Cal pharmacy benefits following the executive order that transitioned responsibility for pharmacy benefits from MCPs to Medi-Cal Rx.
Proposition 56 directed payments for family planning services
Designates family planning services, with dates of service on or after July 1, 2019, to receive directed payments funded by the California Healthcare, Research and Prevention Tobacco Tax Act of 2016 (Proposition 56).
Cancer biomarker testing
Requires MCPs to cover medically necessary cancer biomarker testing for patients with advanced or metastatic stage 3 or 4 cancer and prohibits requiring prior authorization for these tests.
View APL 22-010 summary (PDF, 233 KB)
COVID-19 guidance for Medi-Cal managed care health plans
Shares information about the latest changes to federal and state requirements for COVID-19 testing, treatment, and prevention.
Non-emergency medical and non-medical transportation services and related travel expenses
Updates requirements MCPs must follow when managing non-emergency medical and non-medical transportation services for Medi-Cal members.
View APL 22-008 summary (PDF, 391 KB)
California Housing and Homelessness Incentive Program
Outlines requirements MCPs must follow to qualify for payments from the Housing and Homelessness Incentive Program.
Medi-Cal managed care health plan responsibilities for non-specialty mental health services
Explains MCPs’ responsibilities for providing non-specialty mental health services, along with the regulatory requirements for the Medicaid Mental Health Parity Final Rule and how MCPs should refer to and coordinate with County Mental Health Plans to provide services.
View APL 22-006 summary (PDF, 349 KB)
No wrong door for mental health services policy
Ensures that members receive timely mental health services without delay regardless of the delivery system where they seek care and that members can maintain treatment relationships with trusted providers without interruption.
View APL 22-005 summary (PDF, 253 KB)
Strategic approaches for use by managed care plans to maximize continuity of coverage as normal eligibility and enrollment operations resume
In preparation for the end of the COVID-19 public health emergency, describes strategies for helping eligible members retain Medi-Cal coverage or transition to Covered California health care plans.
Medi-Cal managed care health plan responsibility to provide services to members with eating disorders
Clarifies the responsibility of MCPs to coordinate and provide medically necessary services for members who are diagnosed with eating disorders and are currently receiving Specialty Mental Health Services from a county Mental Health Plan.
View APL 22-003 summary (PDF, 78 KB)
Alternative format selection for members with visual impairments
Requires MCPs to track and report when written materials in alternative formats (Braille, large print, audio, etc.) are requested by members with visual impairments.
View APL 22-002 summary (PDF, 99 KB)
APL 22-002 Provider Training Guide (PDF, 94 KB)
Public and private hospital directed payment programs for state fiscal years 2017-18 and 2018-19, the bridge period, and calendar year 2021
Instructs MCPs on the payment process for hospitals in various statewide payment programs.
View APL 21-018 summary (PDF, 113 KB)
Community Supports requirements
Explains requirements for the Community Supports program (formerly called In Lieu of Services or ILOS), which apply to both Medi-Cal and Cal MediConnect providers.
View APL 21-017 summary (PDF, 99 KB)
California Advancing and Innovating Medi-Cal incentive payment program
Provides guidance on the incentive payments linked to the Enhanced Care Management (ECM) and Community Supports (In Lieu of Services [ILOS]) programs that are part of the California Advancing and Innovating Medi-Cal (Cal-AIM) initiative. The incentive program is expected to be in effect from January 1, 2022 to June 30, 2024.
View APL 21-016 summary (PDF, 89 KB)
Benefit standardization and mandatory managed care enrollment provisions of the California Advancing and Innovating Medi-Cal initiative
Standardizes managed care and fee-for-service (FFS) enrollment statewide, as part of the California Advancing and Innovating Medi-Cal (Cal-AIM) initiative. Beneficiaries in certain voluntary or excluded aid codes that are currently enrolled in Medi-Cal FFS plans will be required to enroll in a Medi-Cal managed care plan. In addition, all MCPs will be required to cover major organ transplants and institutional long-term care. Specialty mental health services will be carved out and instead covered by county health plans.
View APL 21-015 summary (PDF, 124 KB)
Alcohol and drug screening, assessment, brief interventions and referral to treatment
Explains updated requirements for administering alcohol and drug abuse screening, assessment, brief interventions, and treatment referrals to members ages eleven and older, including pregnant women.
View APL 21-014 summary (PDF, 91 KB)
Dispute resolution process between mental health plans and Medi-Cal managed care health plans
Describes how MCPs should submit a service delivery dispute to DHCS when the dispute cannot be resolved at the local level with a Mental Health Plan.
View APL 21-013 summary (PDF, 90 KB)
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.
View APL 21-012 summary (PDF, 109 KB)
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.
View APL 21-011 summary (PDF, 91 KB)
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.
Collecting social determinants of health data
Designates 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.
View APL 21-009 summary (PDF, 90 KB)
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)
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)
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)
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.
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)
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)
IPA Specialist Terminations Report Template (Excel, 14 KB)
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)
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.
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.
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.
Retracted by DHCS
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.”
View APL 20-018 summary (PDF, 89 KB)
Requirements for reporting managed care program data
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)
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.
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.
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)
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)
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.
Retracted by DHCS
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.
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.
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..
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.
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.
Network certification requirements
Informs managed care providers about the annual network certification requirements for the contract year.
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.