March 2023 DHCS Legislative updates + Medi-Cal Rx PA requirements reinstated
March 2023 DHCS Legislative Updates
The latest legislative updates are available from the Department of Health Care Services (DHCS). Below are these March 2023 updates, summarized by All Plan Letter (APL) topic, relevant provider takeaways and Alliance policies for reference. For more information, please contact your Provider Relations representative.
- DHCS APL 20-022 (Revised): COVID-19 Vaccine Administration
- Members aged 6 months and older should be vaccinated.
- Homebound members should contact their doctor, local health dept, or 211 to get an in-home vaccination.
- APL Link: APL 20-022(Revised)
- DHCS APL 22-020: Community-Based Adult Services (CBAS) Emergency Remote Services (ERS)9
- Qualified CBAS providers are required to provide Emergency Remote Services (ERS) as a mode of service delivery when members experience emergencies for up to three consecutive months. Emergencies may be public (state/local disasters) or personal (serious illness/injury, crisis, care transition)
- Contracted CBAS providers must obtain ERS approval and provide each participant’s discharge plan to the Alliance within 30 days of discharge. Additional reporting & documentation requirements are within the APL.
- ERS for an emergency occurrence may not exceed three consecutive months, either within or crossing over an authorized period, without assessment and review for possible continued need for remote/telehealth delivery of services and supports as part of the reauthorization of the individual’s care plan.
This is in the Alliance Provider Manual: Section 6, pages 45-48
- APL Link: APL 22-020
- Alliance Policy: 405-111 Community Based Adult Services
- DHCS APL 22-022: Abortion Services
- Abortion services are a covered benefit. There is no medical justification or utilization management required for outpatient abortion services. However, non-emergency inpatient hospitalization may require prior authorization.
- Member confidentiality should be safeguarded in accessing abortion services, including for minors.
- No physician, provider or person is required to participate in an abortion and no person refusing to participate is subject to penalty for such choice. The Alliance will assist members in accessing timely access to abortion services if a provider refuses to perform them.
- APL Link: APL 22-022
- Alliance Policy:
- 404-1309 Member Access to Self-Referred Services
- 404-1702 Provision of Family Planning Services to Members
- DHCS APL 22-023: Street Medicine Provider: Definitions and Participation in Managed Care
- Street medicine refers to a set of health and social services developed specifically to address the unique needs and circumstances of individuals experiencing unsheltered homelessness, delivered directly to them in their own environment. The fundamental approach of street medicine is to engage people experiencing unsheltered homelessness exactly where they are and on their own terms to maximally reduce or eliminate barriers to care access and follow through.
- The Alliance will operate a street medicine program, and associated criteria. There are certain training, systems and data sharing requirements. Members may select a street medicine provider as their PCP if appropriate requirements are met.
- APL Link: APL 22-023
- Alliance Policy: 300-4046 Street Medicine Providers
- DHCS APL 22-025: Responsibilities for Annual Cognitive Health Assessment for Eligible Members 65 years of Age or Older
- Provider Training and Payment for Annual Cognitive Health Assessments
- Managed care health plans must cover an annual cognitive health assessment for their members who are 65 years of age or older and who do not have Medicare coverage. The annual cognitive health assessment is intended to identify whether the patient has signs of Alzheimer’s disease or related dementias, consistent with the standards for detecting cognitive impairment under the Medicare Annual Wellness Visit and the recommendations by the American Academy of Neurology (AAN).
- In order to be reimbursed for this assessment, providers must have previously completed the DHCS Dementia Care Aware cognitive Health Assessment training. More details are available within the APL.
- APL Link: APL 22-025
- Alliance Policy:
- 300-4195 Provider Training and Payment for Annual Cognitive Health Assessments
- 401-1502 Adult Preventive Care
- DHCS APL 22-027: Cost Avoidance and Post-Payment Recovery for OHC
- Prior to delivering services to members, Providers must review the Medi-Cal Eligibility Record for the presence of OHC. If the requested service is covered by the OHC, Managed care health plans must ensure Providers instruct the member to seek the service from the OHC carrier. Regardless of the presence of OHC, Providers must not refuse a covered Medi-Cal service to a Medi-Cal member.
- APL Link: APL 22-027
- FAQ: FAQs
- Alliance Policy:
- 702-1780 Other Health Coverage Confirmation
- 702-2100 Other Health Coverage Premium Payment Program
- 702-1750 Coordination of Benefits Guidelines for Providers
- APL Link: APL 22-027
- DHCS APL 22-028: Adult and Youth Screening and Transition of Care Tools for Medi-Cal Mental Health Services
- The Department of Health Care Services (DHCS) California Advancing and Innovating Medi-Cal (CalAIM) initiative for “Screening and Transition of Care Tools for Medi-Cal Mental Health Services” aims to ensure all Medi-Cal members receive timely, coordinated services across Medi-Cal mental health delivery systems and improve member health outcomes. The goal is to ensure member access to the right care, in the right place, at the right time.
- APL Link: APL 22-028
- DHCS APL 22-029: Dyadic Care Services and Family Therapy Benefit
- The Alliance covers dyadic care services for members and their caregivers that are medically necessary.
- A dyad refers to a child and their parent(s) or caregiver(s). Dyadic care refers to serving both parent(s) or caregiver(s) and child together as a dyad and is a form of treatment that targets family well-being as a mechanism to support healthy child development and mental health. It is provided within pediatric primary care settings whenever possible and can help identify behavioral health interventions and other behavioral health issues, provide referrals to services, and help guide the parent-child or caregiver-child relationship. Dyadic care fosters team-based approaches to meeting family needs, including addressing mental health and social support concerns, and it broadens and improves the delivery of pediatric preventive care.
- The Alliance covers family therapy for at least two family members when medically necessary. .
- Family therapy is a type of psychotherapy covered under Medi-Cal’s Non-Specialty Mental Health Services (NSMHS) benefit since 2020 Family therapy sessions, which must have at least two family members, address family dynamics as they relate to mental status and behavior(s). It is focused on improving relationships and behaviors in the family and between family members, such as between a child and parent(s) or caregiver(s).
- Examples of family therapy include but not limited to:
- Child-parent psychotherapy (ages 0 through 5)
- Parent child interactive therapy (ages 2 through 12)
- Cognitive-behavioral couple therapy (adults)
- APL Link: APL 22-029
- DHCS APL 22-031: Doula Services
- Effective January 1, 2023, the Alliance covers doula services for prenatal, perinatal, and postpartum members.
- Doula services can be provided virtually or in-person with locations in any setting including, but not limited to, homes, office visits, hospitals, or alternative birth centers.
- The Alliance covers doula services to include personal support to pregnant individuals and families throughout pregnancy, labor, and the postpartum period.
- To be eligible for doula services, and be covered under Medi-Cal managed care, a beneficiary must be eligible for Medi-Cal, enrolled with the Alliance, and have a recommendation for doula services from a physician or other licensed practitioner.
- Doula Providers must meet the requirements and qualifications (i.e., training/experience pathway, continuing education, etc.), as outlined in APL 22-031 linked below.
- APL Link: APL 22-031
- Alliance Policy: 300-4045 – Doula Requirements
- DHCS APL 22-032: Continuity of Care
- Beneficiaries who mandatorily transition from Medi-Cal FFS to enroll as members in the Alliance or transition from the Alliance with contracts expiring or terminating to a new health plan on or after January 1, 2023, have the right to request Continuity of Care with Providers in accordance with federal and state law and the health plan contract, with some exceptions.
- APL Link: APL 22-032
- Alliance Policy: 404-1114 Continuity of Care
Questions?
Please reach out to your Provider Relations representative.
Starting March 24, 2023, Medi-Cal Rx PA requirements reinstated for NCPDP Reject CODE 75
As of March 24, 2023, Medi-Cal Rx will initiate the first of a series of transition policy lifts for Standard Therapeutic Classes (STCs) for beneficiaries 22 and older (Phase III, Lift 1). Prior authorization (PA) requirements will be reinstated for NCPDP Reject CODE 75 – Prior Authorization Required.
For full details, please review the Feb. 23 notification from DHCS.
You can also keep up to date on Medi-Cal reinstatement on the Medi-Cal Rx Education and Outreach webpage.
| Phase III, Lift 1 (P3/L1) Drug Classes | ||
|---|---|---|
| Diuretics (STC 79, 53) | Anti-Lipemic Agents (STC 65, 66) | Hypoglycemics (STC 58) |
| Antihypertensives (STC 71) | Coronary Vasodilators (STC 72) | Cardiovascular Agents (STC 76, 74) |
| Anticoagulants and Antiplatelets (STC 77) | Niacin, Vitamin B and Vitamin C (STC 81) | Opioids (STC 40) |
| Benzodiazepines (HIC3: H20, H21, H22, H4A, H8G, H8K) ** | ||
** Listed HIC3s fall within STCs 07, 47, and 48; other drugs within these STCs are not impacted by this transition lift. Refer to the Medi-Cal Rx Approved NDC List for additional detail.
How to submit a PA for P3/L1 changes
If a beneficiary is currently receiving a medication in the STCs that are impacted by P3/L1 as outlined in the table above, consider the following in preparation for the retirement of the Transition Policy:
- Consider covered therapies that may not require prior authorization (PA), if clinically appropriate.
Resources:- Medi-Cal Rx Contract Drugs Lists & Covered Products Lists
- Medi-Cal Rx Approved NDC List
- Refer to your ePrescribing application.
- If a change in therapy is not appropriate, submit PA requests beginning February 24, 2023. Submission methods:
- CoverMyMeds®
- Medi-Cal Rx Secured Provider Portal
- NCPDP P4 Transaction
- Fax or mail
Additional resources
Questions?
Call the Medi-Cal Rx Customer Service Center at 800-977-2273 (available 24/7) or email Medi-Cal Rx Education & Outreach at [email protected]
