All Plan Letters

• The objective of this APL is to ensure that health plans provide clear, consistent and comprehensive information regarding benefits, exclusions, limitations and member rights.
• Content requirements:
  • Exclusions and limitations: Detailed listing of services not covered or with coverage limits.
  • Members’ rights and responsibilities: Information on enrollee entitlements and obligations.
  • Definitions: Clear explanations of terms used within the EOC/disclosure form.
• Formatting standards:
  • Uses plain language to ensure understandability. Consistent structure and layout.
• For more information, please refer to DMHC APL 25-004.
• Please watch out for future Alliance policies and procedures in the Alliance Provider Manual (if applicable) pertaining to this APL.

• This APL provides guidance on the coverage requirements for mobile crisis services under Medi-Cal, ensuring timely and appropriate behavioral health crisis intervention for beneficiaries.
• Mobile Crisis Services provides community-based interventions for individuals experiencing behavioral health crises, delivered wherever the individual is located (e.g., home, work, school).
• The service delivery is provided by multidisciplinary teams comprising behavioral health professionals such as clinicians, peer support specialists and other trained personnel. Teams are trained in trauma-informed care, de-escalation techniques and harm reduction strategies.
• Medi-Cal Managed Care Plans (MCPs) are required to cover mobile crisis services as a Medi-Cal benefit. MCPs cannot require prior authorization for behavioral health crisis stabilization services that mobile crisis teams provide.
• The Medi-Cal Mobile Crisis Training and Technical Assistance Center (M-TAC) offers training, resources and ongoing support to counties and mobile crisis teams to provide additional training and support for providers. The training focus areas include crisis assessment, trauma-informed care, de-escalation techniques, harm reduction, safety planning and strategies for special populations.
• For more information, please refer to DMHC APL 25-006.
• Please watch out for future Alliance policies and procedures in the Alliance Provider Manual (if applicable) pertaining to this APL.

• This APL establishes standards ensuring that Medi-Cal beneficiaries with limited English proficiency (LEP) or disabilities have meaningful access to health care services and information.
• A threshold language is identified when at least 3,000 beneficiaries or 5% of the beneficiary population in a geographic area indicate a primary language other than English.
• Nondiscrimination requirements: Department of Health Care Services (DHCS) adheres to federal and state civil rights laws ensuring no unlawful discrimination based on; sex, race, color, religion, ancestry, national origin, ethnic group identification, age, mental or physical disability, medical condition, genetic information, marital status, gender, gender identity or sexual orientation.
• Language assistance services: Oral interpretation and written translation services must be available at no cost to the member and all vital documents must be translated into threshold languages.
• Alternative formats: Available alternative formats include documents being available in large print (20-point Arial), audio format, accessible electronic format (e.g., data CD) and Braille.
• For more information, please refer to DHCS APL 25-005.
• Please watch out for future Alliance policies and procedures in the Alliance Provider Manual (if applicable) pertaining to this APL.

• This APL outlines community reinvestment obligations for Medi-Cal Managed Care Plans (MCPs) and their qualifying subcontractors.
• MCPs with positive net income are required to reinvest a minimum of 7.5% of their annual net income into community reinvestment initiatives.
• Community reinvestment funds can be allocated to various categories, including:
  • Improving access to care.
  • Enhancing care coordination.
  • Addressing social determinants of health.
  • Supporting workforce development.
• For more information, please refer to DHCS APL 25-004.
• Please watch out for future Alliance policies and procedures in the Alliance Provider Manual (if applicable) pertaining to this APL.

• The Skilled Nursing Facility Workforce & Quality Incentive Program (SNF WQIP) is a California Department of Health Care Services (DHCS) initiative designed to enhance care quality, promote health equity and invest in skilled nursing facilities (SNFs).
• SNF WQIP is a direct payment program for skilled nursing facilities under Medi-Cal Managed Care. The program aims to improve care quality, promote workforce investment and enhance health equity.
• SNFs must be in a Medi-Cal Managed Care network and meet workforce standards to receive incentive payments. Incentive payments are based on performance in clinical quality, workforce retention and disproportionate share metrics.
• For more information, please refer to DHCS APL 25-002.
• Please watch out for future Alliance policies and procedures in the Alliance Provider Manual (if applicable) pertaining to this APL.

• AB 133 established the Children and Youth Behavioral Health Initiative (CYBHI), part of the Master Plan for Kids’ Mental Health. The CYBHI introduced a new category of behavioral health providers, the Certified Wellness Coach, in its directive to HCAI to assist in expanding the supply of behavioral health providers.
• The scope of services provided by Certified Wellness Coaches is limited to prevention and early intervention behavioral health services to children and youth through age 25 and their families.
• For more information, please refer to DMHC APL 24-022.
• Please watch out for future Alliance policies and procedures in the Alliance Provider Manual (if applicable) pertaining to this APL.

• This APL outlines the newly enacted statutory requirements for health care service plans regulated by the Department of Managed Health Care. This APL identifies and discusses the 23 total bills enacted this session.
• For more information, please refer to DMHC APL 24-023.
• Please watch out for future Alliance policies and procedures in the Alliance Provider Manual (if applicable) pertaining to this APL.

• Please review the APL for updated screening and enrollment requirements for providers.
• For more information, please refer to DHCS APL 22-013.
• Please watch out for future Alliance policies and procedures in the Alliance Provider Manual (if applicable) pertaining to this APL.

• Assembly Bill (AB) 665 amends certain statutory sections allowing minors aged 12 and older to consent to outpatient mental health treatment or counseling without parental consent, provided they are deemed mature enough by a professional.
• Minors aged 12 or older can independently consent to non-specialty outpatient Medi-Cal mental health treatment or counseling if, in the professional’s opinion, they are mature enough.
• The law applies to non-specialty outpatient mental health services. Specialty mental health services are governed by county Mental Health Plans (MHPs).
• Minors cannot consent to convulsive therapy, psychosurgery, or psychotropic drugs without parental consent.
• For more information, please refer to DHCS APL 24-019.
• Please watch out for future Alliance policies and procedures in the Alliance Provider Manual (if applicable) pertaining to this APL.

• The Whole Child Model (WCM) Program integrates CCS-covered services into Medi-Cal managed care for comprehensive care coordination encompassing primary, specialty and behavioral health services for CCS-eligible children and youth.
• MCPs are responsible for authorizing, case managing and paying for services that correct or ameliorate CCS-eligible conditions, adhering to CCS Program standards.
• Care must be provided by CCS-paneled providers, CCS-approved Special Care Centers, or CCS-approved pediatric acute care hospitals.
• This APL supersedes APL 23-034 and aims to ensure that MCPs and County CCS Programs effectively collaborate to provide comprehensive and coordinated care for CCS-eligible children and youth within the WCM framework.
• For more information, please refer to DHCS APL 24-015.
• Please watch out for future Alliance policies and procedures in the Alliance Provider Manual (if applicable) pertaining to this APL.

• This APL provides Medi-Cal managed care plans (MCPs) with guidance regarding the transgender, gender diverse, intersex (TGI) cultural competency training program and Provider Directory changes that Senate Bill (SB) 923 requires to provide trans-inclusive health care to MCP Members.
• SB 923, the TGI Inclusive Care Act, established requirements to improve trans-inclusive health care in California. A TGI Working Group was created to develop training standards and gather community input. Trans-inclusive care emphasizes respecting bodily autonomy, avoiding gender assumptions and treating all individuals with compassion and respect.
• For more information, please refer to DHCS APL 24-017.
• Please watch out for future Alliance policies and procedures in the Alliance Provider Manual (if applicable) pertaining to this APL.

• Managed Care Plans (MCP) must develop and implement DEI training programs encompassing sensitivity, diversity, cultural competency, cultural humility and health equity for all MCP staff and network providers. The MCP’s Chief Health Equity Officer is responsible for overseeing the DEI training program, ensuring that training materials are current, evidence-based and region-specific. MCPs must also establish mechanisms to monitor training completion and address deficiencies. The DEI training programs must align with the National Committee for Quality Assurance (NCQA) Health Equity Accreditation Standards, aiming to improve communication between providers and members from diverse backgrounds, thereby enhancing access to care and health outcomes.
• Supersedes APL 99-005 & APL 22-013.
• For more information, please refer to DHCS APL 24-016.
• Please watch out for future Alliance policies and procedures in the Alliance Provider Manual (if applicable) pertaining to this APL.

• This APL provides guidance regarding the implementation of Senate Bill 923-Gender-Affirming Care, including filing and compliance with requirements for all full-service and certain specialized health care services plan(s).
• This APL formally adopts the Transgender, Gender Divers, or Intersex (TGI) Working Group recommendations regarding the topics in the training curriculum for health care service plan staff. 
• This APL requires a plan to ensure all health care service staff complete evidence-based cultural competency training when providing trans-inclusive health care for individuals who identify as TGI. For more information, refer to pages 7-10 of the APL. 
• The Alliance is required to include which in-network providers offer gender-affirming services in provider directories and call centers no later than Feb.14, 2025.  
• Please fill out this form to let us know if you offer gender-affirming services.  
• For more information, please refer to DMHC APL 24-018. 
• Please watch out for future Alliance policies and procedures in the Alliance Provider Manual (if applicable) pertaining to this APL. 

• This APL clarifies the intent and objectives of the Medi-Cal Managed Care Plan (MCP) Child Welfare Liaison, formerly referred to as the Foster Care Liaison. This is to improve care coordination and outcomes for children and youth involved in child welfare by ensuring effective collaboration between MCPs and other involved entities.
• The primary responsibilities of the designated MCP Child Welfare Liaison include but are not limited to:
  • Serving as a key point of contact for escalated issues related to child welfare.
  • Providing guidance and resources to MCP staff involved in care coordination for members and building partnerships with specified entities.
  • Supporting MCP staff and providers with trauma informed approaches when interacting with children, youth or others involved.
• Foster Youth Bill of Rights: The California Department of Social Services provides resources regarding the rights of foster youth, including documents and guidelines often distributed to foster youth and their caregivers. Resources are available on their official website.
• Trauma-Informed Care: The National Child Traumatic Stress Network (NCTSN) is a key federal resource offering extensive training, materials and information on trauma-informed care. The Substance Abuse and Mental Health Services Administration (SAMHSA) provides national resources and guidelines for trauma-informed approaches, including the Trauma-Informed Care in Behavioral Health Services publication.
• CBI Provider Incentives: The Alliance offers a $200 incentive per provider for completing the ACEs Aware Core Training and Attestation on the ACEs Aware website. For more details on this incentive, please refer to our CBI webpage. You may contact Dr. Dianna Myers, Medical Director, Alliance Child Welfare Liaison with questions at (800) 700-3874 ext. 5513 or via email at [email protected].
• Please watch out for future Alliance policies and procedures in the Alliance Provider Manual (if applicable) pertaining to this APL.

• Health plans are required to conduct regular outreach to members who may benefit from mental health services by conducting screenings and assessments during routine interactions.
• The outreach and education plan must include information about the mental health benefits that are covered by the Managed Care Plan (MCP). Please see APL 18-016, or any superseding APL, for additional guidance and requirements regarding outreach, education and member information.
• Health plans must update outreach and education plans in subsequent years, as needed, based on learnings from the Diversity, Equity and Inclusion training programs, as outlined in APL 23-025, or any superseding APL.
• For more information, please refer to DHCS APL 24-012.
• Please watch out for future Alliance policies and procedures in the Alliance Provider Manual (if applicable) pertaining to this APL.

• CalAIM seeks to move Medi-Cal to a more consistent and seamless system by reducing complexity and increasing flexibility through benefit standardization. To further these goals, the Department of Health Care Services (DHCS) is implementing benefit standardization – also termed a “carve-in” – of the ICF/DD Home benefit statewide.
• Effective January 1, 2024, DHCS will require Non-Dual and Dual LTC Members (including those with Medi-Cal Share of Cost coverage) to enroll in an MCP and receive their LTC ICF/DD Home benefit through their MCP. Enrollment into an MCP does not change a Member’s relationship with their Regional Center. Access to Regional Center services and to the current IPP process will remain the same.
• ICF/DD Homes that collect SOC payments or obligated payments are responsible for certifying SOC in the Medi-Cal eligibility verification system to show the Member has paid or obligated payment for the monthly SOC amount owed. Instructions for Providers to perform SOC clearance transactions in the Medi-Cal eligibility verification system are provided in Part 1 of the Medi-Cal Provider Manual.
• For more information, please refer to DHCS APL 24-011.
• Please watch out for future Alliance policies and procedures in the Alliance Provider Manual (if applicable) pertaining to this APL.

• Subacute Care Facility services include those provided to both adult and pediatric populations, that are provided by a licensed general acute care hospital with distinct part skilled nursing beds, or by a freestanding certified nursing facility. 2 In each case, the facility must have the necessary contract with the Department of Health Care Services (DHCS)
• Effective January 1, 2024, DHCS will require non-dual and dual LTC Members (including those with a Share of Cost) receiving institutional LTC services in a Subacute Care Facility or Intermediate Care Facility for the Developmentally Disabled (ICF/DD) to be enrolled in an MCP. This APL focuses on subacute care services as part of institutional LTC services
• The physician’s prescriptions for SOC expenditures must be maintained in the Member’s medical record. If a Member spends part of their SOC on necessary, noncovered, medical or remedial care services or items, the Subacute Care Facility will subtract those amounts from a Member’s SOC and collect the remaining SOC amount owned. The Subacute Care Facility will adjust the amount on the claim and submit the claim to the MCP to pay the balance. Further DHCS guidance regarding Johnson v. Rank requirements are available in the Medi-Cal LTC Provider Manual. Subacute Care Facilities that collect SOC payments or obligated payments are responsible for certifying SOC in the Medi-Cal eligibility verification system to show the Member has paid or obligated payment for the monthly SOC amount owed. Instructions for Providers to perform SOC clearance transactions in the Medi-Cal eligibility verification system are provided in Part 1 of the Medi-Cal Provider Manual.
• For more information, please refer to DHCS APL 24-010.
• Please watch out for future Alliance policies and procedures in the Alliance Provider Manual (if applicable) pertaining to this APL.

• CalAIM seeks to move Medi-Cal to a more consistent and seamless system by reducing complexity and increasing flexibility through benefit standardization. The Medi-Cal program provides benefits through both a Fee-For-Service (FFS) and managed care delivery system. While Medi-Cal managed care is available statewide, the benefits vary among counties depending on the managed care plan model. Variations in benefits include coverage of SNF services. Prior to January 1, 2023, MCPs operating in 27 counties covered SNF services under the institutional LTC services benefit. Conversely, managed care Members in 31 counties were disenrolled from managed care to Medi-Cal FFS if they required institutional LTC services.
• Effective January 1, 2024, institutional LTC Members receiving institutional LTC services in a Subacute Care Facility or Intermediate Care Facility for the Developmentally Disabled (ICF/DD) must be enrolled in an MCP. APLs specific to subacute care services (provided in both freestanding and hospital-based, as well as pediatric and adult subacute care facilities) and ICF/DD services will be released separately.
• Because of the Johnson v. Rank lawsuit, Medi-Cal Members, not their Providers, can elect to use the SOC funds to pay for necessary, non-covered, medical or remedial care services, supplies, equipment, and drugs (medical services) that are prescribed by a physician and part of the plan of care authorized by the Member’s attending physician. The physician’s prescriptions for SOC expenditures must be maintained in the Member’s medical record. Instructions for Providers to perform SOC clearance transactions in the Medi-Cal eligibility verification system are provided in Part 1 of the Medi-Cal Provider Manual.
• For more information, please refer to DHCS APL 24-009.
• Please watch out for future Alliance policies and procedures in the Alliance Provider Manual (if applicable) pertaining to this APL.

• The changes to this APL supersede APL 18-004 and APL 16-009. This APL clarifies requirements related to providing immunization services.
•  Effective Aug. 1, 2024, retroactive to Jan. 1, 2023, Vaccines for Children (VFC) program providers who administer VFC-funded vaccines to VFC-eligible Medi-Cal members and bill VFC-funded vaccines as a pharmacy benefit to Medi-Cal Rx can now be reimbursed. Providers will be reimbursed for pharmacy administration of the vaccines and the professional dispensing fee in accordance with recommendations by the Advisory Committee on Immunization Practices (ACIP).
• Providers are required to document each member’s need for ACIP-recommended immunizations as part of all regular health visits, including but not limited to the following types:
  • Illness, care management or follow-up appointments.
  • Initial Health Appointments (IHAs).
  • Pharmacy services.
  • Prenatal and postpartum care.
  • Pre-travel visits.
  • Sports, school or work physicals.
  • Visits to an LHD (local health department).
  • Well patient checkups.
  • The Alliance will provide the specified pharmacist services as a reimbursable Medi-Cal benefit when rendered to a member in the outpatient pharmacy setting. Pharmacist services may be billed on a medical claim for Alliance members. The Alliance will reimburse pharmacy providers for rendering the specified pharmacist services in accordance with the requirements of Business and Professions Code (B&P) and California Code of Regulations (CCR).
• For more information, please refer to DHCS APL 24-008.

Please watch out for future Alliance policies and procedures in the Alliance Provider Manual (if applicable) pertaining to this APL.

• Alliance policies related to this APL.
  • 401-1506: Immunization Services and Reimbursement. 
  • 401-1509: Timely Access to Care. 

• The changes of this APL supersede DHCS APL 22-016. This APL provides guidance on the qualifications to become a Community Health Worker (CHW), the definitions of populations eligible for CHW services and descriptions of applicable conditions for the CHW benefit.
• Please review the changes made to the “Provider Enrollment” section of the APL.
• Please watch for future Alliance policies and procedures in the Alliance Provider Manual (if applicable) pertaining to this APL.
• Alliance policies related to this APL:
  • 300-4035: Community Health Workers Requirements.
  • 300-4110: Organizational Provider Credentialing Guidelines.
  •  300-5010: FQHC Access Reimbursement FQC Services.
  • 404-1738: Community Health Worker Services.