All Plan Letters

• The “Blood Lead Testing & Anticipatory Guidance” document has been retired and removed from APL 20-016. Please review this update to APL 20-016, which includes minor and technical edits.
• For more information, please refer to DHCS APL 20-016.
• Please watch out for future Alliance policies and procedures in the Alliance Provider Manual (if applicable) pertaining to this APL.

• The purpose of this All Plan Letter (APL) is to summarize and clarify existing federal and state protections and alternative health coverage options for American Indian members enrolled in Medi-Cal managed care plans (MCPs).
• This APL supersedes APL 09-009.
• This APL also consolidates various MCP requirements relating to protections for Indian Health Care Providers.
• The MCP contract defines “American Indian” as a member who meets the criteria for an “Indian” as defined in federal law. For consistency with the MCP contract, this APL uses the term “American Indian.”
• Tribal Liaison: Effective Jan. 1, 2024, MCPs are required to have an identified tribal liaison dedicated to working with each contracted and non-contracted IHCP in its service area. The tribal liaison is responsible for coordinating referrals and payment for services provided to American Indian MCP members who are qualified to receive services from an IHCP.
  • You can contact Cynthia Balli, Provider Relations Supervisor for Merced County, with questions regarding the Alliance’s tribal liaison, at (209) 381 –7394.

• Please review this APL from the Department of Managed Health Care (DMHC) that outlines multiple new statutory requirements for health care plans.

• This APL provides guidance to Medi-Cal managed care plans (MCPs) on how to use street medicine providers to address clinical and non-clinical needs of Medi-Cal members experiencing homelessness. This APL supersedes DHCS APL 22-023.
• Under this APL, street medicine providers should bill Place of Service (POS) code 27 (outreach site/street) to Medi-Cal Fee-For-Service (FFS) or MCPs when rendering services for street medicine as of Oct. 1, 2023.
• Please note that DHCS is currently making updates in the California Medicaid Management Information System (CA-MMIS) to accommodate POS code 27. Any FFS claims that are denied for using POS code 27 during CA-MMIS updates do not need to be resubmitted and will be processed automatically once the system changes are complete.
• Continue to use POS codes 04 (Homeless Shelter), 15 (Mobile Unit) and 16 (Temporary Lodging) for services provided in those respective settings. Both street medicine and mobile medicine are reimbursable services in accordance with billing protocols and a provider’s scope of practice.
• Please read the Alliance Policy related to this APL: 300-4046-Street Medicine Providers.

You can find related Alliance policies and procedures in the Alliance Provider Manual.

• This initiative seeks to provide direction and guidance to providers participating in the California Children’s Services (CCS) Whole Child Model (WCM) Program.
• The Alliance is responsible for the CCS program in Merced, Monterey and Santa Cruz counties.
• Starting January 2025, the Alliance will be responsible for CCS in Mariposa and San Benito counties. For now, the county CCS programs will coordinate CCS services to CCS-eligible members in Mariposa and San Benito Counties.
• This APL conforms with CCS Numbered Letter (N.L.) 12-1223, which provides direction and guidance to county CCS programs on requirements related to the WCM program.

• All Medi-Cal Members enrolled in Managed Care Plans who are eligible for Medi-Cal dental services are entitled to dental services under IV moderate sedation and deep sedation/general anesthesia when medically necessary in an appropriate setting.
• Prior Authorization for IV moderate sedation and deep sedation/general anesthesia for dental services must be submitted using the criteria provided in Attachment A.
• In addition, please refer to the Intravenous Moderate Sedation and Deep Sedation/General Anesthesia: Prior Authorization/Treatment Authorization Request and Reimbursement Scenarios in Attachment B.
• For more information, please contact Provider Relations at 800-700-3874, ext. 5504 or 831-430-5504.

• The California Advancing and Innovating Medi-Cal (CalAIM) Initiative seeks to move Medi-Cal to a more consistent and seamless system by reducing complexity and increasing flexibility through benefit standardization.
• Effective January 1, 2024, the Alliance will authorize and cover medically necessary adult and pediatric subacute care services (provided in both freestanding and hospital-based facilities).
• The Alliance will determine medical necessity consistent with definitions in Title 22 of the Code of California Regulations (CCR) sections 51124.5 and 51124.6, Welfare and Institutions Code (W&I) section 14132.25 and the Medi-Cal Manual of Criteria.
• Additionally, members who are admitted into a subacute care facility will remain enrolled in Medi-Cal managed care instead of being disenrolled to Medi-Cal FFS.
• The Alliance will ensure that members in need of adult or pediatric subacute care services are placed in a health care facility that provides the level of care most appropriate to the member’s medical needs, as outlined in the Alliance Contract and as documented by the member’s provider(s).
• If a member needs adult or pediatric subacute care services, the Alliance will ensure they are placed in a health care facility that is either under contract or actively applying for a contract for subacute care with the DHCS Subacute Contracting Unit (SCU).
• The Alliance is reaching out to regional and statewide subacute and ICF/DD providers to ensure network adequacy.

• From January 1 to July 1, 2024, the Alliance will assess needs for the servicing regions, biases and member experiences.
• From July 1, 2024 to December 31, 2024, the Alliance will begin to develop a DEI training program for network providers in partnership with managed care plans throughout the regions.
• From January 1 to July 1, 2025, the Alliance will pilot the DEI training program and assess and address issues/concerns.
• Please watch for future Alliance policies and procedures in the Alliance Provider Manual and on the Alliance provider training webpage.

• Effective January 1, 2023, doula services are a covered Alliance Medi-Cal benefit. Please review this APL and the Alliance doula policies to learn more.
• Become a credentialed doula with the Alliance on the Alliance Credentialing page.
• Check out the Newly Contracted Doula Orientation on the Alliance Provider Training webpage.

• The California Advancing and Innovating Medi-Cal (CalAIM) Initiative 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.
• The ICF/DD Home living arrangement is a Medi-Cal covered service offered to individuals with intellectual and developmental disabilities who are eligible for services and supports through the Regional Center service system.
• Effective January 1, 2024, members who reside in an ICF/DD Home will remain enrolled in managed care, instead of being disenrolled and transferred to FFS Medi-Cal.
• Members who are residing in an ICF/DD Home will be transferred from FFS Medi-Cal to Medi-Cal managed care such as the Alliance.
• Enrollment with the Alliance does not change a member’s relationship with their Regional Center.
• Access to Regional Center services and to the current Individualized Program Plan (IPP) process will remain the same.
• Covered and non-covered services are listed in Attachment A in the APL (pages 22-24).
• The Alliance is reaching out to regional and statewide subacute and ICF/DD providers to ensure network adequacy.

• This letter 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.
• Members may request up to 12 months of Continuity of Care with a provider if a verifiable relationship exists with that provider.
• Members have the right to Continuity of Care for covered services and active prior treatment authorizations for covered services.
• The Alliance will work with approved out-of-network (OON) providers and communicate requirements on letters of agreements, including referral and authorization processes, to ensure that the OON provider does not refer the member to another OON provider without authorization from the Alliance. The Alliance will make the referral if it is medically necessary and the Alliance does not have an appropriate provider within its network.

• APL 23-019 provides guidance on directed payments, funded by the California Healthcare, Research and Prevention Tobacco Tax Act of 2016 (Proposition 56), for the provision of specified physician services.
• Please see Table A of this APL for more information on covered services and CPT codes.

• On July 1, 2022, 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: https://www.medi-cal.ca.gov/TSTA/TSTAattest.aspx 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:
      1. PEARLS child tool, for ages 0-11, to be completed by a parent/caregiver;
      2. PEARLS adolescent, for ages 12-19, to be completed by a parent/caregiver; and
      3. 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.

• Beginning July 1, 2022, 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: https://www.dhcs.ca.gov/services/Pages/DP-proposition56.aspx.

• 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.

• 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.

Network Providers are required to sign the California Health and Human Services Agency (CalHHS) Data Exchange Framework (DxF) Data Sharing Agreement (DSA) as outlined in the California Health and Safety Code § 130290. The California Health and Human Services Agency (CalHHS) Data Exchange Framework (DxF) Data Sharing Agreement (DSA) ensures that every Californian, as well as the health and human service and governmental entities who serve them, can access information needed to provide safe and effective care for all Californians, regardless of where in the state they are located.

The Department of Health Care Services (DHCS) published the CalAIM Data Sharing Authorization Guidance[1] in March of 2022, which supports data sharing between Managed Care Plans, health care providers, community-based social and human service providers, local health jurisdictions, and county and other public agencies that provide services and manage care under CalAIM.

The DxF advances health equity for all Californians by facilitating the secure and appropriate exchange of health and social services information. The DxF will, in addition to other goals, identify gaps in, and propose solutions to gaps, in the life cycle of health information, including:

• Health information creation, including the use of national standards in clinical documentation, health plan records, and social services data.
• Translation, mapping, controlled vocabularies, coding, and data classification.
• Storage, maintenance, and management of health information.
• Linking, sharing, exchanging, and providing access to health information.

Sign the Data Sharing Agreement today at https://signdxf.powerappsportals.com/.

Network Providers can also work with their County Health Information Exchange organizations. Please see the established County Health Information Exchange organizations below:

Monterey County
Central Coast Connect
Website: https://centralcoasthealthconnect.org/
Phone Number: (831) 644-7494
Email: [email protected]

Santa Cruz County
Serving Communities HIO
Website: https://schio.org/
Phone Number: (831) 610-3700
Email: [email protected]

Network Providers are required to sign the California Health and Human Services Agency (CalHHS) Data Exchange Framework (DxF) Data Sharing Agreement (DSA) as outlined in the California Health and Safety Code § 130290. The California Health and Human Services Agency (CalHHS) Data Exchange Framework (DxF) Data Sharing Agreement (DSA) ensures that every Californian, as well as the health and human service and governmental entities who serve them, can access information needed to provide safe and effective care for all Californians, regardless of where in the state they are located.

The Department of Health Care Services (DHCS) published the CalAIM Data Sharing Authorization Guidance^[1] in March of 2022, which supports data sharing between Managed Care Plans, health care providers, community-based social and human service providers, local health jurisdictions, and county and other public agencies that provide services and manage care under CalAIM.

The DxF advances health equity for all Californians by facilitating the secure and appropriate exchange of health and social services information. The DxF will, in addition to other goals, identify gaps in, and propose solutions to gaps, in the life cycle of health information, including:

• Health information creation, including the use of national standards in clinical documentation, health plan records, and social services data.
• Translation, mapping, controlled vocabularies, coding, and data classification.
• Storage, maintenance, and management of health information.
• Linking, sharing, exchanging, and providing access to health information.

Sign the Data Sharing Agreement today at https://signdxf.powerappsportals.com/.

Network Providers can also work with their County Health Information Exchange organizations. Please see the established County Health Information Exchange organizations below. 

Monterey County

Central Coast Connect
Website: https://centralcoasthealthconnect.org/
Phone Number: (831) 644-7494
Email: [email protected]

Santa Cruz County

Serving Communities HIO
Website: https://schio.org/
Phone Number: (831) 610-3700
Email: [email protected]

^[1] CalAIM – Data Sharing Authorization Guidance: https://www.dhcs.ca.gov/Documents/MCQMD/CalAIM-Data-Sharing-Authorization-Guidance.pdf

• ​Enforcement Actions: Administrative and Monetary Sanctions (Supersedes APL 22-015)
• The purpose of this APL provides clarification of DHCS’s policy regarding the imposition of administrative and monetary sanctions, which are among the enforcement actions DHCS may take to enforce compliance with contractual provisions and applicable state and federal laws. This APL supersedes APL 22-015.

• Provides guidance and clarification regarding federal and state legal requirements for recovery of all Overpayments to Providers.

• Provides guidance about the provision of Medically Necessary Behavioral Health Treatment (BHT) services for Members under the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit in accordance with mental health parity requirements.
• Clarifies responsibility of coordination with other entities, and ensures all of a Member’s needs for Medically Necessary BHT services are met across environments, including on-site at school or during virtual school sessions.
• This APL clarifies Medically Necessary Behavioral Health Treatment services covered under Medicaid.