All Plan Letters

• 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.

• 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.