All Plan Letters

Initial Health Appointment (Supersedes APL 13-017 and Policy Letters 13-001 and 08-003)

• 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)

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.

• Please review this APL from the Department of Managed Health Care (DMHC) that lists multiple statutes that impact health plans and our partners.

Cost Avoidance and Post-Payment Recovery for Other Health Coverage (Supersedes APL 21-002)​

• Appendix A​
• Appendix B
• FAQs

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.

​Interoperability and Patient Access Final Rule

• 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.

​Population Health Management Program Guide (Supersedes APLs 17-012 and 17-013)

• 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.

• 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.

​Proposition 56 Behavioral Health Integration Incentive Program​

• 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

​Proposition 56 Value-Based Payment Program Directed Payments (Supersedes APL 20-014)​

Skilled Nursing Facilities — Long Term Care Benefit Standardization and Transition of Members to Managed Care

Superseded by 23-004

Primary Care Provider Site Reviews: Facility Site Review and Medical Record Review (Supersedes APL 20-006)

• ​Facility Site Review Standards
• Medical Record Review Standards​

• Provides guidance regarding the qualifications for becoming a Community Health Worker (CHW), the definitions of eligible populations for CHW services, and descriptions of applicable conditions for the CHW benefit.
• CHW services can be provided as individual or group sessions. The services can also be provided virtually or in-person with locations in any setting including, but not limited to, outpatient clinics, hospitals, homes, or community settings. There are no service location limits. Supervising Providers should refer to the Telehealth section in Part 2 of the Provider Manual for guidance regarding providing services via telehealth. Services include Health Education, Health Navigation, Screening and Assessment, Individual Support or Advocacy.
• The Alliance encourages Network Providers to communicate about the availability of these services with Alliance members.
• Watch for a new Provider Training that will review the referral process and billing requirements in the coming months.
• Please refer to the Provider Manual and following Policies for more information.

Enforcement Actions: Administrative and Monetary Sanctions (Supersedes APL 18-003)​

Superseded by 23-012

​Electronic Visit Verification Implementation Requirements​

Provider Credentialing/Re-Credentialing and Screening/Enrollment (Supersedes APL 19-004)

Governor’s Executive Order N-01-19, Regarding Transitioning Medi-Cal Pharmacy Benefits from Managed Care to Medi-Cal RX (Supersedes APL 20-020)

• Appendix A – Medi-Cal Rx Transition and NCQA Requirements​