All Plan Letters

• 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

​Enforcement Actions: Administrative and Monetary Sanctions (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.

• Clarifies contractual obligations for authorizing post-stabilization care services.

• 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.
• DHCS requested approval from CMS for this directed payment arrangement for CY 2022 and CY 2023.
• Subject to future appropriation of funds by the California Legislature and the necessary federal approvals of the directed payment arrangement, DHCS intends to continue this directed payment arrangement on an annual basis for the duration of the program. The requirements of this APL may change if necessary to obtain CMS approvals applicable to this directed payment arrangement or to comport with future state legislation.
• This directed payment program is intended to enhance the quality of patient care by ensuring that Providers in California who offer family planning services receive enhanced payment for their delivery of family planning services. Timely access to vital family planning services is a critical component of Member and population health. In particular, this program is focused on the following categories of family planning services:
  • Long-acting contraceptives
  • Other contraceptives (other than oral contraceptives) when provided as a medical benefit
  • Emergency contraceptives when provided as a medical benefit
  • Pregnancy testing
  • Sterilization procedures (for females and males)

Telehealth Services Policy (Supersedes APL 19-009)

Delegation and Subcontractor Network Certification (Supersedes APL 17-004)

• Attachment A: Subcontractor Network Certification Instruction Manual​
• Attachment B: Subcontractor Network Exemptions Request
• Attachment C: Network Adequacy and Access Assurances Report

Requirements For Coverage of Early and Periodic Screening, Diagnostic, and Treatment Services for Medi-Cal Members Under the Age of 21 (Supersedes APL 19-010)​

• Provides requirements on the Skilled Nursing Facility (SNF) Long Term Care (LTC) benefit standardization provisions of the California Advancing and Innovating Medi-Cal (CalAIM) initiative, including the mandatory transition of beneficiaries to managed care plans such as the Alliance.