March 9, 2021
All Medi-Cal Managed Care Health Plans
This All Plan Letter (APL)
As the Department of Health Care Services (DHCS) continues to respond to the concerns and changing circumstances resulting from the pandemic, DHCS provides the updated guidance to MCPs.
Revised text is found in italics .
The following declarations were renewed on January 7, 2021:
The following is the list of waiver/ modification requirements:
Note: The Section 1135 Waiver requests and CMS approval letters can be found on the DHCS COVID-19 Response webpage under Waiver Requests & Approvals – 1135 Waiver Requests & Approvals at the following link: https://www.dhcs.ca.gov/Pages/DHCS-COVID%E2%80%9119-Response.aspx.
To streamline the Section 1135 Waiver request and approval process, CMS issued a number of blanket waivers for many Medicare provisions that do not require individualized approval. While not all of these waivers apply to Medicaid, CMS has provided guidance for specified health care providers regarding blanket waivers on a variety of topics, including, but not limited to, the following:
Updates to this guidance
DHCS provides updates to this guidance to reflect any additional Section 1135 Waiver approvals not reflected in the above-mentioned approval letters, as appropriate.
On March 6, 2020, DHCS issued a Memorandum (Memo) to MCPs to
On March 16, 2020, DHCS subsequently updated the Memo to include additional guidance.
Note: This APL incorporates the guidance provided in that Memo.
On May 13, 2020, and August 20, 2020, CMS issued letters approving DHCS’ proposed amendments to add section 7.4 Medicaid Disaster Relief for the COVID-19 National Emergency to California’s Medicaid State Plan.
Note: SPA requests and approvals can be found on the DHCS COVID-19 Response webpage under Waiver Requests & Approvals – State Plan Amendments Requests & Approvals.
State Plan Amendments (SPA) 20-0024 and 20-0025 implement temporary policies, different from those otherwise applied under California’s Medicaid state plan, during the period of the Presidential and Secretarial emergency declarations related to the COVID-19 outbreak.
DHCS guidance hyperlink
DHCS guidance on various temporary policies included in SPA 20-0024 and 20-0025 are posted on the DHCS COVID-19 Response webpage under Waiver Requests & Approvals - State Plan Requests & Approvals. It also addresses the relevant changes affecting the Medi-Cal managed care delivery system are also addressed in this APL.
CMS’ responses to DHCS’ flexibility requests are applicable, in part, to the Medi-Cal managed care delivery system, including the following:
DHCS has received CMS approval to extend the timeframe for MCP members to request a SFH.
Reference: For details, refer to the
Note: APLs, along with any Supplements, can be found at: https://www.dhcs.ca.gov/formsandpubs/Pages/AllPlanLetters.aspx Waiver Requests & Approvals – State Plan Amendments Requests & Approvals.
On December 31, 2020, DHCS received approval from CMS to modify the timeframe under 42 Code of Federal Regulations (CFR) section 438.420(a)(i) related to the continuation of benefits (i.e., Aid Paid Pending (APP)).
This APL modifies the guidance in APL 17-006 for the duration of the PHE.
Use the table below for APP.
When the ...
Then the MCP ...
MCP provided APP for the member pending the outcome of an appeal
provides APP pending the outcome of an SFH.
member requests an SFH
Through the duration of the PHE, when a member’s appeal involves the
termination, suspension, or reduction of previously authorized services,
then the MCPs follows the table below:
When the member files an appeal ...
Then the MCP ...
within the current timeframes :
provides APP .
between 11 and 30 days of the NOA, before the MCP makes a final decision on the appeal
reinstates APP .
In the March 23, 2020 response, CMS approves certain temporary flexibilities for provider screening and enrollment. DHCS issues guidance regarding these flexibilities for the provider enrollment that applies to both
Note: MCPs that conduct provider enrollment through their own process must implement a similar process to that contained in this guidance.
Guidance listing hyperlink
This guidance is listed as “Guidance for Emergency Medi-Cal Provider Enrollment” on the DHCS COVID-19 Response webpage under Providers & Partners – Guidance for Multiple Provider Types. It allows for an emergency provider enrollment process.
The table below describes the stages of the DHCS’ Provider Enrolment Division (PED) directing potential new providers for MCPs.
DHCS’ Provider Enrollment Division (PED) directs the potential new providers to the process outlined in the DHCS guidance.
The potential new providers complement the emergency enrollment application process through PED.
The providers receive an approval
Note: The information states that they have been granted enrollment for 60 days, with the possibility of extension in 60-day increments.
The providers submit a copy of their approval letter as proof of the approved temporary enrollment to the MCP prior to providing services to MCP members.
The Section 1135 Waiver approvals relating to prior authorization focus on Medi-Cal FFS. The list below provides guidance for Medi-Cal FFS prior authorization.
Reference: For details, refer to the “FFS Prior Authorization – Section 1135 Waiver Flexibilities” guidance, including any subsequently released updates to this guidance, which is available on the DHCS COVID-19 Response webpage under Providers & Partners – Guidance for Multiple Provider Types.
MCPs adheres to the COVID-19 testing requirements outlined in the COVID-19 Virus and Antibody Testing guidance document.
Reference: The document is found on the DHCS COVID-19 Response webpage under Providers & Partners – Guidance for Multiple Provider Types.
The list below provides the guidance for reimbursement.
There is provision of care in the following locations:
The list below provides CMS guidance for provision of care in the locations listed above.
Reference: The link Providing Care in Alternate Settings, Hospital Capacity, Transportation, Blanket 1135 Flexibilities is found on the DHCS COVID-19 Response webpage under Providers & Partners – Guidance for Multiple Provider Types.
On April 3, 2020, DHCS issued the “Off-label and/ or Investigational Drugs Used to Treat COVID-19 and/ or Related Conditions” guidance document.
The DHCS guidance issued on April 3, 2020 provides information regarding
DHCS issued the guidance document “Information Regarding the Use of Subcutaneous Depot Medroxyprogesterone Acetate During the 2019 Novel Coronavirus Public Health Emergency”.
This guidance temporarily allows the pharmacy dispensing of Subcutaneous Depot Medroxyprogesterone Acetate directly to beneficiaries for self-administration at home.
Note: MCPs follows the requirements contained in these pharmacy guidance documents, including any subsequently released updates to this guidance.
The link to the guidance can be found on the DHCS COVID-19 Response webpage under Providers & Partners – Hospitals, Clinics, Pharmacies, and Other Facilities for
As the State of California responds to the COVID-19 situation, DHCS is regularly updating and distributing guidance to the
Reference: Refer to the DHCS COVID-19 Response webpage for the most up-to-date information available.
MCPs can send questions, concerns and reports of member access issues to their DHCS Managed Care Operations Division (MCOD) Contract Manager.
DHCS reminds MCPs to
As the COVID-19 PHE continues, many Californians are experiencing secondary impacts on their mental health.
The directors of DHCS and the California Department of Public Health collaborated with the California Surgeon General to write a to all California medical and behavioral health providers encouraging them to ask their patients the four “Ask Suicide Screening Questions” developed by the National Institute of Mental Health.
Note: The July 10, 2020 Suicide Prevention Practices for Providers letter is available on the COVID-19 Response webpage under Providers & Partners – Behavioural Health.
Sharing patient information
DHCS encourages MCPs to share this information with their network providers and subcontractors, as appropriate.
MCPs must work with their contracted providers to use telehealth services to deliver care when medically appropriate, as a means to
Reference: For clarification on the Medi-Cal telehealth policy for the duration of the PHE, refer to the
The list below provides the DHCS guidelines for reimbursement of telehealth services:
DHCS notes that the United States Department of Health and Human Services Office of Civil Rights (HHS-OCR) has clarified that it will exercise its enforcement discretion for noncompliance with the regulatory requirements under the Health Insurance Portability and Accountability Act (HIPAA).
The HHS-OCR will not impose penalties against providers who use telehealth in good faith.
The list below provides guidance for remote communication.
DHCS issued telehealth guidance related to DHCS’ Section 1135 Waiver and SPA 20-0024 approvals. The list below provides DHCS guidance to use telehealth.
Well-child visits or regular checkups are an important way to
With California’s stay at home guidance, and federal guidance on non-essential medical procedures, DHCS recognizes that members/ parent caregivers may be cautious about making medical appointments for well-child visits.
As recommended by the American Academy of Pediatrics (AAP)/ Bright Futures, and in accordance with the AAP Periodicity Schedule under the Early and Periodic Screening, Diagnostic, and Treatment benefit, Medi-Cal covers
In light of COVID-19, the AAP has developed guidance on providing pediatric well-care during COVID-19, including guidance on the necessary use of telehealth during the COVID-19 pandemic. (Note:
In accordance with the AAP guidance, and to ensure continued adherence to the Bright Futures guidelines, DHCS encourages MCPs to
To the extent there are components of the comprehensive well-child visit provided in-person (due to those components not being appropriately provided via telehealth) that are a continuation of companion services provided via virtual/ telephonic communication, the provider should only bill for one encounter/ visit. (Note: The Telehealth and Virtual Communications: Payment in FFS and Medi-Cal Managed Care guidance is available on the DHCS COVID-19 Response webpage under Providers & Partners – Guidance for Multiple Provider Types.)
MCPs must approve transportation requests in a timely manner if a member, who may be infected with COVID-19, needs to see a provider in person and requests transportation.
MCPs are responsible for determining the appropriate mode of transportation required to meet the members’ medical needs, paying special attention to those with urgent needs such as
Please refer to DHCS’ “COVID-19 Guidance for Non-Emergency Medical Transportation (NEMT), and Non-Medical for recommendations on safety procedures and protocols to help prevent Transportation (NMT) Providers” for recommendations on safety procedures and protocols to help prevent the spread of COVID-19. (Note:
MCPs must act proactively to ensure member access to needed prescription medications. Proactive steps for MCPs include the following:
In the event of a shortage of any prescription drug, MCPs must waive prior authorization and/ or step therapy requirements if the member’s prescribing provider recommends the member take a different drug to treat the member’s condition.
DHCS has delayed Medi-Cal redetermination processing to ensure members continue to have access to services.
Members with upcoming redetermination dates will not need to start the redetermination process. Members’ redetermination dates will remain the same, and existing managed care members will continue to be enrolled in their MCP.
Reference: For more information about these changes, please refer to the Medi-Cal Eligibility Division which can be found on the DHCS COVID-19 Response webpage Information Letters, under Providers & Partners - Eligibility.
Medi-Cal beneficiaries who have active eligibility with an MCP HOLD status of 59 or 61 in the Medi-Cal Eligibility Data System are not without coverage. These individuals can access services through the Medi-Cal FFS providers.
DHCS reminds MCPs that they must
The list below provides the guidance for EDV.
Based on CMS guidance, DHCS is allowing flexibility for Health Homes Program services to be conducted in a manner that prioritizes the safety of both the providers and the members.
In order to minimize the risk of serious illness due to COVID-19, DHCS encourages MCPs and their contracted Community-Based Care Management Entities to implement telephonic and video call assessments to substitute for face-to-face assessments, in compliance with Medi-Cal’s telehealth policy, as described above.
DHCS is suspending its current in-person visit requirements until the COVID-19 emergency declaration is rescinded.
For any member, newly enrolled in the MCP between December 1, 2019, and the end of the PHE, DHCS is temporarily suspending the requirement to complete an Initial Health Assessment (IHA), as described in the MCP contract with DHCS, within the timeframes outlined in the contract (120 days for most members).
MCPs are permitted to defer the completion of the IHA for these members until the COVID-19 emergency declaration is rescinded. However, DHCS will require the completion of the IHA for these members once the PHE is over.
The list below gives guidance to the Quarterly Monitoring Response Template (QMRT). DHCS
In order to allow MCPs to prioritize their resources on activities related to COVID-19, MCPs will only be required to submit their responses for B-1: Grievances and B-2: SFHs report, until the COVID-19 emergency declaration is rescinded.
MCPs are not required to provide responses on the following components of the QMRT:
If DHCS identifies any areas of concern for other quarterly monitoring components, it will work with the MCPs on an individual basis.
MCPs should direct questions regarding quarterly monitoring to DHCS-PMU@dhcs.ca.gov
DHCS has ceased the timely access survey calls to alleviate burden on provider offices during this critical time.
In order to ease administrative demands on MCPs during the COVID-19 response, DHCS is extending the compliance deadline for the Managed Care Program Data Improvement Project (MCPDIP) from July 1, 2020, to July 1, 2021.
MCPs may begin to submit production data for July 2020 as early as August 1, 2020, consistent with the original project schedule, if they
File and use means that once an MCP submits the documents or scripts to DHCS, the MCP can immediately begin using those documents or scripts with its members, subject to further DHCS directive.
DHCS has approved for MCPs to submit certain documents, including proposed telephone outreach scripts, related to COVID-19 as file and use. All information communicated to members must be information related to COVID-19 that directly came from DHCS, the California Department of Public Health, or the CDC.
In addition, pursuant to HIPAA, the documents or scripts must not contain any Protected Health Information or Personal Information of a member.
If there are any edits or changes that need to be made to those documents or scripts after DHCS completes its review, the MCP must make those edits and changes within a specified number of days, as directed by DHCS.
The following documents and scripts have been approved for file and use:
The table below lists the topic(s) in this part.
|Temporary Reinstatement of Acetaminophen and Cough/ Cold Medicines|
|Temporary Addition of Provider Types at FQHCs and RHCs|
|Long Term Care Reimbursement|
Primary symptoms of COVID-19 involve
The preferred treatments for the symptoms are
These treatments are often the safest, most effective, and least costly alternatives for the population most at risk of both contracting the virus and subsequently experiencing the most severe symptoms.
Therefore, pursuant to SPA 20-0024, DHCS issued guidance on May 13, 2020, regarding the temporary reinstatement of non-legend acetaminophen-containing, and non-legend cough and cold products for adults as covered benefits with the Medi-Cal FFS program.
No prior authorization required
MCPs are required to follow this FFS-issued guidance, including the provision of these over-the-counter drugs without prior authorization.
Pursuant to SPA 20-0024, DHCS issued guidance on May 20, 2020, temporarily adding the services at FQHCs and RHCs as billable visits for
The California Board of Behavioral Sciences (BBS) does not consider ACSWs or AMFTs to be licensed practitioners.
Therefore, licensed behavioral health practitioners must supervise and assume the professional liability of services furnished by the unlicensed ACSW and AMFT practitioners.
The licensed practitioner complies with supervision requirements established by the BBS.
FQHCs or RHCs can be reimbursed in accordance with the terms of the MCP’s contract with the State related to FQHCs and RHCs for a visit between an FQHC or RHC patient and an ACSW or AMFT.
The visit may
Approval of SPA 20-0024 enables DHCS to temporarily provide an additional 10 percent reimbursement for LTC per diem rates, effective March 1, 2020.
Unless otherwise agreed to between the MCP and the LTC provider, DHCS encourages MCPs to reimburse LTC providers at these LTC per diem rates.
On August 20, 2020, the Centers for Medicare and Medicaid Services (CMS) approved State Plan Amendment 20-0025.
The SPA is in accordance with the CMS Interim Final Rule for 42 CFR section 440.30(d) to allow coverage of laboratory tests and x-ray services during the COVID-19 PHE and any future PHE, if the service is to diagnose or detect COVID or the communicable disease named in the PHE.
As stated above, MCPs must adhere to the COVID-19 testing requirements outlined in the COVID-19 Virus and Antibody Testing guidance document.
Reference: For more information , please see the COVID-19 Virus and Antibody Testing guidance document on the DHCS COVID-19 Response webpage under Providers & Partners – Guidance for Multiple Provider Types.
If you have any questions regarding this APL, please contact your MCOD Contract Manager.
Original Signed by Nathan Nau
Nathan Nau, Chief
Managed Care Quality and Monitoring Division