Beginning July 1, 2018, all Medi-Cal managed care plans (MCPs) will be required to submit annual network certifications in addition to continuing requirements for reporting significant changes to their networks.

MCPs must confirm that their networks will meet the anticipated needs of their service areas.  This means that plans must maintain a provider network adequate to serve their service areas.  DHCS requires network capacity adequate to serve 60% of all eligible beneficiaries in the service areas of county/two-plan model plans, 60% of geographic managed care plans, and 100% of county-organized health system plans.  MCPs must also meet FTE provider-to-beneficiary ratios of 1 FTE PCP to every 2000 beneficiaries, and 1 FTE network physician to every 1200 beneficiaries.

MCP provider networks must include FTE adult and pediatric PCPs, FTE adult and pediatric core specialists, mental health providers, hospitals, pharmacies, and ancillary services.  MCPs must also include at least one FQHC, one rural health clinic, and one freestanding birth center, where available in the contracted service area.  Plans must also meet requirements regarding midwifery, Indian Health Facilities, and Behavioral Health Treatment.

Effective July 1, 2018, DHCS has also established time and distance standards based on county population density.  These standards apply to primary and specialty care for adults and children, OB/GYN services, hospitals, pharmacy, and mental health services.  Primary care and mental health outpatient services should be offered within 10 business days of request, while specialty care appointments should be offered within 15 business days of request.  Primary care, hospital, and pharmacy sites must be located within 10 miles or 30 minutes of a beneficiary’s residence regardless of county; time and distance standards vary by county density designation.

Plans may use telehealth and mail order pharmacies to meet network adequacy requirements, but plans may not require use of either in place of in-person services.  Plans may also subcontract, but subcontractors must have an adequate provider network.

Dental managed care plans also must meet DHCS-required network adequacy standards.  Primary care dental appointments must be located 10 miles or 30 minutes from a beneficiary’s residence.  Routine appointments must be provided within 4 weeks of request, while specialty dental services must be scheduled within 30 business days of request for adults and 30 calendar days of request for children.  Emergency appointments must be available within 24 hours from the request for appointment.

DHCS APL 18-005 (February 16, 2018)

DHCS APL 18-005 Attachment A

DHCS Dental APL 18-003 (January 9, 2018)

DHCS Dental APL 17-008 (November 8, 2017)

Voluntary inpatient detoxification (VID) services are a Medi-Cal benefit carved out of managed care and covered through Medi-Cal fee for service.  To be eligible, inpatient detoxification must be the primary reason for voluntary admission.  DHCS’s All Plan Letter sets out medical criteria for inpatient admission for VID.

When a managed care plan sees a member who does not meet the medical necessity criteria, the plan should refer the member to the county’s behavioral health department for referral to other medically necessary substance use disorder treatment services.  Plans must also provide care coordination to ensure appropriate referrals to available services.

To receive VID services, plans must refer members to VID service providers in general acute care hospitals.  The VID service provider must submit a TAR to a local Medi-Cal field office with documentation verifying admission criteria and medical necessity.

DHCS APL 18-001 (January 11, 2018).

SB 1339 codified the Medi-Cal Intercounty Transfer (ICT) process, effective June 1, 2017.  Medi-Cal beneficiaries must notify either the county they are leaving (sending county) or the county to which they are moving (receiving county) of a change in residence.  Once this happens, it is the responsibility of the notified county to initiate an ICT for all public benefits within seven business days of notice of new residence.

The bill prohibits counties from requiring the beneficiary to reapply for Medi-Cal benefits in the receiving county.  Benefits must continue without interruption during the ICT process.  The ICT must be completed no later than the first day of the next available benefit month following the 30 days after the beneficiary’s initial notification of change in residence.

If a beneficiary moves and is still enrolled in a managed care plan from the sending county, the beneficiary should continue to have access to emergency services and authorized out-of-network coverage until the ICT is processed and the beneficiary is disenrolled from the plan.  If the beneficiary needs non-emergency care the same month in the new county, the Medi-Cal Managed Care Ombudsman should disenroll the beneficiary from the plan on an expedited basis.  Changes requested by phone to the Ombudsman will be effective within two business days of processing the request.

If an individual household member moves out of the county, Medi-Cal eligibility must continue uninterrupted.  For short-term changes, counties can update the address; this does not initiate an ICT.  If an individual beneficiary moves to a new county but continues to be claimed as a member of a tax household in their former county, the county will update the individual’s address only.  This is not considered an ICT, but the individual will be able to enroll in a health plan in the new county while remaining in the existing case.

DHCS ACWDL 18-02 (January 11, 2018).

Effective January 1, 2018, the community spouse resource allocation (CSRA) under the Medicare Catastrophic Coverage Act has been increased to $123,600.  The minimum monthly maintenance needs allowance (MMMNA) has also been increased to $3090 per month.

DHCS ACWDL 17-40 (December 29, 2017).