Medi-Cal Managed Care Network Adequacy Requirements

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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)

CalFresh changes to reporting requirements

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CDSS has provided implementing instructions for changes to federal regulations regarding reporting requirements.  For periodic reporting, any increase in unearned income that is less than $100 will be disregarded.  All unearned income increases must still be reported on the SAR 7 form.  However, any unearned income increases that is less than $100 reported on the SAR 7 will be disregarded.  In the future, the amount of unearned income increase that is disregarded will be adjusted annually and will be rounded to the nearest $25.

For mandatory mid-period reports, income increases over the Income Reporting Threshold (IRT) must be reported within 10 days of receipt of the first payment attributable to the change, that is, the first payment that places the household over the IRT.  For mandatory mid-period reporting of a drop in ABAWD work hours below 20 hours per week, the household must report within 10 days of the date the drop in ABAWD work hours becomes known to the household.

Federal regulations now specify that counties must send a reminder notice to households that do not submit a complete SAR 7 form by the filing date.  If a household fails to submit a complete SAR 7 report by the 5th of the month, the county must provide a reminder notice advising that household that it has 10 days to submit a complete SAR 7.  This includes failure to submit a SAR 7 at all and submitting a SAR 7 by the due date but the SAR 7 is missing required information.  CDSS developed a new reminder notice for this purpose.  If the household does not respond within 10 days, the county will send the appropriate notice of action.  (ACL 18-18, February 16, 2018.)

Expiration of indigence exception for CAPI

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CDSS has provided clarification about the process for renewal of an indigence exception in the Cash Assistance Program for Immigrants (CAPI) program.  For CAPI, if an immigrant’s sponsor has signed the New Affidavit of Support (I-864 form), the sponsor’s income and resources are deemed to the immigrant for 10 years (extended CAPI cases).  If the sponsor becomes disabled, deeming continues indefinitely (basic CAPI cases).  Counties determine the sponsor’s income and resources using the SOC 860 form.  Sponsor deeming can be suspended under the indigence exception.  When the immigrant is no longer being provided with support by their sponsor, and as a result the immigrant is no longer able to provide themselves with food and shelter, the immigrant may be eligible for the indigence exception to sponsor deeming.

The indigence exception applies 12 months after it is granted.  After 12 months, the application for the indigence exception must be completely redone.  CDSS recommends that the CAPI redetermination process begin no later than 10 months after the previous redetermination to have enough time to receive the redetermination paperwork.

For renewal of the indigence exception, the recipient must complete the SOC 809 CAPI Indigence Exception Statement.  The sponsor must complete the SOC 860 form.  The county must then complete the SOC 813 CAPI Indigence Exception Determination form.

The SOC 860 sponsor income and resources form must be redone at each annual redetermination, regardless of whether the recipient requests the indigence exception unless the sponsor’s whereabouts are unknown.  The form is sent to the sponsor and the recipient.  If it is not returned, CAPI is suspended and benefits stopped.  (ACL 17-33, summarized here.)[1]

The initial clarification incorrectly stated that counties could redetermine the indigence exception if the county becomes aware of a change in circumstances.  In fact, the CAPI indigence exception applies for a full 12 month period.  CDSS issued an errata correcting this error.  (ACL 17-70, July 21, 2017 and ACL 17-70E, December 21, 2017.)

[1] Two lawsuits have been filed challenging the policy in ACL 17-33 to suspend CAPI benefits if the sponsor does not return the SOC 860 form.

CalFresh Maximum Certification Periods

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CDSS has provided information about amendments to Welfare and Institutions Code Section 18910.1 that requires counties to assign the maximum certification period allowable for the household type.  The maximum certification period is generally 12 months.  Households in which all adult members are elderly or disabled are certified for 24 months.  Households with only elderly and/or disabled members with no earned income are assigned a 36 month certification period.

Any determination of a certification shorter than 12 months should be made on a case-by-case basis.  (ACL 17-101, December 22, 2017.)

Eligible foods for SNAP purchases

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The United States Department of Agriculture Food and Nutrition Service (FNS) has issued policy about which foods are eligible for purchase with Supplemental Nutrition Assistance Program (SNAP, known as CalFresh in California) benefits.

In general, food items intended for human consumption are eligible for purchase with SNAP.  This includes cooking ingredients normally consumed only after being incorporated into food with other ingredients, vegetable products imparting flavor to food and items not labeled as food such as water and ice.

Certain non-food items can also be purchased with SNAP including

  • garden seeds and plants used to produce food for human consumption
  • military commissary surcharges
  • container deposits under state law
  • sales tax only if it is included in the shelf price of an eligible item.

Items excluded from purchase with SNAP include:

  • alcohol
  • tobacco and nicotine delivery products
  • hot food, which is defined as foods and beverages that are hot at the point of sale
  • prepared food intended for on-premises consumption, but prepared food intended for off-premises consumption is eligible as long it is not hot at the point of sale
  • firearms, ammunition and explosives
  • medicines and dietary supplements; live animals, except for shellfish
  • fish as long as they are removed from water prior to removal from the sales premises, and other animals live at the point-of-sale if they are slaughtered prior to removal from the premises
  • gift baskets if the value of non-food items is over half of the purchase price
  • non-food items
  • fees, including retailer fees for the delivery of food and grocery bag fees
  • sales tax unless it is included in the shelf price of an item.

(RPMD Policy Memorandum 2018-2, January 16, 2018.)