MediCal Managed Care Advisory Group Meeting December 5

Medi-Cal Managed Care Advisory Group Meeting December 5, 2019 Webex Meeting number (access code): 921 844 841 Meeting password: 1111 Join by video system: Dial 921844841@dhcs. webex. com You can also dial 173. 243. 2. 68 and enter your meeting number. Join by phone: +1 -415 -655 -0001 US Toll Access code: 921 844 841

Agenda § § § Welcome and Introductions Cal. AIM Telehealth Policy Medi-Cal Rx RFP Procurement Updates • Transitions and Implementations • Ombudsman Report • Sanctions • Dashboard § APLs and DPLs Update § Open Discussion § Next Meeting – March 12, 2020 12/05/2019 2

Welcome and Introductions 12/05/2019 3

Cal. AIM Jacey Cooper, Senior Advisor, Health Care Programs Michelle Retke, Chief, Managed Care Operations Division Nathan Nau, Chief, Managed Care Quality Monitoring Division Sandra Williams, Chief, Medi-Cal Eligibility Division 12/05/2019 4

Cal. AIM: California Advancing and Innovating Medi-Cal 12/05/2019 5

Cal. AIM • Overview, Goals and Advancing Key Priorities • Review of Cal. AIM Proposals • From Medi-Cal 2020 to Cal. AIM: A Crosswalk • Stakeholder Engagement 12/05/2019 6

Cal. AIM Overview DHCS has developed a comprehensive and ambitious framework for the upcoming waiver renewals that encompasses a broader delivery system, and program and payment reform across the Medi-Cal program, called Cal. AIM: California Advancing and Innovating Medi-Cal. Includes initiatives and reforms for: Medi-Cal Managed Care Behavioral Health Dental Other County Programs and Services 12/05/2019 7

Cal. AIM Overview • Medi-Cal has significantly expanded and changed over the last ten years • Depending on the needs of the beneficiary, some may need to access six or more separate delivery systems • As one would expect, need for care coordination increases with greater system fragmentation, greater clinical complexity, and/or decreased patient capacity for coordinating their own care. 12/05/2019 8

Cal. AIM Overview • Offers solutions to reinforce the stability of the Medi-Cal program and allows the critical successes of waiver demonstrations such as Whole Person Care, the Coordinated Care Initiative, public hospital system delivery transformation, and the coordination and delivery of quality care to continue and be expanded. • Seeks to build upon past successes and improve the entire continuum of care across Medi-Cal, ensuring the system more appropriately manages patients over time through a comprehensive array of health and social services spanning all levels of intensity of care, from birth to end of life. 12/05/2019 9

Cal. AIM Overview Advances several key priorities of the Newsom Administration by leveraging Medi-Cal as a tool to help address many of the complex challenges facing California’s most vulnerable residents, such as: • homelessness, • increasing behavioral health care access, • children with complex medical conditions, • growing number of justice-involved populations who have significant clinical needs, and • growing aging population. 12/05/2019 10

Cal. AIM Goals Cal. AIM has three primary goals: • Identify and manage member risk and need through Whole Person Care approaches and addressing social determinants of health; • Move Medi-Cal to a more consistent and seamless system by reducing complexity and increasing flexibility; and • Improve quality outcomes and drive delivery system transformation through value-based initiatives, modernization of systems and payment reform. 12/05/2019 11

Overview of Cal. AIM Proposals 12/05/2019 12

Identify and Manage Member Risk and Need The following proposals fall under this goal as well as incorporate third goal of improved quality outcomes: • Population Health Management • Enhanced Care Management • Mandatory Medi-Cal Application & Behavioral Health Coordination • In Lieu of Services and Incentives • Mental Health IMD Waiver (SMI/SED) • Full Integration Plans • Long-Term Plan for Foster Care 12/05/2019 13

Population Health Management Medi-Cal managed care plans shall develop and maintain a patient-centered population health strategy, which is a cohesive plan of action for addressing member needs across the continuum of care based on data driven risk stratification, predictive analytics, and standardized assessment processes. The plan shall include, at a minimum, a description of how it will: • Keep all members healthy by focusing on preventive and wellness services; • Identify and assess member risks and needs on an ongoing basis; • Manage member safety and outcomes during transitions, across delivery systems or settings, through effective care coordination; and • Identify and mitigate social determinants of health and reduce health disparities or inequities. 12/05/2019 14

Enhanced Care Management • DHCS proposes to establish a new, statewide enhanced care management benefit effective January 1, 2021. • An enhanced care management benefit would provide a whole-person approach to care that addresses the clinical and non-clinical needs of high-need Medi-Cal beneficiaries. • Enhanced care management is a collaborative and interdisciplinary approach to providing intensive and comprehensive care management services to individuals. • The proposed benefit builds on the current Health Homes Program and Whole Person Care pilots and transitions those pilots to this new statewide benefit to provide a broader platform to build on positive outcomes from those programs. 12/05/2019 15

Enhanced Care Management Target populations include, but are not limited to: • High utilizers with frequent hospital or emergency room visits/admissions; • Individuals at risk for institutionalization with Serious Mental Illness, children with Serious Emotional Disturbance or Substance Use Disorder with co-occurring chronic health conditions; • Individuals at risk for institutionalization, eligible for long-term care; • Nursing facility residents who want to transition to the community; • Children or youth with complex physical, behavioral, developmental and oral health needs (i. e. California Children Services, foster care, youth with Clinical High Risk syndrome or first episode of psychosis); • Individuals transitioning from incarceration; and • Individuals experiencing chronic homelessness or at risk of becoming homeless. 12/05/2019 16

In Lieu of Services • Medi-Cal managed care plans will integrate in lieu of services into their population health management plans – often in combination with the new enhanced care management benefit. • In lieu of services may be focused on addressing combined medical and social determinants of health needs and avoiding higher levels of care. • For example, in lieu of services might be provided as a substitute for, or to avoid, hospital or nursing facility admissions, discharge delays, and emergency department use. 12/05/2019 17

In Lieu of Services DHCS is proposing to cover the following distinct services as in lieu of service under Medi-Cal managed care. Details regarding each proposed set of services are provided in Appendix D of the Cal. AIM proposal. • Housing Transition/Navigation Services • Housing Deposits • Housing Tenancy and Sustaining Services • Short-Term Post-Hospitalization Housing • Recuperative Care (Medical Respite) • Respite • Day Habilitation Programs • Nursing Facility Transition/Diversion to Assisted Living Facilities • Nursing Facility Transition to a Home • Personal Care (beyond In-Home Supportive Services) and Homemaker Services • Environmental Accessibility Adaptations (Home Modifications) • Meals/Medically Tailored Meals • Sobering Centers 12/05/2019 18

Moving Medi-Cal to a Consistent and Seamless System The following proposals fall under this goal as well as incorporate the third goal of improved quality outcomes: • • • Standardize the Managed Care Benefit Standardize Managed Care Enrollment Transition to Statewide MLTSS Annual Medi-Cal Health Plan Open Enrollment NCQA Accreditation of Medi-Cal Managed Care Plans Regional Rates for Medi-Cal Managed Care Behavioral Health Proposals – Payment Reform – Revisions to Medical Necessity – Administrative Integration Statewide – Regional Contracting – SUD Managed Care Renewal (DMC-ODS) Future of Dental Transformation Initiative Reforms Enhancing County Oversight and Monitoring Improving Beneficiary Contact and Demographic Information 12/05/2019 19

Stakeholder Engagement 12/05/2019 20

Stakeholder Engagement Throughout 2019 and 2020, DHCS will conduct extensive stakeholder engagement for both Cal. AIM and the renewal of the 1115 and 1915 b waiver(s). DHCS intends to work with the Administration, Legislature and our other partners on these proposals and recognizes the important need to discuss these issues and their prioritization within the state budget process. These are initial proposals whose implementation will ultimately depend on whether funding is available. 12/05/2019 21

Stakeholder Engagement DHCS is undertaking a robust Cal. AIM workgroup process that will cover key issue areas: • • Population Health Management Enhanced Care Management and In Lieu of Services Behavioral Health National Committee on Quality Assurance (NCQA) accreditation • Full Integration Plans Each Cal. AIM workgroup will be open to the public, so DHCS encourages interested parties to attend and/or submit written comments. Workgroup schedules, agendas, materials, and other Cal. AIM updates will be made available on the Cal. AIM webpage. 12/05/2019 22

Stay Informed Please subscribe to DHCS' stakeholder email service to receive Cal. AIM updates. Listen-in on all workgroup meetings and attend the SAC and BH-SAC meetings. For any other comments, questions, or concerns, please contact Cal. AIM@dhcs. ca. gov. 12/05/2019 23

Discussion 12/05/2019 24

Managed Care Benefit Standardization Nathan Nau, Chief Managed Care Quality and Monitoring Division December 5, 2019 12/05/2019 25

Background • Medi-Cal delivers services through a variety of delivery systems • Medi-Cal Managed Care is under 6 different model types that currently differ based on whether certain benefits are part of the Medi-Cal managed care plan’s (MCP) responsibility or provided through a different delivery system 12/05/2019 26

Proposal • Standardize the benefits that are provided by the MCPs statewide by January 1, 2021 regardless of the MCP beneficiaries are enrolled in or their county of residence. • Proposed Changes: Carved Out Benefits – benefits that are currently within scope of some or all MCPs will be carved out Carved In Benefits – benefits that are currently not within the scope of all MCPs will be carved in to all plans statewide 12/05/2019 27

Carved Out Benefits • Effective January 1, 2021 the following benefits will be carved out of all MCPs: – All prescription drugs and/or pharmacy services billed on a pharmacy claim – Specialty mental health services • Currently carved in for Kaiser in Solano and Sacramento counties – Multipurpose Senior Services Program 12/05/2019 28

Carved Out Benefits (cont. ) • Effective January 1, 2020, Medi-Cal will provide the fabrication of optical lenses statewide through the fee -for-service system – Currently Cen. Cal Health and Health Plan of San Mateo provide these services 12/05/2019 29

Carved In Benefits • Effective January 1, 2021 the following benefits will be carved in for all MCPs: – All institutional long-term care service • skilled nursing facilities, pediatric/adult subacute care, intermediate care facilities for individuals with developmental, disabilities, disabled/habilitative/nursing services, specialized rehabilitation in a skilled nursing facility or intermediate care facilities – All major organ transplants – These services, which are currently carved out, will be carved in for all MCPs 12/05/2019 30

Program Benefits • Beneficiaries will no longer have to deal with the confusion that may arise when moving counties/plans; and • DHCS will be able to move to a regional rate setting process that will reduce the number of rates being developed. 12/05/2019 31

Timeline • January 1, 2020: Fabrication of optical lenses statewide. • January 1, 2021: Carved out benefits (Pharmacy drugs and/or services, specialty mental health services, and MSSP). Carved in benefits (institutional long-term care services and all major organ transplants). 12/05/2019 32

Questions? 12/05/2019 33

Mandatory Managed Care Enrollment Michelle Retke, Chief Managed Care Operations Division December 5, 2019 12/05/2019 34

Background • Medi-Cal provides benefits through both a fee-for-service and managed care delivery system. • Enrollment into the fee-for-service delivery system or the managed care delivery system is based upon specific geographic areas, the health plan model, and/or the aid code that the beneficiary is determined to qualify for. 12/05/2019 35

Proposal • Standardize mandatory managed care enrollment verses mandatory fee-for-service enrollment, across all models of care and aid code groups, statewide. • Beneficiaries in a voluntary or excluded from managed care enrollment aid code that are currently accessing the fee-for-service delivery system, would be required to choose a Medi-Cal managed care plan and will not be permitted to remain in fee-for-service. 12/05/2019 36

Mandatory Managed Care Enrollment Populations • Individuals eligible for long-term care services (includes long -term care share of cost populations) • Trafficking and Crime Victims Assistance Program (except share of cost) • Individuals participating in accelerated enrollment • Child Health and Disability Prevention infant deeming • Pregnancy-related Medi-Cal (Pregnant Women only, 138213% citizen/lawfully present) • American Indians • Beneficiaries with other health care coverage • Beneficiaries living in rural zip codes • All dual aid code groups, except share of cost or restricted scope, will be mandatory Medi-Cal managed care, in all models of care starting in 2023 12/05/2019 37

Mandatory Fee-for-Service Enrollment • Omnibus Budget Reconciliation Act: This population was previously mandatory managed care in Napa, Solano, and Yolo counties. • Share of cost: beneficiaries in County organized health systems (COHS) and Coordinated Care Initiative counties • Beneficiaries in the following aid code groups will have mandatory fee-for-service enrollment: Restricted scope Share of cost (including Trafficking and Crime Victims Assistance Program share of cost, excluding long-term care share of cost) Presumptive eligibility State medical parole, County compassionate release, and incarcerated individuals Non-citizen pregnancy-related aid codes enrolled in Medi-Cal (not including Medi-Cal Access Infant Program enrollees. 12/05/2019 38

Program Benefits • Reduce the complexity of the varying models of care delivery in California. • Populations moving between counties will have the same experience when receiving services. • Allow for Medi-Cal managed care plans to provide more coordinated and integrated care. • DHCS will be able to move to a regional rate setting process that will reduce the number of rates being developed. 12/05/2019 39

Timeline • Implementation in two phases: January 1, 2021: Non-Dual and pregnancy related aid code group, and population based transitions January 1, 2023: Dual aid code group transition (discontinuation of the Cal Medi. Connect Coordinated Care Initiative) 12/05/2019 40

Questions? 12/05/2019 41

Medi-Cal: Telehealth Policy Presented by: Cynthia Smiley, Chief Benefits Division 12/05/2019 42

History of Telehealth in Medi-Cal § DHCS began reimbursing for services delivered via telehealth, pursuant to the Telemedicine Development Act of 1996. § Telehealth is a modality to deliver health care services via information technology. § DHCS’ policy originally included the following components: o A list of services and/or benefits appropriate for delivery via telehealth. o Limitations on originating and distant sites. o Modifiers required for payment. o Same payment as for in-person visits. § Recognizing the rapid advances in information technology and desire to ensure Medi-Cal telehealth policy more closely aligned with industry best practices, DHCS began the internal process of clarifying and refining its existing policy in 2017. 12/05/2019 43

Stakeholder Engagement & Feedback § Allow the home to be an originating site § Expand telehealth to match or exceed what Medicare currently covers § Expand access to specific benefits or services § Support for adding E-Consults § Support for telehealth services in emergency rooms, skilled nursing facilities, and inpatient settings § Support for adding Remote Patient Monitoring for chronic conditions 12/05/2019 44

DHCS’ Revised Policy § Establishes a uniform, standardized approach to telehealth in Medi-Cal. § Clarifies that Medi-Cal providers have flexibility to use telehealth as a modality for delivering medically necessary services to their patients. § Affords Medi-Cal providers flexibility to determine if a particular service or benefit is clinically appropriate for telehealth. The policy no longer provides a specific list of services that may be provided via telehealth. § Places no limitations on originating and/or distant sites. § Authorizes E-Consults under the auspices of store and forward. 12/05/2019 45

DHCS’ Revised Policy (Cont. ) § Clarifies when consent is required and who is responsible for maintaining documentation of consent, consistent with applicable state law requirements. § Clarifies that both written and verbal consent is appropriate. § Provides use-friendly references to other sections of the Medi-Cal Provider Manual, including but not limited to, unique policy for Federally Qualified Health Centers, Rural Health Clinics, and Indian Health Services. 12/05/2019 46

DHCS’ Revised Policy (Cont. ) § Defines that a Medi-Cal provider rendering telehealth services must meet licensing requirements of Business & Professions (B&P) Code Section 2290. 5(a)(3) or equivalent requirements under California law in which the provider is considered to be licensed. § Implements Place of Service Code 02 and modifier 95 for services delivered via telehealth. § Does not include policy to address Remote Patient Monitoring. 12/05/2019 47

Telehealth Going Forward § Recently signed bills: § AB 1494, Aguiar-Curry, Chapter 829, Statutes of 2019 § Added Welfare & Institutions (W & I) Code Sections 14132. 723 and 14132. 724 to enable telehealth services during or immediately following a Governor-declared state of emergency. § Prohibits DHCS from requiring face-to-face contact or a patient’s physical presence on the premises of an enrolled community clinic, during or immediately following a Governordeclared state of emergency. § Permits Medi-Cal reimbursement for telehealth services, telephonic services, and all covered services delivered by an enrolled community clinic or other FFS provider if the services are provided somewhere other than the clinic premises. § DHCS must issue, on or before July 1, 2020, provider guidance to facilitate reimbursement for the services described in the bill. 12/05/2019 48

Telehealth Going Forward (Cont. ) § Recently signed bills, continued: § AB 744, Aguiar-Curry, Chapter 867, Statutes of 2019 § Made various changes in state statutes to update telehealth coverage requirements, including changes within the Medi-Cal program, via amendments to Welfare and Institutions Code, Section 14132. 725. § Broadened statute that allowed Medi-Cal reimbursement for teleophthalmology, teledermatology, and teledentistry to allow Medi-Cal reimbursement for any health care service appropriately provided by store and forward, subject to DHCS policies. § Amended B & P Code, Section 2290. 5 to add a qualified autism service provider or qualified autism service professional as a health care provider for telehealth services. 12/05/2019 49

Telehealth Going Forward (Cont. ) § DHCS is committed to continuing to explore opportunities for innovation and advancement in telehealth services. § DHCS will continue to actively monitor and assess applicable federal guidance, as well as public and private sector industry best practices to drive policy development. § DHCS values and encourages ongoing stakeholder engagement and participation to further inform policy development. 12/05/2019 50

Additional Information For more information regarding Medi-Cal’s telehealth policy, please visit our website at Medi-Cal & Telehealth For general questions, please feel free to submit those via email to DHCS-Benefits@dhcs. ca. gov 12/05/2019 51

Thank you from DHCS! Questions? 12/05/2019 52

Medi-Cal Rx Transitioning Medi-Cal Pharmacy Services from Managed Care to Fee-For-Service Presented by: Harry Hendrix, Jr. , Chief Pharmacy Benefits Division Department of Health Care Services 12/05/2019 53

Executive Order (EO) N-01 -19 Overview § The Governor issued EO N-01 -19, which, in part, requires that all Medi-Cal pharmacy services be transitioned from MC to FFS by January 1, 2021 (collectively referred to as “Medi-Cal Rx”). § Medi-Cal Rx will, among other things: o Standardize the Medi-Cal pharmacy benefit statewide, under one delivery system. o Improve access to pharmacy services with a pharmacy network that includes an overwhelming majority of the state’s pharmacies. o Apply statewide UM protocols to all outpatient drugs. o Strengthen California’s ability to negotiate state supplemental drug rebates with drug manufacturers. 12/05/2019 54

Medi-Cal Rx: What managed care entities does it impact? § Medi-Cal Rx will impact all Medi-Cal Managed Care Plans (MCPs), including SCAN and AIDS Healthcare Foundation § Medi-Cal Rx will not apply to PACE plans 12/05/2019 55

Medi-Cal Rx: What Medi-Cal Pharmacy Services Does it Apply to? § Medi-Cal Rx applies to all pharmacy services billed on pharmacy claims, including but not limited to: o Outpatient drugs (prescription and over-thecounter), including Physician Administered Drugs o Enteral Nutrition Products o Medical Supplies § Medi-Cal Rx does not apply to pharmacy services billed on medical/institutional claims. 12/05/2019 56

Medi-Cal Rx: Pre- and Post-Transition Pharmacy Claims Processing Please Note: This transition applies to all drugs currently “carved-out” of managed care delivery system (i. e. , HIV/AIDS, Blood Factors, Anti-Psychotics, drugs used to treat substance use disorders). As of January 1, 2021, no MCPs will be responsible for covering these drugs, and will be available only through the FFS delivery system. 57

Medi-Cal Rx: What is not changing? § Medi-Cal Rx will not change: o The scope of the existing Medi-Cal pharmacy benefit o Provision of pharmacy services in an inpatient or longterm care setting, regardless of delivery system o Existing Medi-Cal managed care pharmacy carve-outs (e. g. , blood factor, HIV/AIDS drugs, antipsychotics, or drugs used to treat substance use disorder) o The State Fair Hearing process 12/05/2019 58

Request For Proposal (RFP) #19 -96125 § To effectuate EO N-01 -19, on August 22, 2019, DHCS released RFP #19 -96125, for the takeover, operation, and eventual turnover of administration of Medi-Cal Rx. § DHCS released a Notice of Intent to Award November 7, 2019. For more information, please visit the FI$Cal/Cal e. Procure website § Questions regarding this RFP should be submitted via email to: CSBRFP 1@dhcs. ca. gov 12/05/2019 59

Post-Transition Responsibilities: DHCS § Maintain Medi-Cal pharmacy policy, including but not limited to drug coverage, rebate, and utilization management § Make final determination of prior authorization (PA) denials and retain state fair hearings § Negotiation of, and policy related to, contracting of state supplemental drug rebates § Establishing pharmacy reimbursement methodologies § Establishing and maintaining the Medi-Cal pharmacy provider network 12/05/2019 60

Post-Transition Responsibilities: Medi-Cal Rx Contractor § Claims administration, processing, and payment § Coordination of benefits with other health coverage, including Medicare § Utilization Management (UM), including ensuring all prior authorization (PA) adjudication within 24 hours (note: all PA denials will require DHCS review prior to final determination) § Prospective and Retrospective Drug Utilization Review (DUR) services § Drug rebate administration services, which are compliant with federal and state laws, and adhere to DHCS policies and direction 12/05/2019 61

Post-Transition Responsibilities: Medi-Cal Rx Contractor (Cont. ) § Provide beneficiary and provider supports, including 24/7/365 Customer Service Center to support all provider and beneficiary calls, as well as outreach, training, and informing materials § Provide to Medi-Cal providers and plan partners realtime data access (through electronic database/portal), and daily data feeds for the purposes of coordinating care § Provide direct plan partner liaisons to assist with care coordination and clinical issues 12/05/2019 62

Post-Transition Responsibilities: Medi-Cal Plan Partners § § Maintain beneficiary care coordination Oversee clinical aspects of pharmacy adherence Provide disease and medication management Processing and payment of all pharmacy services billed on medical and institutional claims § Participation on the Medi-Cal Global Drug Utilization Review (DUR) Board and other DHCS pharmacy committees 12/05/2019 63

Medi-Cal Rx Policy Considerations § DHCS is currently exploring options for potential statutory and/or policy changes in the following areas: o Removal of the existing Medi-Cal FFS drug prescription co-pay ($1 dollar) in state law. o Removal of the existing monthly six prescription limit in state law. o Creating policy to allow multi-year prior authorizations (PA) for certain disease conditions/classes of drugs based upon established and documented clinical criteria. o Implementing enhanced and/or expanded auto-adjudication functionalities related to PA. o Implementing enhancing existing opioid management tools, depending on the Proposals received as part of the procurement process. o Implementing pharmacy lock-in programs, depending on the Proposals received as part of the procurement process. 12/05/2019 64

DHCS’ Managed Care Plan (MCP) Engagement § DHCS is committed to working closely with MCPs to ensure a smooth and successful transition and implementation of Medi-Cal Rx. § DHCS has established a regularly occurring meeting with the health plan associations and a subgroup of MCPs to discuss topics including, but not limited to the scope of Medi-Cal Rx, clinical pharmacy services, care coordination and integration, as well as data and reporting needs. o There have been three meetings to date, with the next scheduled for December 16 th. o Additional meetings are scheduled for approximately every three weeks. 12/05/2019 65

DHCS’ Ongoing Commitment to Stakeholder Engagement § DHCS is committed to working with its external partners (including but not limited to, MCPs, counties, providers, Tribal Health programs, consumer advocates and beneficiaries) to ensure a smooth and successful transition and implementation of Medi-Cal Rx through the following: o Publicly releasing for comment various Medi-Cal Rx draft informing materials (e. g. , provider and beneficiary notices, All Plan Letters, etc. ). o Ensuring MCPs, counties, providers, consumer advocates and beneficiaries receive timely and accurate information relating to the transition and associated implementation activities. o Providing status updates and gathering stakeholder feedback through various DHCS sponsored public meetings. 12/05/2019 66

DHCS Medi-Cal Rx Advisory Workgroup Starting January 2020 and continuing through April 2021, DHCS will conduct seven (7) in-person, targeted meetings to help facilitate more effective and informative stakeholder engagement and collaboration around Medi. Cal Rx. § Meetings will each be approximately four (4) hours in length and held in Sacramento. § Workgroup membership will be limited (less than 30 members) to ensure a collaborative and productive discussion environment, and will be comprised of organizations and entities such as hospitals, clinics, health plans, counties, pharmacies, tribal health programs, and consumer advocates. 12/05/2019 67

DHCS Medi-Cal Rx Advisory Workgroup (cont. ) During the Medi-Cal Rx Advisory Workgroup, DHCS will provide updates on the pharmacy transition, and lead targeted discussions on the following topics: § Roles and responsibilities between DHCS, the Medi. Cal Rx Contractor, and Medi-Cal Managed Care Plans § DHCS’ implementation strategies, tools, and timelines, including but not limited to, provider education and outreach and beneficiary notifications § Medi-Cal pharmacy policy development, which will include the scope of carve out, prior authorization, and utilization management protocols § Changes to existing Medi-Cal pharmacy committees 12/05/2019 68

DHCS Medi-Cal Rx Advisory Workgroup Meeting Dates § § § § January 14, 2020 (Tuesday 9: 00 am – 1: 00 pm) March 18, 2020 (Wednesday 1: 00 – 5: 00 pm) May 27, 2020 (Wednesday 1: 00 – 5: 00 pm) July 29, 2020 (Wednesday 1: 00 – 5: 00 pm) October 21, 2020 (Wednesday 1: 00 – 5: 00 pm) February XX, 2021 (X) TBD April XX, 2021 (X) TBD 12/05/2019 69

DHCS Medi-Cal Rx Public Forums Throughout calendar years 2020 and 2021, DHCS will host several larger Medi-Cal Rx Public Forums via webinar and in-person meetings to ensure the broader stakeholder community is up-to-speed with Medi-Cal Rx implementation activities and timelines. § DHCS will post information regarding the dates and time for the Medi-Cal Rx Public Forums as those become available and release reminder notices through various DHCS stakeholder email distribution lists. 12/05/2019 70

DHCS Medi-Cal Rx Public Forums Dates • February 18, 2020 (Tuesday 2: 00 – 3: 00 pm) • June 17, 2020 (Wednesday 2: 00 – 3: 00 pm) • December 9, 2020 (Wednesday 2: 00 – 3: 00 pm) 12/05/2019 71

Additional Information § For more information about Medi-Cal Rx, including Frequently Asked Questions, please visit DHCS’ dedicated Medi-Cal Rx website: Medi-Cal Rx: Transition § For questions and/or comments regarding Medi. Cal Rx, please submit those via email to Rx. Carve. Out@dhcs. ca. gov 12/05/2019 72

RFP Procurement Michelle Retke, Chief, Managed Care Operations Divisions 12/05/2019 73

Updates • • Transitions and Implementations Ombudsman Report Sanctions Dashboard 12/05/2019 74

APLs and DPLs Update 12/05/2019 75

MEDI-CAL MANAGED CARE HEALTH PLAN LETTERS ISSUED SINCE THE SEPTEMBER 2019 MANAGED CARE ADVISORY GROUP MEETING ALL PLAN LETTERS (APLS) Letter Number Title and Description of Letter Date of Issue Telehealth Services Policy APL 19 -009 (REVISED) 12/05/2019 This APL revision clarifies that providers with no fee-for-service Medi-Cal enrollment pathway do not need to enroll with the Revised: Department of Health Care Services (DHCS) 10/16/2019 in order to provide services via telehealth. Specifically, behavioral analysts do not need to enroll in Medi-Cal to provide services via telehealth. 76

MEDI-CAL MANAGED CARE HEALTH PLAN LETTERS ISSUED SINCE THE SEPTEMBER 2019 MANAGED CARE ADVISORY GROUP MEETING ALL PLAN LETTERS (APLS) Letter Number Title and Description of Letter Health Education and Cultural and Linguistic Population Needs Assessment This APL updates and clarifies the Health Education and Cultural and Linguistic Population Needs Assessment (PNA) requirements for Medi. APL 19 -011 Cal managed care health plans (MCPs). The PNA (SUPERSEDES was formerly referred to as the Group Needs Assessment, or GNA. The APL clarifies the format APL 17 -002) of the annual PNA submittal by MCPs and updates PNA requirements, including the requirements to: 12/05/2019 Date of Issue 9/30/2019 77

MEDI-CAL MANAGED CARE HEALTH PLAN LETTERS ISSUED SINCE THE SEPTEMBER 2019 MANAGED CARE ADVISORY GROUP MEETING ALL PLAN LETTERS (APLS) Letter Number Title and Description of Letter Health Education and Cultural and Linguistic Population Needs Assessment (cont. ) 1. Utilize MCP-specific health disparities data from the Consumer Assessment of Healthcare APL 19 -011 Providers and Systems (CAHPS)® survey as part of (SUPERSEDES the PNA, and 2. Annually adjust the action plan that addresses APL 17 -002) identified member needs and health disparities through targeted health education, cultural and linguistic, and quality improvement strategies. 12/05/2019 Date of Issue 9/30/2019 78

MEDI-CAL MANAGED CARE HEALTH PLAN LETTERS ISSUED SINCE THE SEPTEMBER 2019 MANAGED CARE ADVISORY GROUP MEETING ALL PLAN LETTERS (APLS) Letter Number Title and Description of Letter Date of Issue Federal Drug Utilization Review Requirements Designed to Reduce Opioid Related Fraud, Misuse and Abuse APL 19 -012 (REVISED) 12/05/2019 This APL revision provides an extension for MCPs to submit policies and procedures for the DUR minimum requirements. DHCS extended the submission date from December 31, 2019, to April 1, 2020. Revised: 11/15/2019 79

MEDI-CAL MANAGED CARE HEALTH PLAN LETTERS ISSUED SINCE THE SEPTEMBER 2019 MANAGED CARE ADVISORY GROUP MEETING ALL PLAN LETTERS (APLS) Letter Number Title and Description of Letter Date of Issue Proposition 56 Hyde Reimbursement Requirements for Specified Services APL 19 -013 12/05/2019 This APL provides MCPs with information on required payments from Proposition 56 funds for the provision of specified state-supported 10/17/2019 medical pregnancy termination services. The APL includes information regarding the amount of payments, the timing of payments, the specified CPT-4 codes, and other administrative obligations 80

MEDI-CAL MANAGED CARE HEALTH PLAN LETTERS ISSUED SINCE THE SEPTEMBER 2019 MANAGED CARE ADVISORY GROUP MEETING ALL PLAN LETTERS (APLS) Letter Number Title and Description of Letter Date of Issue Responsibilities for Behavioral Health Treatment Coverage for Members Under the Age of 21 (cont. ) The APL clarifies that MCPs must provide any BHT service if it is determined that these services are medically necessary using the APL 19 -014 EPSDT medical necessity standard (Welfare 11/12/2019 (SUPERSEDES and Institutions Code section 14059. 5) to APL 18 -006) correct or ameliorate the child’s condition. This applies to children diagnosed with Autism Spectrum Disorder as well as children for whom a licensed physician, surgeon, or psychologist has determined BHT services to be medically necessary. 12/05/2019 81

Open Discussion Next Meeting is scheduled on March 12, 2020 For questions, comments or to request future agenda items please email advisorygroup@dhcs. ca. gov. 12/05/2019 82