Provider Alerts

Effective January 1, 2027, Medi-Cal Managed Care Plan (MCP) members with unsatisfactory immigration status (UIS) will transition to the Medi-Cal Fee-for-Service (FFS) delivery system.

As further outlined below, Enhanced Care Management (ECM), California Integrated Care Management (CICM), Community Supports, Complex Care Management (CCM), Transitional Care Services (TCS), and Community Health Worker (CHW) service providers that have agreements with Health Plan or our affiliated Dual Eligible Special Needs Plan [D-SNP], , including Network Provider Agreements, Subcontractor or Downstream Subcontractor Agreements, are required to actively support transitioning members to facilitate a smooth transition for providers and their patients. The Department of Health Care Services (DHCS) is providing the following important information regarding provider enrollment, billing, and requirements for ongoing care responsibilities.

ECM, CICM, Community Supports, CCM, TCS, and CHW Services:
MCPs (or in the case of CICM, their affiliated D-SNPs) are required to continue authorizing, providing, and paying for ECM, CICM, Community Supports, CCM, TCS and CHW services for all eligible members with UIS through December 31, 2026. While ECM, CICM, Community Supports, CCM, and TCS services will no longer be available to transitioned members in Medi-Cal FFS, CHW services will continue to remain available to transitioned members after January 1, 2027. Since transitioned members in Medi-Cal FFS will no longer have access to ECM, CICM, Community Supports, CCM, and TCS services, there may be increased needs for CHW services.

Steps Providers of ECM, CICM, Community Supports, CCM, TCS, and CHW Services Can Take to Start or Continue Serving Transitioning Members:
This transition creates a significant opportunity for Providers to begin serving Medi-Cal FFS members or to expand their existing participation.

Enrolling in Medi-Cal FFS
Interested Providers must be enrolled in Medi-Cal FFS by January 1, 2027, to begin or continue serving Medi-Cal members transitioned to Medi-Cal FFS. In order to receive reimbursement at Medi-Cal FFS rates for services provided, unenrolled providers must complete an enrollment application with the DHCS Provider Enrollment Division (PED) through the Provider Application and Validation for Enrollment (PAVE) portal. For more information on PAVE enrollment, please visit https://www.dhcs.ca.gov/providers-partners/providerapplication-and-validation-for-enrollment.

Providing Medi-Cal FFS Care Management Services
Certain care management, care coordination, or case management services, as well as CHW services are available for coverage and reimbursement when billed in accordance with Medi-Cal coverage policy by eligible providers. Claims for CHW services must be submitted by an enrolled Medi-Cal supervising provider. DHCS plans to provide links and/or a resource document that includes the available codes for billing purposes under Medi-Cal FFS. The resource will include lists of potential codes with links to the appropriate Provider Manual that includes details on billing guidance. Becoming CHW Service Providers (for Providers of ECM, CICM, Community Supports, CCM, and TCS Services) CHW services remain available in Medi-Cal FFS and providers who meet all Medi-Cal provider requirements for an allowable supervising provider type, as outlined in Medi-Cal policy, may enroll to supervise and bill on behalf of CHWs for Medi-Cal FFS CHW services.

Please refer to the DHCS CHW website at https://www.dhcs.ca.gov/providerspartners/community-health-workers/ for more information on becoming a CHW and information on supervising providers. Questions may be sent to CHWBenefit@dhcs.ca.gov.

Requirements for ECM, CICM, CCM, TCS, and CHW Provider Care Coordination with Transitioning Members prior to January 1, 2027:
ECM, CICM, CCM, TCS, and CHW Providers that have agreements with Health Plan (or our affiliated D-SNP), including Network Provider Agreements, Subcontractor or Downstream Subcontractor Agreements, must conduct transition planning and care coordination for members with UIS prior to January 1, 2027. Required activities include, but are not limited to:

• Coordinate with members’ PCPs, other care management service providers, behavioral health providers, county agencies, social service agencies, and community-based organizations to minimize disruptions in services prior to the transition.
• Verify whether members’ current providers can and are willing to continue to provide services in the Medi-Cal FFS delivery system. In instances that provider transition is needed, care management providers must identify alternative providers available to members post-transition within the Medi-Cal FFS delivery system using tools including, but not limited to, the DHCS Medi-Cal Fee-for-Service Provider Finder App at https://data.chhs.ca.gov/dataset/profile-of-enrolled-medi-cal-fee-forservice-ffs-providers/resource/73bf2a5a-27a3-43f5-9db0-42e56dd0f432 or https://www.dhcs.ca.gov/medi-cal/find-care/.
• Assess whether members may qualify for other available Medi-Cal FFS services, including Chronic Care Management, behavioral health services, home and community-based services, county-based programs, or other supports available under Medi-Cal FFS or local delivery systems.

Once new providers who will be receiving transitioning Members are identified, current ECM, CICM, CCM, TCS, and CHW Providers must transmit member assessments and care management plans, ensuring compliance with all required data privacy and confidentiality safeguards, to the appropriate MediCal FFS delivery system providers. If the receiving Medi-Cal FFS provider is able to accept a warm handoff, current and future care management providers must complete that handoff as soon as possible, but no later than December 31, 2026. The receiving provider will not be able to receive reimbursement for the warm handoff. Receiving providers may start providing services and submit bills and claims to Medi-Cal FFS starting January 1, 2027, when those members have been transitioned to the Medi-Cal FFS delivery system.

Support:
Health Plan will provide additional information as DHCS finalizes transition updates, including:

• Updated billing codes for Medi-Cal FFS care management services;
• Member support pathways; and
• Contact information for DHCS or MCP support channels.

If you have any further questions, please contact your Provider Services Representative, or call our Customer Service Department at 1-888-936-PLAN (7526). You may also visit https://www.hpsj.com/alerts/ for online access to the documents shared. The most recent information about Health Plan and our services is always available on our website www.hpsj-mvhp.org