December 13, 2024
Compliance4U newsletter provides you with insight into the day-to-day functions of Health Plan’s Compliance Program.
Big News: Our New Policy Management Application (PMA) is Here!
We’re beyond thrilled to announce that Health Plan's new Policy Management Application (PMA) officially launched on Monday, December 2nd! This is a huge leap forward, as we have transitioned all policies from SAI360 to our streamlined and innovative PMA. (Note: Policies can no longer be submitted or approved in SAI360.)
Why the PMA is a Game-Changer:
Built on modern SharePoint, the PMA features a brand-new design and userfriendly interface. Say goodbye to headaches and hello to timesaving, seamless compliance!
Thank You for Joining Us on This Journey!
A massive shoutout to everyone who attended our training sessions and office hours. You’ve been amazing in helping us bring this vision to life!
Haven’t had a chance to dive into the PMA yet? No worries we’ve got you covered with two more opportunities to join our office hours: � �
� � Friday, December 20, 2024, at 9:00 AM
Learn at Your Pace:
Need a refresher? Check out the PMA training presentation and videos, available anytime to help you get up to speed here:
1. Policy Management Application (PMA) Training for Policy Owners_10.24.24.pptx
2. Policy Management Application (PMA) Training Videos
Got Questions? We’ve Got Answers!
Your Compliance Policy Team is here to support you every step of the way. Reach out at policies@hpsj.com, and let’s make this transition smooth and seamless.
Overview of Compliance Element #6: Risk Assessment, Auditing, and Monitoring
A compliance risk assessment is a process that reviews risks that may adversely impact our ability to comply with requirements. We are formalizing a Risk Assessment tool to comprehensively, consistently, and easily assess risk of the entities with whom we do business.
Auditing involves a deep dive into an organization's compliance performance and provides valuable insights into operational strengths, weaknesses, and opportunities for improvement. Audits help us in demonstrating our commitment to regulatory compliance and quality care to stakeholders including members, providers, regulators, and our community stakeholders.
Monitoring is a continuous look into operations to detect and prevent non-compliance as or before they occur. By proactively identifying potential issues, monitoring allows us to implement timely interventions, mitigate risks and minimize the impact of noncompliance.
Ongoing cycles of risk assessment, auditing and monitoring lead to ongoing, continuous improvement in Health Plan practices and outcomes, which is foundational to an Effective Compliance Program.
Regulatory Affairs & Communication (RAC)
Do you have a question for Compliance? To submit an inquiry, on SharePoint go to Team Sites > Compliance > Requests > Submit an Inquiry or simply use this link: check it out here.
What’s going on at the State and Federal levels? To support you in your role and ensure timely awareness of changes to regulatory and contractual requirements, RAC attends regulatory calls (DHCS Managed Care Plan Call - MCPC) and other regulatory meetings/calls where key regulatory information is shared.
DHCS and CA Bridge hosted a webinar on “Navigating the Community Health Worker (CHW) Certification & Medi-Cal Billing”
On November 22nd, DHCS and CA Bridge held a webinar on Community Health Workers (CHW). CHWs are trained health educators who assist members in understanding healthcare providers and connecting them with necessary services. During the webinar, CA Bridge provided an overview of their goals and impact in the community, discussed their Certification Requirements, and highlighted where CHWs can receive free training. For more details, please refer to "Navigating the Community Health Worker (CHW) Certification & Medi-Cal Billing”.
RAC maintains material from those weekly calls. Check out previous meetings HERE.
All Plan Letters (APL)
DHCS and DMHC release APLs to communicate changes in Federal or State policy or procedure and provide instruction to MCPs on implementing these changes. RAC analyzes the APLs to ensure compliance with the requirements and to meet timely filing. Draft APLs (denoted by “XXX” indicating that a policy number has not been assigned by both regulators) are issued by both DHCS and DMHC on a regular basis to solicit feedback from MCPs before they are officially published and become effective. During this period, MCPs can provide feedback or concerns to DHCS and DMHC on upcoming APLs. Here are the APLs that were recently released:
A. DHCS Regulatory Notices
Draft APL 24-XXX Timely Access Requirements
Release Date: November 14, 2024
Summary: We are required to follow state and federal timely access requirements. The draft APL documents the following changes:
• Timely Access Standards: Updated standards for appointment wait times and access to care.
• Reporting Requirements: New guidelines for reporting compliance with timely access standards.
• Monitoring and Enforcement: Enhanced procedures for monitoring and enforcing compliance.
• Member Protections: Additional measures to protect members’ rights to timely access to care.
Draft APL 24-XXX Establishing Dual Eligible Special Needs Plans by 2026
Release Date: November 15, 2024
Summary: This All-Plan Letter (APL) provides information for us to establish a D-SNP Line of Business by 2026. It outlines requirements for Applicable Integrated Plans (AIP). In California, AIPs are called Medicare-Medicaid Plans (MMPs) and Exclusively Aligned Enrollment (EAE) D-SNPs (like Health Plan is establishing) As an EAE D-SNP, our members are eligible for both Medicare and Medi-Cal benefits and to serve our members Health Plan is expected to: 1) meet state requirements in the DHCS State Medicaid Agency Contract (SMAC); 2) provide an integrated Member and Provider Experience; and 3) meet federal requirements for AIPs as defined in 42 Code of Federal Regulations (CFR) section 422.561.
Our D-SNP contract number with CMS (Centers for Medicare & Medicaid Services) has been assigned and it is H5734.
Draft APL 24-XXX Public Provider (PP) Ground Emergency Medical Transportation (GEMT) Program
Release Date: November 21, 2024
Summary: This draft APL along with APL 24-XXX Ground Emergency Medical Transport Quality Assurance Fee Program supersedes APL 20-002. The purpose of the PP-GEMT program is to offer an increase to the Fee for Service (FFS) schedule rate for GEMT services Here are the key activities we are responsible for:
• Provider Participation: Ensuring that providers participate in the PP-GEMT Program.
• Data Submission: Submitting required data to the Department of Health Care Services (DHCS) for program administration.
• Reimbursement: Facilitating the reimbursement process for eligible providers.
• Compliance: Adhering to all program requirements and guidelines set forth by DHCS.
Draft APL 24-XXX Ground Emergency Medical Transport Quality Assurance Fee Program
Release Date: November 21, 2024
Summary: This APL provides Medi-Cal managed care plans (MCPs) with guidance regarding the Ground Emergency Medical Transport (GEMT) Quality Assurance Fee (QAF) program’s enhanced reimbursement obligations for private Provider services that are reported using the Current Procedural Terminology (CPT) codes as outlined in the APL. Here are the key points on how it impacts Health Plan:
• Fee Implementation: We will be required to implement and manage the quality assurance fee for ground emergency medical transport services.
• Reporting Requirements: We must adhere to new reporting requirements to ensure compliance with the program.
• Financial Impact: There may be financial implications for us due to the administration of the fee and potential adjustments in reimbursement rates.
• Quality Assurance: We will need to ensure that the quality of emergency medical transport services meets the standards set by the program.
Draft APL 24-XXX Administrative and Monetary Sanctions
Redlined Draft APL: REDLINE DRAFT APL 24-XXX Sanctions.pdf
Release Date: November 25, 2024
Summary: This APL provides clarification to Medi-Cal managed care plans (MCPs) of the Department of Health Care Services’ (DHCS) policy regarding the imposition of administrative and monetary sanctions, which are among the enforcement actions DHCS may take to enforce compliance with MCP contractual provisions and applicable state and federal laws. This APL supersedes APL 23-012. Here are the key changes in this APL:
• Sanctions and Penalties: The APL outlines new sanctions and penalties for managed care plans that fail to comply with Quality metrics also known as Managed Care Accountability Set (MCAS) requirements.
• Compliance Requirements: It details updated compliance requirements that plans must adhere to, including reporting and operational standards.
• Enforcement Actions: The APL specifies the enforcement actions that will be taken against plans that do not meet the new standards.
• Implementation Timeline: It provides a timeline for when these changes will take effect and the deadlines for compliance.
Draft APL 24-XXX Standards for Threshold Languages, Nondiscrimination Requirements, Language Assistance Services, and Alternative Formats
Redlined Draft APL: Redlined DRAFT APL 24-XXX Threshold.pdf
Release Date: November 27, 2024
Summary: This APL informs all Medi-Cal managed care plans (MCPs) of the dataset for threshold and concentration languages and clarifies the threshold and concentration standards specified in state and federal laws and the DHCS Contract. This dataset identifies the threshold and concentration languages in which, at a minimum, MCPs must provide written translated Member information. This APL supersedes APL 21-004. Here are the key changes that impact Health Plan:
• Threshold Languages: Updated standards for identifying and providing services in threshold languages.
• Nondiscrimination Requirements: Enhanced requirements to ensure nondiscrimination in service delivery.
• Language Assistance Services: New guidelines for offering language assistance services to members.
• Alternative Formats: Expanded requirements for providing information in alternative formats for members with disabilities.
APL 24-015 California Children’s Services Whole Child Model Program
Issue Date: December 2, 2024
Summary: This APL provides direction and guidance to Medi-Cal managed care plans (MCPs) participating in the California Children’s Services (CCS) Whole Child Model (WCM) Program. This APL conforms with CCS Numbered Letter (N.L.) 10-1224 or any superseding version of this N.L., which provides direction and guidance to County CCS Programs on requirements pertaining to the WCM Program. This APL supersedes APL 23-034. **Not Applicable to Health Plan**
DHCS APL 24-016 Diversity, Equity, and Inclusion training program requirements
Issue Date: December 5, 2024
Summary: This APL provides Medi-Cal managed care plans (MCPs) with guidance regarding the Diversity, Equity, and Inclusion (DEI) training program requirements. Here are some key takeaways:
• Implementation of DEI Initiatives: We must integrate Diversity, Equity, and Inclusion (DEI) initiatives into their operations.
• Training Requirements: Mandatory DEI training for all staff to ensure cultural competency.
• Data Collection and Reporting: Enhanced data collection and reporting on DEI metrics.
• Community Engagement: Increased efforts to engage with diverse communities to improve health outcomes.
The goal is to ensure Plans are more inclusive and equitable in services.
DHCS APL 24-017 transgender, gender diverse, intersex cultural competency training program and Provider Directory Requirements
Issue Date: December 5, 2024
Summary: This APL provides Plans with guidance regarding the transgender, gender diverse, intersex (TGI) cultural competency training program and Provider Directory changes required by Senate Bill (SB) 923 (Chapter 822, Statutes of 2022) for the purpose of providing trans-inclusive health care to MCP Members. These are key points from this APL:
• Cultural Competency Training: We must provide annual training on cultural competency, specifically addressing the needs of transgender, gender non-conforming, and intersex (TGI) individuals.
• Provider Directories: We must update their provider directories to include information on providers who offer TGI-specific services.
• Data Collection: We are required to collect and report data on the sexual orientation and gender identity of their members to ensure appropriate care and services.
• Access to Care: We must ensure timely access to TGI-specific care and services, including hormone therapy and gender-affirming surgeries.
These measures aim to improve the quality of care and ensure equitable treatment for TGI individuals.
B. DMHC Regulatory Notices
APL 24-020 RY 2026/MY 2025 Provider Appointment Availability Survey Manual and Report Form Amendments
Issue Date: November 13, 2024
Summary: This APL to provide notice to health care service plans (health plans) of amendments to Rule 1300.67.2.2 and the following reporting year (RY) 2026/measurement year (MY) 2025 Timely Access Compliance Report documents: Provider Appointment Availability Survey (PAAS) Manual, PAAS Report Forms and the Timely Access Submission Instruction Manual (TA Instruction Manual). The following are the amendments:
• Survey Manual Updates: Changes to the guidelines and procedures for conducting the provider appointment availability survey.
• Report Form Modifications: Adjustments to the format and content required in the report forms submitted by Plans.
• Compliance Requirements: New compliance standards and deadlines for submitting the survey results.
• Data Collection Enhancements: Improved methods for collecting and reporting data to ensure accuracy and consistency.
Please note: this APL is applicable to reporting due in 2026 and does not make any changes to the Timely Access Compliance Report that is due on May 1, 2025.
APL 24-XXX_Network Adequacy Standards_RY 2025.docx
Issue Date: December 4th, 2024
Summary: This APL to notice amendments to 28 CCR § 1300.67.2.1, 28 CCR § 1300.67.2, and documents incorporated by reference. The amendments are
noticed pursuant to Senate Bill (SB) 225 (Wiener, Chapter 601, Statutes of 2022). Amendments to the Rule and incorporated documents are effective January 1, 2025. For those plans required to submit an Annual Network Report, the DMHC will apply these requirements to the reporting year (RY) 2025 Annual Network Review.
1. New Facility-Specialty Type: The Centers for Medicare and Medicaid Services (CMS) has added a new facility-specialty type called “Outpatient Behavioral Health” to the network adequacy standards. This new type will be evaluated using time and distance, as well as minimum number standards.
2. Network Adequacy Exceptions: Criteria for network adequacy exceptions have been clarified. We can request exceptions if certain providers or facilities are not available to meet the network adequacy criteria, provided they have contracted with other accessible providers and facilities.
NEW All Plan Letter (APL) Policy Filing Process
We've got some exciting changes to our APL policy filing process that you'll want to know about.
All policies must complete the policy workflow before submission. This means that policy owners revising their policies for an APL will need to make sure their department executive approves the policy before it is submitted to the Compliance policy team. Upon receipt, Compliance will conduct a review before it is submitted to our CEO for approval. Once all approvals have been obtained, Compliance will submit the policy to DHCS/DMHC if applicable.
RESPONSIBLE PERSON
* DHCS/DMHC review and approval is not required for all
Regulatory Reports
Under our contract with DHCS and in compliance with our Knox Keene license (DMHC), we must routinely submit reports demonstrating compliance and performance. Below is a list of reports due for submission in the next few weeks. The table includes a hyperlink to the report and the accountable Director and
Executive for the report. Check out the list to find out which ones are in your department. Click on the report title for more information.
Report Title
Provider Directory File & Use 2024-12
ECM/JSON 2024-12
CBAS Waiver 2024-11
274 File 2024-11
MCPDIP 2024-11
Data Certification 2024-11
Post Payment Recovery 2024-11
SRF 2024-11
PIN 2024-11
Encounter Data 2024-11
CY 2023 MOT RC SDR Template
CY 2022 Phase 2 Payment
Annual CY 2023 MLR Report
Consolidated Billing 2024-11
NEMT/NMT 2024-09
Ana Aranda Liz Le
Clarence Rao Victoria Worthy
Pamela Lee Tracy Hitzeman
Clarence Rao Victoria Worthy
Clarence Rao Victoria Worthy
Tamara Hayes Sunny Cooper
Christopher Navarro Michelle Tetreault
Clarence Rao Victoria Worthy
Ana Aranda Liz Le
Clarence Rao Victoria Worthy
Christopher Navarro Michelle Tetreault
Christopher Navarro Michelle Tetreault
Christopher Navarro Michelle Tetreault
Clarence Rao Victoria Worthy
Dale Standfill Liz Le
DMHC Monthly Financials 2024-11 Sue Nakata Lizeth Granados
Provider Complaints
Provider complaints come to our Health Plan in different forms (e.g. Direct call to us or submission of dispute to DMHC). While our Provider Services and Claims team address those coming into us, Compliance is the point of contact for those coming through DMHC. From January 2024 through December 4th, 2024, we received 63 requests (26 Provider Complaints and 37 additional information requests), disputing 54 claims. In addition, each complaint may contain multiple issues that require a response.
Compliance coordinates a cross-functional group to review each complaint received by us. This group investigates the cases (from the original request to claim processing and dispute resolution) and prepares a comprehensive response to the DMHC about the provider’s concerns and the actions taken by us. These tables outline the status:
Table 1: Provider Complaints Received from DMHC as of December 4th, 2024.
Table 2: Provider Complaint Closures by Decision as of December 4th,2024: 2024
Regulatory Audits
DMHC 2025 Follow up Survey
DMHC is conducting a follow-up survey to ensure that we have addressed the deficiencies identified in our 2021 DMHC Routine Survey. Compliance has been working with Business Owners (BOs) to correct the deficiencies identified since we received the preliminary and subsequent final reports from DMHC in late 2023 and early 2024.
The audit review period is March 1 through September 30, 2024.
Here are the deficiencies DMHC is reviewing during the follow-up survey:
1. Adequate Consideration and Rectification of Grievances.
2. Acknowledgement Letters Contact Person
3. Published DMHC Statement.
4. Grievance Resolution Letter does not include description of Clinical Criteria.
5. Grievance Resolution Letter does not include IMR Form.
6. For Expedited Grievances, Members are not informed they may contract DMHC.
7. Online Grievance Form does not include the Regulatory Paragraph.
8. Delegate oversight of grievances and appeals.
9. Process for updating Provider Directory does not meet requirements.
10. UM NOA does not include Regulatory Paragraph in the required format.
11. Process for the denial of experimental care
12. UM NOA denial decision is not clear.
13. Annual Notification to request authorizations for post-stabilization care.
14. Timely notifications of decision on authorization request for post stabilization.
15. Rx NOA denial decision is not clear.
16. Pharmacy Formulary all required information.
17. Delegate oversight of prescription drug coverage.
18. IMR decisions are not communicated timely and in writing
19. Summary of UM process on public facing website.
20. Provider Directory does not include Disclosure Notices.
21. 24-hr access to request authorizations for post-stabilization care.
PreOnsite Deliverables
We have submitted file universes for Utilization Management Reviews (including hospital admissions), Pharmacy, Customer Service inquiries, Expedited and standard Grievance and Appeals. In addition to the universe, the corrective action plans for the above 21 deficiencies were submitted on 12/11/24.
Interviews
Staff interviews will be conducted beginning February 24, 2025. The interviews are estimated to last less than one week.
Program Integrity Unit (PIU)
The PIU investigates and reports all potential fraud, waste or abuse (FWA) and HIPAA violations, along with conducting exclusion monitoring for Third Parties. Here are some recent items we have been working on:
Privacy & Security Incidents
Privacy Tip #1 – Remember to wear a headset if you are on a work-related call and there are other people around you who can hear your conversation.
Privacy Tip #2 – Remember to use a strong password to log into your work computer.
Below is a summary of the types of HIPAA incidents that have recently been investigated. As you look through these, think about how you can prevent these incidents from recurring, and make sure to report them when they occur We had 13 HIPAA incidents that occurred between November 1 – November 30,
2024. None of these were reportable to DHCS. Below are some reminders for your reference purposes:
1. Our staff disclosed member PHI to a third-party caller.
Reminder: Prior to assisting a caller with a members account, we should ensure that the caller is either the member themselves or an approved authorized representative for the member. No PHI should be disclosed to third-party callers.
2. A Provider mistakenly sent the Health Plan the PHI of their patient who is not our member.
Reminder: Although this incident was committed by the Provider, it is a good practice to remind our providers to be mindful when processing PHI communication.
3. Our staff sent member PHI to the incorrect Provider.
Reminder: Before faxing a document, we should always double-check to ensure that we are sending PHI to the correct recipient.
Fraud, Waste, and Abuse (FWA)
The PIU is on constant alert, managing potential FWA incidents at every stage of investigation.
Recent Updates: In the last month, we received two (2) leads. Our team is actively investigating 19 ongoing cases.
Why It Matters
The funds we manage come from taxpayers, and it’s our duty to use them responsibly. Preventing fraud, waste, and abuse isn’t just about compliance – it’s about safeguarding resources that support our community’s health and wellbeing.
Your Role
If you notice a suspicious activity or have concerns about possible FWA, don’t hesitate to report it. Together, we can ensure our resources are used efficiently and ethically. Stay vigilant. Stay committed.
Provider Exclusion Monitoring
We are obligated to verify the eligibility of our Third Parties for their participation in the Medi-Cal Program. In accordance with state and federal regulations, our PIU team assesses eligibility no less than monthly. This is performed with a Third-
Party vendor that checks an inventory of our providers against several sources (e.g. List of Suspended and Ineligible Providers, U.S. Department of Health and Human Services, Office of Inspector General, System of Award Management, SSA Death Master file, and more). In addition to the monthly monitoring, exclusion checks are completed throughout the month ahead of a new Letter of Agreement 1 (LOA) being established with an out of network provider. PIU received 82 requests during this reporting period. Zero (0) restrictions were found.
Audit & Oversight (A&O)
Risk Assessments and the A&O Audit Work Plan
Risk Assessments are key to ensuring regulatory compliance, identifying vulnerabilities, enhancing member safety, and identifying gaps. Last month we looked at why Risk Assessments are conducted, what resources are used to conduct them, and the outcome of a Risk Assessment. Now, let’s look at the connection between Risk Assessments and the A&O Audit Work Plan.
Once the Risk Assessment is complete, a Risk Matrix is put together listing entities by their potential risk level. The Audit & Oversight (A&O) department uses the Risk Matrix to build an oversight work plan, ensuring the entities with the highest risk levels are scheduled with the highest priority regarding auditing and monitoring activities. In consideration of time and bandwidth to oversight every single entity every year, those with a low risk level may be scheduled for another year or may be assigned a lower-intensity oversight activity, such as an attestation. Once A&O has the work plan drafted, the Audit & Oversight Committee (AOC) reviews the plan. The AOC analyzes the recommendations and can ask questions or recommend changes.
Once this review takes place and the AOC approves the A&O Audit Work Plan, the next step is for A&O to schedule and conduct the audit and monitoring activities according to the plan. Monitoring is done on a regular, ongoing basis,
1Compliance - Provider Exclusions Check - All Entries (sharepoint.com)
and audits typically take 30-90 days depending on the risk level, the volume of information to be audited, and the responsiveness of the entity.
The A&O Audit Work Plan provides a framework for the A&O operational work, and throughout the year it may be updated or revised, of course with the input and agreement of the AOC. One reason the Audit Work Plan may be changed is if an issue arises (incident risk) and A&O must conduct an unanticipated audit. Each year A&O refreshes the Risk Assessment and updates the Audit Work Plan, keeping compliance with state and federal regulations at the forefront of the work we do!
Policies and Procedures
If you are a Policy Review Committee (PRC) voting member, please remember to cast your November 2024 PRC Meeting e-votes by COB Friday, 12/13/2024. We did not have quorum at the November 27, 2024, meeting, so we want to be sure we hear from you about the committee charter and policies up for committee review.
You can access all published policies directly via the Policies link on our Intranet. If you have any policy-related questions, please contact the Policy Review Team at Policies@hpsj.com.
Did you know?
The next Policy Review Committee (PRC) meeting will be held on Wednesday, December 18, 2024.
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