HomeMy WebLinkAboutManaged Care Plan MOU-Blue Cross Anthem CalViva Health Kaiser Foundation_A-25-433.pdf COtj County of Fresno Hall of Records, Room 301
2281 Tulare Street
Fresno,California
601 Board of Supervisors 93721-2198
O� 1$56 0 Telephone: (559)600-3529
FRV,t' Minute Order Toll Free: 1-800-742-1011
www.fresnocountyca.gov
August 19, 2025
Present: 5- Vice Chairman Garry Bredefeld, Supervisor Luis Chavez, Supervisor Nathan Magsig,
Chairman Buddy Mendes, and Supervisor Brian Pacheco
Agenda No. 49. Public Health File ID: 24-0598
Re: Approve and authorize the Chairman to execute a Memorandum of Understanding (MOU)with Blue
Cross of California Partnership Plan, Inc.dba Anthem (Anthem), Fresno-Kings-Madera Regional
Health Authority dba CalViva Health (CalViva)and Kaiser Foundation Health Plan, Inc. (Kaiser),for the
coordination of and compensation for services provided by the Department of Public Health to Anthem,
CalViva, and Kaiser Medi-Cal Managed Care members effective upon execution by all parties with
unlimited 12 month auto-renewals unless terminated by any party,for an annual estimated amount of
$99,700
PRIOR TO BOARD DISCUSSION,SUPERVISOR MAGSIG RECUSED HIMSELF UNDER THE
LEVINE ACT; AND COUNTY COUNSEL CLARIFIED, PER GOVERNMENT CODE SECTION
1091.5(a)(9),THE AGENDA ITEM PROVIDES NOTICE THAT VICE CHAIRMAN BREDEFELD SITS
ON THE BOARD OF THE FRESNO-KINGS-MADERA REGIONAL HEALTH AUTHORITY,AND HE
MAY VOTE ON THIS ITEM. A MOTION WAS MADE BY SUPERVISOR PACHECO,SECONDED BY
VICE CHAIRMAN BREDEFELD,THAT THIS MATTER BE APPROVED AS RECOMMENDED.THE
MOTION CARRIED BY THE FOLLOWING VOTE:
Ayes: 4- Bredefeld, Chavez, Mendes, and Pacheco
Recuse: 1 - Magsig
Agreement No. 25-433
County of Fresno Page 50
co
Board Agenda Item 49
O 1856 O
FRE`'�
DATE: August 19, 2025
TO: Board of Supervisors
SUBMITTED BY: Joe Prado, Interim Director, Department of Public Health
SUBJECT: Revenue and Coordination of Care Memorandum of Understanding with Managed
Care Plans Blue Cross of California, CalViva Health, and Kaiser Permanente
RECOMMENDED ACTION(S):
Approve and authorize the Chairman to execute a Memorandum of Understanding (MOU)with Blue
Cross of California Partnership Plan, Inc. dba Anthem (Anthem), Fresno-Kings-Madera Regional
Health Authority dba CalViva Health (CalViva) and Kaiser Foundation Health Plan, Inc. (Kaiser), for
the coordination of and compensation for services provided by the Department of Public Health to
Anthem, CalViva, and Kaiser Medi-Cal Managed Care members effective upon execution by all
parties with unlimited 12 month auto-renewals unless terminated by any party, for an annual
estimated amount of$99,700.
Approval of the recommended action will allow the Department of Public Health (DPH)to seek claims
reimbursement from the California Department of Health Care Services (DHCS) Medi-Cal program and to
coordinate care with the Medi-Cal Managed Care Plans (MCPs)for Medi-Cal Managed Care (MCMC)
beneficiaries who receive DPH services. It is anticipated that MCMC claims will generate approximately
$99,700 in FY 2025-26 with no Net County Cost. Estimated reimbursements for subsequent years will be
budgeted annually. This item is countywide.
ALTERNATIVE ACTION(S):
Should your Board not approve the recommended action, DPH would be unable to bill the MCPs for services
provided as outlined in this MOU; however, DPH would retain responsibility to provide these services to
low-income Fresno County residents. Entering into this MOU allows for DPH to bill for services that would
otherwise be uncompensated.
FISCAL IMPACT:
There is no increase in Net County Cost associated with the recommended action. The MOU will allow
reimbursement to the County for public health services provided to Anthem, CalViva, and Kaiser MCMC
members at existing Medi-Cal Fee-For-Service (FFS) rates which is estimated will generate revenue of
approximately$99,700 annually. Sufficient appropriations and estimated revenues are included in the
Department's Org 5620 FY 2025-26 Recommended Budget. The portion of Medi-Cal reimbursement that
covers direct and indirect costs is unknown; Medi-Cal typically provides only partial cost reimbursement.
The County's current indirect cost rate is 24.426 percent. Any portion of services rendered that is not
reimbursed by Medi-Cal will be covered by Health Realignment.
County of Fresno Page I File Number.24-0598
File Number:24-0598
DISCUSSION:
MCMC is the system of health care for the Medi-Cal eligible population, which contracts for health care
services through established networks of organized systems of care. Managed care plans are intended to
be a cost-effective use of the health care resources that improve health care access and quality of care.
On October 11, 2023, the California Department of Health Care Services (DHCS) released All Plan Letter
23-029 which requires the County and MCPs to enter into this MOU. The purpose of this MOU is to clarify
the roles and responsibilities for coordination of the delivery of care and services to all MCMC plan
members, to establish agreed upon processes for how the parties will collaborate and coordinate on
population health and/or other programs and memorialize what data will be shared between the parties, in
addition to setting FFS as the rate for services covered under this MOU. The MOU does not impose new
requirements on the Department but restates or cross-references existing requirements.
The County has two separate MOUs in place with Anthem Blue Cross (06-072) and CalViva (11-058) and,
should this action be approved, this MOU will supersede those MOUs. Traditionally, Kaiser has not been
part of the traditional MCPs in Fresno County; however effective January 1, 2024, DHCS contracted with
Kaiser to operate as a MCP in 32 California counties to include Fresno County. All three MCPs are included
in one single MOU as the DHCS requirements apply to all three MCPs.
Fresno County Board of Supervisor Garry Bredefeld (District 2 Supervisor)sits on the Board of the
Fresno-Kings-Madera Reginal Health Authority's CalViva Health, which is a party of this MOU and is a
non-profit managed care plan. The Department is requesting this MOU be executed as an "evergreen"
agreement due to the MOU between the County and MCPs being a requirement by DHCS for the
foreseeable future. Anthem, CalViva Health and Kaiser are the only MCPs in Fresno County as well as
surrounding counties. This MOU shall become effective upon execution and shall automatically be extended
for an unlimited number of years upon the same terms and conditions unless written notice of non-renewal
is given by the MCPs or the Department's director, or designee, not later than sixty (60)days prior.
REFERENCE MATERIAL:
BAI #44, May 16, 2017
BAI #26, February 8, 2011
BAI #9, March 3, 2009
BAI #22, March 28, 2006
ATTACHMENTS INCLUDED AND/OR ON FILE:
On file with Clerk- MOU with Anthem, CalViva, and Kaiser
On file with Clerk- DHCS All Plan Letter 23-029
CAO ANALYST:
Ronald Alexander
County of Fresno page 2 File Number.24-0598
PV H C S
CALIFORNIA DEPARTMENT OF
HEALTH CARE SERVICES
Michelle&iau I Director
DATE: October 11, 2023
ALL PLAN LETTER 23-029
TO: ALL MEDI-CAL MANAGED CARE PLANS
SUBJECT: MEMORANDUM OF UNDERSTANDING REQUIREMENTS FOR MEDI-
CAL MANAGED CARE PLANS AND THIRD-PARTY ENTITIES
PURPOSE:
The purpose of this All Plan Letter (APL) is to clarify the intent of the Memorandum of
Understanding (MOU) required to be entered into by the Medi-Cal managed care plans
(MCPs) and Third Party Entities (defined below) under the Medi-Cal Managed Care
Contract (MCP Contract) with the Department of Health Care Services (DHCS), and to
specify the responsibilities of MCPs under those MOUs. In addition, this APL contains an
MOU template with general provisions required to be included in all MOUs (Base
Template) that the MCPs must execute pursuant to the MCP Contract and MOU
templates tailored for certain programs, which contain the required general MOU
provisions and program-specific provisions (Bespoke Templates).
Further, this APL addresses DHCS' expectations and oversight of MCP obligations
under this APL and the MOUs, including MCP reporting requirements.
BACKGROUND AND INTENT:
The MCP Contract requires MCPs to build partnerships with the following Third Party
Entities: local health departments; local educational and governmental agencies, such
as county behavioral health departments for specialty mental health care and
Substance Use Disorder (SUD) services; other local programs and services, including
social services; child welfare departments; Continuum of Care programs; First 5
programs and providers; Regional Centers; Area Agencies on Aging; Caregiver
Resource Centers; Women, Infants and Children Supplemental Nutrition Programs
(WIC); Home and Community-Based Services (HCBS) waiver agencies and providers;
and justice departments to ensure Member care is coordinated and Members have
access to community-based resources in order to support whole-person care. This
requirement can be found in the MCP Contract, Exhibit A, Attachment III, Section 5.6
(MOUs with Third Parties).
The MOUs are intended to be effective vehicles to clarify roles and responsibilities
among parties, support local engagement, and facilitate care coordination and the
exchange of information necessary to enable care coordination and improve the referral
California Department of Health Care Services State of California
Managed Care Quality and Monitoring Division Gavin Newsom, Governor
1501 Capitol Avenue, P.O. Box 997413
Sacramento,CA 1 95899-7413
MS 4410 1 Phone(916)449-5000 1 www.dhcs.ca.gov California Health and Human Services Agency
ALL PLAN LETTER 23-029
Page 2
processes between the parties. The MOUs are also intended to improve transparency
and accountability by setting forth certain existing requirements for each party as it
relates to service or care delivery and coordination so that the parties are aware of each
other's obligations.
Each MOU is a binding, contractual agreement between the MCP and a Third-Party
Entity (referred to in this APL as the "Other Party") and outlines the responsibilities and
obligations of the MCP to coordinate and facilitate the provision of services to Members
where Members are served by multiple parties. The purpose of the MOU is to:
• List the minimum MOU components required by the MCP Contract;
• Clarify roles and responsibilities for coordination of the delivery of care and
services of all Members, particularly across MCP carved-out services, which may
be provided by the Other Party;
• Establish negotiated and agreed upon processes for how the MCP and the Other
Party will collaborate and coordinate on population health and/or other programs
and initiatives;
• Memorialize what data will be shared between the MCP and the Other Party and
how the data will be shared to support care coordination and enable monitoring;
• Provide public transparency into relationships and roles/responsibilities between
the MCP and the Other Party; and
• Provide mechanisms for the parties to resolve disputes and ensure overall
oversight and accountability under the MOU.
The MOU does not impose new requirements on the Other Party, but rather restates or
cross-references existing requirements imposed on the Other Party by their respective
oversight body, if any, in order to clarify the Other Party's roles and responsibilities
under existing laws, regulations, and guidance ("existing requirements").
POLICY:
MCPs must make a good faith effort to execute MOUs with Other Parties by either
January 1, 2024, July 1, 2024, or January 1, 2025, as outlined below:
MOUs Effective January 1, 2024
Department Program/Services
County Behavioral ttl
Specialty Mental Health Services
Departments
ALL PLAN LETTER 23-029
Page 3
MOUs Effective January 1, 2024
Department Program/Services
County Behavioral Health SUD Services
Departments
County Behavioral Health SUD Services in Drug Medi-Cal (DMC) State Plan
Departments Counties
Including, without limitation, California Children's
Local Health Departments Services (CCS),' Maternal, Child, and Adolescent
Health (MCAH), and Tuberculosis Direct Observed
Therapy
WIC Local Agencies or WIC
Non-Profit Entities
Regional Centers Intermediate Care Facility — Developmentally Disabled
Services
Local Government In-Home Supportive Services (IHSS)
Agencies (LGA)
LGA/County Social County Social Services programs and Child Welfare
Services Departments
MOUs Effective July 1, 2024
Department Program
LGA County-Based Targeted Case Management (TCM)'
' The County TCM MOU will be effective July 1, 2024, to align with the program changes set
forth in the Enhanced Care Management Policy Guide dated July of 2023, available at:
https://www.dhcs.ca.gov/Documents/MCQMD/ECM-Policy-Guide.pdf
ALL PLAN LETTER 23-029
Page 4
MOUs Effective January 1, 2025
HCBS Waiver Agencies and Programs
LGA/California Department of Corrections and Rehabilitation, county jails, and youth
correctional facilities
Continuum of Care
First 5 Programs
Area Agencies on Aging
California Caregiver Resource Centers
Local Education Agencies (LEAs)
Indian Health Services/Tribal Entities
PROVISIONS REQUIRED TO BE INCLUDED IN MOUs
MCPs are responsible for providing Medically Necessary Covered Services to Members
and coordinating Member care, particularly for services carved out of the MCP Contract.
The MOU between the MCP and the Other Party is intended to serve as the primary
vehicle for documenting and developing processes and procedures to ensure the MCP
and the Other Party coordinate services, including health related social service needs,
when Members are accessing services from both systems. For example, for the CCS
program, the MOU will outline the roles and responsibilities of the MCP as well as the
local agency county health departments for coordinating care, exchanging information,
and conducting administrative activities related to CCS-enrolled Members accessing
and receiving care.
Each MOU with all Other Parties must include, at a minimum, all of the provisions
required in Attachment A, Base MOU Template and as required in the MCP Contract,
including the following:
• Services Covered by This MOU: Describes the services that the MCP and the
Other Party must coordinate for Members who reside in the Other Party's
jurisdiction or who receive the Other Party's services.
• Party Obligations: Describes each party's provision of services and oversight
responsibilities (e.g., the parties must designate liaisons to coordinate with each
other and ensure compliance with the MOU requirements, including the MCP
ensuring compliance by its Subcontractors, Downstream Subcontractors, and
Network Providers). The intent of this provision is to ensure each party is aware
of what services the other is required to provide or arrange under existing
ALL PLAN LETTER 23-029
Page 5
requirements. This provision is also intended to ensure that the parties know how
and who to contact for each party to support the MOU implementation. This
provision also requires the MCP to impose certain MOU requirements on its
Subcontractors, Downstream Subcontractors, and Network Providers.
• Training and Education: Requires the MCP to provide education to Members and
Network Providers about accessing Covered Services and the Other Party's
services. Requires the MCP to train its employees who carry out responsibilities
under the MOU and, as applicable, train Network Providers, Subcontractors and
Downstream Subcontractors on the MOU requirements and services provided by
the Other Party. This provision is intended to ensure the MCP provides its
Subcontractors, Downstream Subcontractors, and Network Providers with
information necessary for them to coordinate care with, and make referrals to, or
receive referrals from, the Other Party.
• Referrals: Describes the requirement that the parties refer to each other as
appropriate and describes each party's referral pathways to ensure both parties
understand and are able to refer to or assist Members with obtaining services
from each other. The intent of this provision is to encourage the parties to
develop and document how parties can refer Members to one another and what
information may need to accompany each referral.
• Care Coordination: Describes the policies and procedures for coordinating care
between the parties, addressing barriers to care coordination, and ensuring the
ongoing monitoring and improving of such care coordination. This provision is
intended to encourage the parties to develop and document how the parties will
coordinate care, monitor whether those processes are working, and improve the
processes, as necessary.
• Quarterly Meetings: Requires the parties to meet at least quarterly to address
care coordination, Quality Improvement (QI) activities, QI outcomes, systemic
and case-specific concerns, and communicating with others within their
organizations about such activities. Within 30 Working Days after each quarterly
meeting, the MCP must post on its website the date and time the quarterly
meeting occurred in order to demonstrate transparency that the meetings are
taking place. The intent of this provision is to ensure that the parties have a set
time to meet to assess whether the MOU is effective in supporting care
coordination and whole-person care, as well as to address specific issues that
may have arisen in the prior quarter. These meetings are not intended to be open
to the public. These meetings may be conducted virtually.
• Quality Improvement: Requires that the parties have in place MOU-specific QI
policies to ensure each party's ongoing oversight and improvement of the MOU
requirements. These QI policies and activities are separate and apart from an
MCP's other QI requirements. The intent of this provision is to encourage the
parties to develop and document how they will assess whether the MOU is
ALL PLAN LETTER 23-029
Page 6
improving care coordination and whole-person care and to develop metrics to
evaluate whether the MOU is effective in achieving its goals.
• Data Sharing and Confidentiality: Describes the minimum data and information
that the MCP must share with the Other Party to ensure the MOU requirements
are met and describes the data and information the Other Party may share with
the MCP to improve care coordination and referral processes. This provision is
intended to encourage the parties to determine and document the minimum
necessary information that must be shared to facilitate referrals and coordinate
care, how to share that information, and whether Member consent is required.
The data sharing requirements set forth in the MOUs are not intended to
supersede any federal or state laws or regulations governing the ability of the
MCP or Other Party to exchange information.
• Dispute Resolution: Describes the policies and procedures for resolving disputes
between the parties and the process for bringing the disputes to DHCS (and
other departments as appropriate) when the parties are unable to
resolve disputes between themselves. The intent of this provision is to encourage
the parties to develop and document a dispute resolution process to resolve
conflicts with regard to each parties' responsibilities under the MOU.
• General: Describes additional general Contract requirements, such as the
requirements that the MCP must publicly post the executed MOU, the MCP must
annually review the MOU, and the MOU cannot be delegated, except as
permitted under the MCP Contract.
Program-Specific MOU Requirements (Bespoke Templates)
MOUs are intended to acknowledge the unique relationships and specific needs that
exist at the local level, as outlined in the MCP Contract. As such, the Attachment B,
Bespoke Templates build on the Base Template requirements by including tailored
provisions for the following programs:
1. Specialty Mental Health Services;
2. SUD Services;
3. SUD Services in DMC State Plan Counties;
4. Local Health Departments, including program-specific exhibits
for CCS, MCAH, Tuberculosis Direct Observed Therapy, and Non-Contracted
Services;
5. WIC;
6. Regional Centers;
7. IHSS;
8. County Social Services programs and Child Welfare; and
9. TCM.
ALL PLAN LETTER 23-029
Page 7
MCPs cannot remove or alter the minimum requirements in the Base Template or
Bespoke Templates. However, the MCP and the Other Party may agree to include
additional provisions, including, without limitation, the optional provisions included in the
templates, provided any additional provision does not conflict with the required minimum
provisions. The templates include language that the parties may want to add to their
MOUs to increase collaboration and communications. The proposed language is not
exhaustive.
MOU COMPLIANCE AND OVERSIGHT REQUIREMENTS
The MCP Contract outlines specific processes that MCPs must have in place in order to
maintain collaboration with the Other Party and have appropriate oversight of the MOU
requirements.
Ultimately, the MCP compliance officer is responsible for MOU compliance, and
ensuring compliance with the MOU must be part of the MCP's compliance program. The
MCP compliance officer must ensure that deficiencies in MOU compliance are
addressed in accordance with MCP's compliance program policies.
MCP Responsible Person and MCP-Other Party Liaison
The MCP must designate a responsible person(s) for overseeing the MCP's compliance
with the relevant MOU(s) and the relevant provisions (MCP Responsible Person). This
MCP Responsible Person must provide reports to the MCP compliance officer. For
example, the MCP may consider designating staff within their contract management,
provider relations, or community relations functional areas. The MCP must ensure the
responsible person(s) is well-versed with the MOU(s) provisions, has developed
relationships with the relevant Other Party, and is empowered to meet compliance with
the MOU(s). MCPs must notify DHCS of a change in the responsible person/liaison as
soon as practicable, but no later than five Working Days of the change.
As outlined in the Base Template, and incorporated in the Bespoke Templates, under
"MCP Obligations: Oversight Responsibility," the MCP Responsible Person must:
1. Conduct regular meetings, on at least a quarterly basis, to address policy and
practical concerns that may arise between MOU parties (See the Quarterly
Meetings Section of the Base Template for an example of the required
language);
2. Ensure an appropriate level of leadership (i.e., persons with decision-making
authority) are involved in implementation and oversight of the MOU
engagements and ensure the appropriate levels of leadership from the Other
Party are invited to participate in the MOU engagements, as appropriate;
ALL PLAN LETTER 23-029
Page 8
3. Report on the MCP's compliance with the MOU to the MCP's compliance
officer no less frequently than quarterly;
4. Ensure there is sufficient staff at the MCP to support compliance with, and
management of, the relevant MOU(s) and its provisions;
5. Ensure training and education regarding MOU provisions are conducted
annually for the MCP's employees responsible for carrying out activities
under the MOU, and as applicable, for Network Providers, Subcontractors,
and Downstream Subcontractors;
6. Ensure that the MCP's Subcontractors, Downstream Subcontractors, and
Network Providers, as applicable, comply with all applicable provisions of the
MOUs (see the "Subcontractor and Network Providers" section below and the
MOU templates for further details); and
7. Serve as, or designate a person at the MCP to serve as, the point of contact
and liaison with the Other Party or Other Party programs (MCP-Other Party
Liaison). This liaison is to serve as the subject matter expert for the Other
Party to address day-to-day concerns for administering the MOU. For
example, the MCP-CCS Liaison would serve as the contact for the CCS
County administrator to address immediate concerns related to specialty care
services for CCS Members in a particular county. The MCP must notify the
Other Party of any changes to the MCP-Other Party Liaison in writing as soon
as reasonably practical but no later than the date of change and must notify
DHCS within five Working Days of the change.
Data Sharing and Confidentiality
MCPs must share the minimum necessary data and information to facilitate referrals
and coordinate care under the MOU. MCPs must have policies and procedures for
supporting the timely and frequent exchange of Member information and data, which
may include behavioral health and physical health data; for ensuring the confidentiality
of exchanged information and data; and, if necessary, for obtaining Member consent.
MCPs must share information in compliance with applicable law, which may include the
Health Insurance Portability and Accountability Act and its implementing regulations, as
amended, Title 42 Code of Federal Regulations (CFR) Part 2, as well as other state and
federal privacy laws.' As applicable and for the purposes of care management and
coordination, MCPs should share information in compliance with the California Health
and Human Services Agency Data Exchange Framework as referenced in APL 23-013
2 The CFR is searchable at: https://www.ecfr.gov/
ALL PLAN LETTER 23-029
Page 9
and any subsequent iterations on this topic, as well as DHCS' California Advancing and
Innovating Medi-Cal Data Sharing Authorization Guidance.3
Dispute Resolution
MCPs must work collaboratively with the Other Party to establish dispute resolution
processes and timeframes within the MOU. This includes how the MCP will work with
the Other Party to resolve issues related to coverage or payment of services under
conflicts regarding respective roles for care management for specific Members, or other
concerns related to the administered services to Members. See the Base Template
"Dispute Resolution" section for an example of the required language.
After a failure to resolve the dispute pursuant to the process and timeframe established
in the MOU, the MCP must submit a written "Request for Resolution" to DHCS and the
Other Party may submit the dispute to the relevant department with oversight of the
Other Party (e.g., California Department of Social Services, California Department of
Public Health, or California Department of Developmental Services). If the MCP submits
the Request for Resolution, it must be signed by the MCP's Chief Executive Officer
(CEO) or the CEO's designee. If the Request for Resolution is submitted by the Other
Party, it should be signed by an authorized representative of the Other Party.
MCP's Request for Resolution to DHCS must include:
1. A summary of the disputed issue(s) and a statement of the desired
remedies, including any disputed services that have been or are expected to be
delivered to a Member;
2. A history of the attempts to resolve the issue(s) with the Other Party;
3. Justification for the desired remedy; and
4. Any additional documentation relevant to resolve the disputed issue(s), if
applicable.
MCPs must submit the Request for Resolution to DHCS via secure email to
MCPMOUS(a-)-dhcs.ca.gov.
DHCS, in collaboration with the sister department as appropriate, will communicate the
final decision to the MCP and the Other Party, including any actions the MCP must take
to implement the decision.
3 APLs are searchable at: https://www.dhcs.ca.gov/formsandpubs/Pages/AlIPIanLetters.aspx
ALL PLAN LETTER 23-029
Page 10
Subcontractors and Network Providers
MCPs must ensure that their Subcontractors, Downstream Subcontractors, and Network
Providers, as applicable, comply with all applicable provisions of the MOUs.
If an MCP has a Subcontractor or Downstream Subcontractor arrangement delegating
part or all of the responsibilities relating to effectuating the MOUs to a Knox-Keene
licensed health care service plan(s), this Subcontractor or Downstream Subcontractor
must be added as an express party to the MOU and named in the MOU as having the
responsibilities set forth as applicable to this Subcontractor or Downstream
Subcontractor. For example, if an MCP delegates risk for an assigned portion of its
membership to a Subcontractor or Downstream Subcontractor, the signatories of the
MOU must include the MCP, the Subcontractor or Downstream Subcontractor, and the
Other Party.
Training
MCPs must provide training and orientation on the MOU requirements to their
employees who carry out responsibilities under the MOU and, as applicable, to their
Subcontractors, Downstream Subcontractors, and Network Providers. The training must
include information on MOU requirements and the services that are provided or
arranged for by each party and how those services can be accessed or coordinated for
the Member. MCPs must provide this training within a specified time after the MOU is
effective and at least annually thereafter.
Local Engagement
As noted, the MOU is intended to be a vehicle to support engagement with local
partners. To that end, the MCP must ensure an appropriate local presence at its
quarterly meetings by inviting the appropriate responsible person(s) and program
executives from the Other Party. At each quarterly meeting, the MCP must ensure there
is the opportunity to discuss and address care coordination and MOU-related issues
with county executives.
Signatories
As noted above, if an MCP has a Subcontractor or Downstream Subcontractor
arrangement delegating part or all of the responsibilities related to effectuating the
MOU to a Knox-Keene licensed health care service plan(s), the signatories of the
MOU must include the MCP, the Subcontractor or Downstream Subcontractor, and
the Other Party. In addition, to minimize administrative burden on counties and Other
Parties, DHCS encourages multi-party MOUs, which may include more than one MCP
and/or Other Party signing an MOU. In addition, MCPs may work with the Other Party
to consolidate signature pages for multiple types of MOUs, for example, if an MCP is
ALL PLAN LETTER 23-029
Page 11
entering into an agreement for multiple county administered programs.
MONITORING AND REPORTING
Starting January 1, 2025, MCPs must submit to their DHCS Managed Care Operations
Division (MCOD) Contract Manager an annual report that includes updates from the
quarterly meetings with the Other Party and the results of their annual MOU review. The
quarterly meetings are to discuss care coordination activities and the specific MOU-
related issues. The report must include the following elements:
• A list of all attendees, including MCP Responsible Person(s), leadership, and
county executives;
• All care coordination and referral concerns discussed;
• Strengths, barriers, and plans to improve effective collaboration between the
MCP and the Other Party;
• All disputes and resulting outcomes;
• Strategies to address duplication of services; and
• Member engagement challenges and successes
To continuously evaluate the effectiveness of the MOU processes, MCPs must review
their MOUs annually to determine if any amendments are needed, including
incorporating any applicable contractual requirements and policy guidance to their
MOUs. The annual report submission must include evidence of the annual review as
well as copies of any MOUs amended or renewed as a result. The evidence of the
annual review described in the annual report must include a summary of the review
process and outcomes, and any resulting amendments to the MOU or policies and
procedures.
If DHCS requests a review of any MOU and/or any requested policies and procedures
related to the MOU, the MCP must submit the requested MOU documents to DHCS
within ten Working Days of receipt of the request.
Quarterly Reporting
MCPs must demonstrate a good faith effort to meet the requirements of this APL. MCPs
that are unable to execute their MOUs by the required execution date for MOUs for
which DHCS has issued templates, must submit quarterly progress reports and
documentation to DHCS demonstrating evidence of their good faith effort to execute the
MOU.
DHCS Submissions and Reports
MCPs must submit all fully executed MOUs to their MCOD Contract Manager for file
and use. In their submissions, MCPs must attest that they did not modify any of the
ALL PLAN LETTER 23-029
Page 12
provisions of the Base Template or Bespoke Templates except to add provisions that do
not conflict with or reduce either party's obligations under the Base Template or
Bespoke Templates. If the MCP modifies any of the provisions of the Base Template or
Bespoke Templates, the MCP must submit a redlined version of the MOU to DHCS for
review and approval, prior to execution.
MCP Website Posting
MCPs must publish the MOU(s) and the annual report on their websites within 30
calendar days of MOU execution and report due date, respectively.
Subcontractor Compliance
MCPs are further responsible for ensuring that their Subcontractors, Downstream
Subcontractors, and Network Providers comply with all applicable state and federal laws
and regulations, Contract requirements, and other DHCS guidance, including APLs and
Policy Letters.' These requirements must be communicated by each MCP to all
Subcontractors, Downstream Subcontractors, and Network Providers. DHCS may
impose Corrective Action Plans (CAP), as well as administrative and/or monetary
sanctions for non-compliance. For additional information regarding administrative and
monetary sanctions, see APL 23-012, and any subsequent iterations on this topic. Any
failure to meet the requirements of this APL may result in a CAP and subsequent
sanctions.
If you have any questions regarding this APL, please contact your MCOD Contract
Manager.
Sincerely,
Original Signed by Dana Durham
Dana Durham, Chief
Managed Care Quality and Monitoring Division
4 For more information on Subcontractors and Network Providers, including the definition and
applicable requirements, see APL 19-001, and any subsequent APLs on this topic.
LOCAL HEALTH DEPARTMENT MEMORANDUM OF UNDERSTANDING
COVER PAGE
Agreement No. 25-433
Memorandum of Understanding
This Memorandum of Understanding ("MOU") is entered into by and between the
County of Fresno, a political subdivision of the State of California ("COUNTY" or "LHD"
a local health department), Blue Cross of California Partnership Plan, Inc. (Anthem),
The Fresno-Kings-Madera Regional Health Authority, dba CalViva Health, its
Subcontractor, Health Net Community Solutions, Inc., and Kaiser Foundation Health
Plan, Inc. (Kaiser),Managed Care Plans ("MCPs"), effective as of the 19t" day of
August , 2025 ("Effective Date"). MCP, and MCP's relevant Subcontractor and/or
Downstream Subcontractor, and LHD may be referred to herein as a "Party" and
collectively as "Parties."
WHEREAS, MCPs are required under the Medi-Cal Managed Care Contract Exhibit A,
Attachment III, to enter into this MOU, a binding and enforceable contractual
agreement, to ensure that Medi-Cal beneficiaries enrolled, or eligible to enroll, in MCPs
("Members") are able to access and/or receive services in a coordinated manner from
MCPs and LHD;
WHEREAS, the Parties desire to ensure that Members receive services available
through LHD direct service programs in a coordinated manner and to provide a process
to continuously evaluate the quality of care coordination provided; and
WHEREAS, the Parties understand and agree that to the extent any data that is
protected health information ("PHI") or personally identifiable information ("PII")
exchanged in furtherance of this agreement originates from the California Department of
Public Health ("CDPH") owned databases, LHD must comply with all applicable federal
and State statutes and regulations and any underlying CDPH/LHD agreement terms
and conditions that impose restrictions on access to, use of, and disclosure of that data.
In consideration of the mutual agreements and promises hereinafter, the Parties agree
as follows:
1. Definitions. Capitalized terms have the meaning ascribed by MCP's Medi-Cal
Managed Care Contract with the Department of Health Care Services ("DHCS"), unless
otherwise defined herein. The Medi-Cal Managed Care Contract is available on the
DHCS webpage at www.dhcs.ca.gov.
a. "MCP Responsible Person" means the person designated by MCP to
oversee MCP coordination and communication with the LHD Responsible Person,
facilitate quarterly meetings in accordance with Section 9 of and ensure MCP's
compliance with this MOU as described in Section 4 of this MOU. It is recommended
that this person be in a leadership position with decision-making authority and authority
to effectuate improvements in MCP practices.
b. "MCP-LHD Liaison" means MCP's designated point of contact(s)
responsible for acting as the liaison between MCP and LHD Program Liaison(s) as
described in Section 4 of this MOU. The MCP-LHD Liaison(s) must ensure that the
appropriate communication and care coordination are ongoing between the Parties,
facilitate quarterly meetings in accordance with Section 10 of this MOU, and must
provide updates to the MCP Responsible Person and/or MCP compliance officer as
appropriate.
c. "LHD Responsible Person" means the person designated by LHD to
oversee coordination and communication with MCP, facilitate quarterly meetings in
accordance with Section 10 of this MOU, and ensure LHD's compliance with this MOU
as described in Section 5 of this MOU. It is recommended that this person be in a
leadership position with decision-making authority and authority to effectuate
improvements in LHD practices.
d. "LHD Program Liaison" means LHD's designated point of contact(s)
responsible for acting as the liaison between MCP and LHD as described in Section 5 of
this MOU. The LHD Program Liaison(s) should ensure the appropriate communication
and care coordination are ongoing between the Parties, facilitate quarterly meetings in
accordance with Section 9 of this MOU, and should provide updates to the LHD
Responsible Person as appropriate.
2. Term. This MOU is in effect as of the Effective Date and shall automatically
renew annually, unless written notice of non-renewal is given in accordance with
Section 17.c. of this MOU or as amended in accordance with Section 17.f of this MOU.
3. Services Covered by This MOU. This MOU governs the coordination between
LHD and MCP for the delivery of care and services for Members who reside in LHD's
jurisdiction and may be eligible for services provided, made available, or arranged for by
LHD. The Parties are subject to additional requirements for specific LHD programs and
services that LHD provides, which are listed in the applicable program-specific exhibits
("Program Exhibits"), each labeled with the specific program or service.
4. MCP Obligations.
a. Provision of Covered Services. MCP is responsible for authorizing
Medically Necessary Covered Services and coordinating care for Members provided by
MCPs' Network Providers and other providers of carve-out programs, services and
benefits, such as dental benefits.
b. Oversight Responsibility. The designated MCP Responsible
Persons, listed in Exhibit A of this MOU, are responsible for overseeing MCPs'
compliance with this MOU. The MCP Responsible Person must:
i. Meet at least quarterly with the LHD Responsible Person and LHD
Program Liaisons, as required by Section 10 of this MOU;
ii. Report no less frequently than quarterly on MCP's compliance with
the MOU to MCP's compliance officer who is responsible for MOU compliance oversight
reports as part of MCP's compliance program and must address any compliance
deficiencies in accordance with MCP's compliance program policies;
iii. Ensure there is sufficient staff at MCP who support compliance with
and management of this MOU;
iv. Ensure the appropriate level of MCP leadership (i.e., persons with
decision-making authority) are involved in implementation and oversight of the MOU
engagements and ensure the appropriate levels of leadership from LHD are invited to
participate in the MOU engagements, as appropriate;
v. Ensure training and education regarding MOU provisions are
conducted annually for MCP's employees responsible for carrying out activities under
this MOU, and as applicable for Subcontractors, Downstream Subcontractors, and
Network Providers; and
vi. Serve, or may designate a person at MCP to serve, as the MCP-
LHD Liaison, the point of contact and liaison with LHD or LHD programs. The MCP-LHD
Liaison is listed in Exhibit A of this MOU. MCP must notify LHD of any changes to the
MCP-LHD Liaison in writing as soon as reasonably practical but no later than the date
of change and must notify DHCS within five (5) Working Days of the change.
c. Compliance by Subcontractors, Downstream Subcontractors, and
Network Providers. MCP must require and ensure that its Subcontractors,
Downstream Subcontractors, and Network Providers, as applicable, comply with all
applicable provisions of this MOU.
5. LHD Obligations.
a. Provision of Services. LHD is responsible for services provided or made
available by LHD.
b. Oversight Responsibility. Fresno County's Director of Public Health, or
his or her designated LHD Responsible Person, listed in Exhibit B of this MOU, is
responsible for overseeing LHD's compliance with this MOU. It is recommended that
this person be in a leadership capacity with decision-making authority on behalf of LHD.
LHD must designate at least one person to serve as the designated LHD Program
Liaison, the point of contact and liaison with MCP, for the programs relevant to this
MOU. It is recommended that this person be in a leadership capacity at the program
level. The LHD Program Liaison(s) is listed in Exhibit B of this MOU. LHD may
designate a liaison(s) by program or service line. LHD must notify MCP of changes to
the LHD Program Liaison(s) as soon as reasonably practical but no later than the date
of change, except when such prior notification is not possible, in which case, notice
should be provided within five (5) Working Days of the change.
6. Training and Education.
a. To ensure compliance with this MOU, MCP must provide training and orientation
for its employees who carry out responsibilities under this MOU and, as applicable, for MCP's
Network Providers, Subcontractors, and Downstream Subcontractors who assist MCP with
carrying out MCP's responsibilities under this MOU. The training must include information on
MOU requirements, what services are provided or arranged for by each Party, and the policies
and procedures outlined in this MOU. For persons or entities performing these responsibilities
as of the Effective Date, MCP must provide this training within sixty (60) Working Days of the
Effective Date. Thereafter, MCP must provide this training prior to any such person or entity
performing responsibilities under this MOU and to all such persons or entities at least annually
thereafter. MCP must require its Subcontractors and Downstream Subcontractors to provide
training on relevant MOU requirements and LHD programs and services to its Network
Providers.
b. In accordance with health education standards required by the Medi-Cal
Managed Care Contract, MCP must provide educational materials to Members and Network
Providers related to accessing Covered Services, including for services provided by LHD.
c. MCP must provide LHD, Members, and Network Providers with training and/or
educational materials on how MCP's Covered Services and carved-out services may be
accessed, including during nonbusiness hours.
d. If MCP or LHD develops training and education resources covering the services
provided or arranged by the Parties, then each Party must share its training and education
resources with the other Party to ensure the information included in their respective training
and education resources sets forth an accurate set of services provided or arranged for by
each Party and is consistent with MCP and LHD policies and procedures, and with clinical
practice standards.
e. The Parties must make information that describes MCP Covered Services and/or
LHD services or programs under this MOU available to Members, LHD clients, and/or other
individuals who may be eligible for these resources.
f. MCP training materials shared with LHD must include billing and claims
requirements for LHD reimbursement for non-contracted LHD services pursuant to Section 13.
g. MCP must share LHD provider training and/or educational opportunities that
MCP is aware of with Network Providers and practitioners.
h. MCP must provide to the LHD Program Liaison(s) and LHD program providers
training and educational materials on MCP's Covered Services, including non-emergency
medical transportation ("NEMT") and non-medical transportation ("NMT"), to support LHD
program providers in assisting Members with accessing MCP's Covered Services.]
7. Referrals.
a. Referral Process. The Parties must work collaboratively to develop
policies and procedures that ensure Members are referred to the appropriate LHD
program.
i. The Parties must facilitate referrals to the relevant LHD program for
Members who may potentially meet the criteria of the LHD program and must ensure the LHD
program has procedures for accepting referrals from MCP or responding to referrals where
LHD programs cannot accept additional Members. Where applicable, such decisions should
be made through a patient-centered, shared decision-making process. LHD should facilitate
MCP referrals to LHD services or programs by assisting MCP in identifying the appropriate
LHD program and/or should provide referral assistance when it is required.
ii. MCP must refer Members to LHD for direct service programs as
appropriate including, without limitation, those set forth in Section 13.
iii. LHD should refer Members to MCP for any Community Supports
services or additional care management programs for which they may qualify, such as
Enhanced Care Management ("ECM") or Complex Case Management ("CCM"). However, if
LHD is an ECM/CCM Provider pursuant to a separate agreement between MCP and LHD for
ECM/CCM services, this MOU does not govern LHD's provision of ECM/CCM services.
iv. LHD should refer Members to MCP for Covered Services.
8. Care Coordination and Collaboration.
a. Care Coordination.
i. The Parties must adopt policies and procedures for coordinating
Members' access to care and services that incorporate all the specific requirements set forth in
this MOU, including those in the Program Exhibits.
ii. The Parties must discuss and address individual care coordination issues
or barriers to care coordination efforts at least quarterly.
iii. MCP must have policies and procedures in place to maintain collaboration
with LHD and to identify strategies to monitor and assess the effectiveness of this MOU.
CaIAIM Population Health Management Policy Guide available at:
https://www.dhcs.ca.gov/CalAIM/Documents/2023-PHM-Policy-Guide.pdf
6
9. Blood Lead Screening/Follow-up Testing and Lead Case Management.
a. Blood Lead Screening and Follow-up Testing.
i. MCP must cover and ensure the provision of blood lead screenings and
Medically Necessary follow up testing as indicated for Members at ages one (1) and two (2) in
accordance with Cal. Code Regs. tit. 17 Sections 37000 — 37100, the Medi-Cal Managed Care
Contract, and APL 20-016, or any superseding APL.
ii. MCP must coordinate with its Network Providers to determine whether
eligible Members have received blood lead screening and/or any Medically Necessary follow-
up blood lead testing. If eligible Members have not received blood lead screening or indicated
follow-up testing, MCP must arrange for and ensure each eligible Member receives blood lead
screening and any indicated follow-up blood lead testing.
iii. MCP must identify, at least quarterly, all Members under six (6) years of
age with no record of receiving a required blood lead screening and/or Medically Necessary
follow-up blood lead tests in accordance with CDPH requirements2 and must notify the Network
Provider or other responsible provider of the requirement to screen and/or test Members in
accordance with requirements set forth in the Medi-Cal Managed Care Contract.
iv. MCP must ensure that its Network Providers, including laboratories
analyzing for blood lead, report instances of elevated blood lead levels as required by Cal.
Health & Safety Code Section 124130.
v. To the extent LHD, in the administration of a program or service is made
aware that the child enrolled in MCP has not had a blood lead screening and to the extent that
LHD resources allow, LHD will notify MCP of the need for the child to be screened.
vi. If the Member refuses the blood lead screening test, MCP must comply
with the requirements set forth in the Medi-Cal Managed Care Contract to ensure a statement
of voluntary refusal by the Member (if an emancipated minor) or the parent(s) or guardian(s) of
the Member is documented in the Member's Medical Record.
b. Case Management for Elevated Blood Lead Levels
i. Where case management for elevated blood lead levels is provided by the
Childhood Lead Poisoning Prevention Branch ("CLPPB") and administered by Care
Management Section staff at CDPH, MCP must coordinate directly with the CLPPB to address
barriers to care coordination, case management, or other matters related to services for
children with elevated blood lead levels.
ii. Where case management for elevated blood lead levels is provided by
LHD as a contracted entity with the CDPH CLPPB, and to the extent LHD resources allow, MCP
must coordinate with the LHD Program Liaison, as necessary and applicable, to address
barriers to care coordination, case management, or other matters related to services for children
with elevated blood lead levels.
2 For more information see CDPH Childhood Lead Poisoning Prevention Branch,
Standard of Care on Screening for Childhood Lead Poisoning, available at:
https://www.cdph.ca.gov/Programs/CCDPHP/DEODC/CLPPB/Pages/screen reps
3.aspx
10.Quarterly Meetings.
a. The Parties must meet as frequently as necessary to ensure proper
oversight of this MOU, but not less frequently than quarterly in order to address care
coordination, Quality Improvement ("QI") activities, QI outcomes, systemic and case-
specific concerns, and communication with others within their organizations about such
activities. These meetings may be conducted virtually.
i. Within thirty (30) Working Days after each quarterly meeting, MCP
must post on its website the date and time the quarterly meeting occurred and, as
applicable, distribute to meeting participants a summary of any follow-up action items or
changes to processes that are necessary to fulfill MCP's obligations under the Medi-Cal
Managed Care Contract and this MOU.
ii. MCP must invite the LHD Responsible Person, LHD Program
Liaison(s), and LHD executives, to participate in MCP quarterly meetings to ensure
appropriate committee representation, including a local presence, and to discuss and
address care coordination and MOU-related issues. Subcontractors and Downstream
Subcontractors, as well as other LHD program staff should be permitted to participate in
these meetings, as appropriate.
iii. MCP must report to DHCS updates from quarterly meetings in a
manner and at a frequency specified by DHCS.
b. Local Representation. MCP, represented by the MCP-LHD Liaison, must
participate, as appropriate, at meetings or engagements to which MCP is invited by
LHD, such as local county meetings, local community forums, and LHD engagements,
to collaborate with LHD in equity strategy and wellness and prevention activities.
11.Quality Improvement. The Parties must develop QI activities specifically for the
oversight of the requirements of this MOU, including, without limitation any applicable
performance measures and QI initiatives, including those to prevent duplication of
services, as well as reports that track referrals, Member engagement, and service
utilization. MCP must document these QI activities in policies and procedures.
12. Population Needs Assessment ("PNA"). MCP will meet the PNA
requirements by demonstrating meaningful participation in LHD's Community Health
Assessments and Community Health Improvement Plans processes in the service
area(s) where MCP operates.3 MCP must coordinate with LHD to develop a process to
implement DHCS guidance regarding the PNA requirements once issued. MCP must
work collaboratively with LHD to develop and implement a process to ensure that MCP
and LHD comply with the applicable provisions of the PNA guidance within ninety (90)
days of issuance.
3 CaIAIM: Population Health Management Policy Guide (updated August 2023), available
at: https://www.dhcs.ca.gov/CalAIM/Documents/2023-PHM-Policy-Guide-August-
Update081723.pdf
8
13. Non-Contracted LHD Services. If LHD does not have a separate Network
Provider Agreement with MCP and provides any of the following services as an out-of-
network provider:
a. sexually transmitted infection ("STI") screening, assessment, and/or
treatment;
b. family planning services; if applicable
c. immunizations; and
d. HIV testing and counseling.
MCP must reimburse LHD for these services at no less than the Medi-Cal Fee-For-
Service ("FFS") rate as required by the Medi-Cal Managed Care Contract and as
described in Exhibit C of this MOU.
14. Data Sharing and Confidentiality. The Parties must implement policies and
procedures to ensure that the minimum necessary Member information and data for
accomplishing the goals of this MOU are exchanged timely, maintained securely and
confidentially, and in compliance with the requirements set forth below. The Parties must
share information in compliance with applicable law, which may include the Health Insurance
Portability and Accountability Act and its implementing regulations, as amended ("HIPAX), 42
Code of Federal Regulations Part 2, and other State and federal privacy laws.
a. Data Exchange. MCP must, and LHD is encouraged to, share the
minimum necessary data and information to facilitate referrals and coordinate care
under this MOU. The Parties must have policies and procedures for supporting the
timely and frequent exchange of Member information and data, which may include
Member demographic, behavioral, dental and physical health information, diagnoses,
progress notes, assessments, medications prescribed, laboratory results, and known
changes in condition that may adversely impact the Member's health and/or welfare and
that are relevant to the services provided or arranged for by LHD; for ensuring the
confidentiality of exchanged information and data; and, if necessary, for obtaining
Member consent. The minimum necessary information and data elements to be shared
as agreed upon by the Parties are set forth in Exhibit G of this MOU. The Parties must
annually review and, if appropriate, update Exhibit G to facilitate sharing of information
and data.
i. MCP must, and LHD is encouraged to, share information necessary
to facilitate referrals as described in Section 7 and further set forth in the Program
Exhibits. The data elements to be shared must be agreed upon jointly by the Parties,
reviewed annually, and set forth in this MOU.
ii. Upon request, MCP must provide the immunization status of the
Members to LHD pursuant to the Medi-Cal Managed Care Contract and as may be
described in Exhibit G.
b. MCP shall exchange data with the health information exchange (HIE)
system designated in Fresno County or Secure File Transfer Protocol
(SFTP)Interoperability. MCP must make available to Members their electronic
health information held by MCP pursuant to 42 Code of Federal Regulation Section
438.10 and in accordance with APL 22-026. MCP must make available an application
program interface that makes complete and accurate Network Provider directory
information available through a public-facing digital endpoint on MCP's website
pursuant to 42 Code of Federal Regulation Sections 438.242(b) and 438.10(h).
15. Dispute Resolution.
a. The Parties must agree to dispute resolution procedures such that in the
event of any dispute, difference of opinion regarding the Party responsible for service
coverage arising out of or relating to this MOU, the Parties must attempt, in good
faith, to promptly resolve the dispute mutually between themselves. MCP must, and
LHD should, document the agreed-upon dispute resolution procedures in policies and
procedures. Pending resolution of any such dispute, MCP and LHD must continue
without delay to carry out all their responsibilities under this MOU, including providing
Members with access to services under this MOU, unless this MOU is terminated. If
the dispute cannot be resolved within fifteen (15) Working Days of initiating such
dispute or such other period as may be mutually agreed to by the Parties in writing,
either Party may pursue its available legal and equitable remedies under California
law.
b. Disputes between MCP and LHD that cannot be resolved in a good faith
attempt between the Parties must be forwarded by MCP to DHCS and may be
forwarded by LHD to DHCS. Until the dispute is resolved, the Parties may agree to an
arrangement satisfactory to both Parties regarding how the services under dispute will
be provided.
c. Nothing in this MOU or provision constitutes a waiver of any of the
government claim filing requirements set forth in Title I, Division 3.6, of the California
Government Code or as otherwise set forth in local, State, or federal law.
16.Equal Treatment. Nothing in this MOU is intended to benefit or prioritize
Members over persons served by LHD who are not Members. Pursuant to Title VI, 42
United States Code Section 2000d, et seq., LHD cannot provide any service, financial
aid, or other benefit to an individual that is different, or is provided in a different manner,
from that provided to others by LHD.
17.General.
a. MOU Posting. MCP must post this executed MOU on its website.
b. Documentation Requirements. MCP must retain all documents
demonstrating compliance with this MOU for at least ten (10) years as required by the
Medi- Cal Managed Care Contract. If DHCS requests a review of any existing MOU,
MCP must submit the requested MOU to DHCS within ten (10) Working Days of
receipt of the request.
c. Notice. Any notice required or desired to be given pursuant to or in
connection with this MOU must be given in writing, addressed to the noticed Party at
the Notice Address set forth below the signature lines of this MOU. Notices must be (i)
delivered in person to the Notice Address; (ii) delivered by messenger or overnight
delivery service to the Notice Address; (iii) sent by regular United States mail, certified,
return receipt requested, postage prepaid, to the Notice Address; or (iv) sent by email,
with a copy sent by regular United States mail to the Notice Address. Notices given by
in-person delivery, messenger, or overnight delivery service are deemed given upon
actual delivery at the Notice Address. Notices given by email are deemed given the day
following the day the email was sent. Notices given by regular United States mail,
certified, return receipt requested, postage prepaid, are deemed given on the date of
delivery indicated on the return receipt. The Parties may change their addresses for
purposes of receiving notice hereunder by giving notice of such change to each other in the
manner provided for herein.
d. Delegation. MCP may delegate its obligations under this MOU to a Fully
Delegated Subcontractor or Partially Delegated Subcontractor as permitted under the
Medi-Cal Managed Care Contract, provided that such Fully Delegated Subcontractor or
Partially Delegated Subcontractor is made a Party to this MOU. Further, the Parties may
enter into Subcontractor Agreements or Downstream Subcontractor Agreements that
relate directly or indirectly to the performance of MCP's obligations under this MOU.
Other than in these circumstances, MCP cannot delegate the obligations and duties
contained in this MOU.
e. Annual Review. MCP must conduct an annual review of this MOU to
determine whether any modifications, amendments, updates, or renewals of
responsibilities and obligations outlined within are required. MCP must provide DHCS
evidence of the annual review of this MOU as well as copies of any MOU modified or
renewed as a result.
f. Amendment. This MOU may only be amended or modified by the Parties
through a writing executed by the Parties. However, this MOU is deemed automatically
amended or modified to incorporate any provisions amended or modified in the Medi-
Cal Managed Care Contract, or as required by applicable law or any applicable
guidance issued by a State or federal oversight entity.
g. Insurance. Each Party shall insure its activities in connection with this
MOU and maintain at all times insurance in coverage and limit amounts reasonably
necessary to protect itself against injuries and damages arising from the acts or
omissions caused by each Party, their respective Boards, officers, employees and
agents in the performance of this MOU. This insurance requirement may be satisfied
through a program of self-insurance, or insurance coverage afforded to public entities
through a Joint Powers Authority (JPA) risk pool.
h. Governance. This MOU is governed by and construed in accordance with
the laws of the State of California.
i. Independent Contractors. No provision of this MOU is intended to
create, nor is any provision deemed or construed to create any relationship between
LHD and MCP other than that of independent entities contracting with each other
hereunder solely for the purpose of effecting the provisions of this MOU. Neither LHD
nor MCP, nor any of their respective contractors, employees, agents, or
representatives, is construed to be the contractor, employee, agent, or representative of
the other.
j. Termination without Cause. The Parties may terminate this
Agreement by giving at least sixty (60) days advance written notice.
k. Counterpart Execution. This MOU may be executed in counterparts,
signed electronically and sent via PDF, each of which is deemed an original, but all of
which, when taken together, constitute one and the same instrument.
I. Superseding MOU. This MOU constitutes the final and entire agreement
between the Parties and supersedes any and all prior oral or written agreements,
negotiations, or understandings between the Parties that conflict with the provisions set
forth in this MOU. It is expressly understood and agreed that any prior written or oral
agreement between the Parties pertaining to the subject matter herein is hereby
terminated by mutual agreement of the Parties.
(Remainder of this page intentionally left blank)
Docusign Envelope ID:OA713872-6B99-474B-ABF6-F844F6BAA8DF
The Parties represent that they have authority to enter into this MOU on behalf of
their respective entities and have executed this MOU as of the Effective Date.
Blue Cross of California Partnership Plan, Inc. COUNTY OF FRESNO:
t4 Digitally signed
,by Les Ybarra
-f'Date:2025.06.23
Signature: 16:28:10-07'00' Signature
Date:6/23/2025 Date: -a 0 a 5-
Name: Les Ybarra Name: Ernest Buddy Mendes
Title: President Title: Chairman of the Board of
Supervisors of the County of
Fresno
Notice Address: Notice Address:
21215 Burbank Blvd. Suite 100 Director, County of Fresno
Woodland Hills, CA 91367 Department of Public Health
P.O. Box 11867
Fresno, CA 93775
ATTEST:
Bernice E. Seidel
Clerk of the Board of Supervisors
County of Fresno, State of California
By: -?el� --
Deputy
FRESNO COUNTY:
FOR ACCOUNTING USE ONLY:
Org No.: 56201650 ($12,400.00) Org No.: 56201601 ($71,600.00)
56201654 ($15,700.00) Account No. 5036
Account No.: 5027 Fund No.: 0001
Fund No.: 0001 Subclass No.:10000
Subclass No.:10000
13
Docusign Envelope ID:OA713872-6B99-474B-ABF5-F844F5BAA8DF
The FRESNO-KINGS-MADERA REGIONAL HEALTH AUTHORITY, dba CALVIVA
HEALTH:
Signature: a"Mq4�t
Date: 7 t3 t o z s
Name: Jeffrey Nkansah
Title: Chief Executive Officer (CEO)
Notice Address:
7625 North Palm Avenue, Suite 109
Fresno, CA 93711
CalViva Health Subcontractor: Health Net Community Solutions, Inc.
Signature: 'V
Date: 07/09/2025
Name: Dorothy Seleski
Title: Medi-Cal President
Notice Address:
21281 Burbank Blvd.
Woodland Hills, CA 91367
14
Docusign Envelope ID:OA713872-6B99-474B-ABF5-F844F5BAA8DF
KAISER FOUNDATION HEALTH PLAN, INC.:
DocuSigned by:
a wig mis
Signature: D ArA'i(7ggCAPfI
Date: 6/30/2025 1 2:40 PM PDT
Name: Celia Williams
Title: Executive Director, Medicaid Care Delivery and Operations
Notice Address: 393 E. Walnut St., Pasadena, CA 91188
Electronic Delivery: KPMOU@kp.org
15
Exhibits A and B.
MCP and LHD Program Liaisons as referenced in Sections 4.b and 5.b
of this MOU
Exhibit A
MCP Liaison MCP Liaison MCP Liaison
Programs CalViva Health &
Anthem Health Net Kaiser Permanente
Mgr I GBD Quality Mgmt -
Childhood Lead Poisoning Plan (US) CA Medicaid Program Manager; Director of MOU
Prevention Program QM; County Account Service Coordination Implementation;
Management Program Liaison MOU Coordinator
Manager
Mgr I GBD Quality Mgmt -
Plan (US) CA Medicaid Program Manager; Director of MOU
Immunization Program QM; County Account Service Coordination Implementation;
Management Program Liaison MOU Coordinator
Manager
Provider Clinical Liaison Program Manager; Director of MOU
HIV/STD Program CA (US); County Account Service Coordination Implementation;
Management Program Liaison MOU Coordinator
Manager
Provider Clinical Liaison Program Manager; Director of MOU
Tuberculosis Services CA (US); County Account
Program Management Program Service Coordination Implementation;
Liaison MOU Coordinator
Manager
Maternal, Child, and Provider Clinical Liaison Program Manager; Director of MOU
Adolescent Health CA (US); County Account Service Coordination Implementation;
Program Management Program Liaison MOU Coordinator
Manager
Mgr I Medical Mgmt Program Manager;
California Children's (US) — CA Medicaid Service Coordination Director of MOU
HCMS; County Account Implementation;
Services Program Liaison; Public Programs
Management Program MOU Coordinator
Manager CCS Liaison
16
Exhibit B
Programs Designated LHD Program
Liaison(s)
Childhood Lead Poisoning Prevention Program Community Health Division Manager or his/her
Pro ram Desi nee
Immunization Program Community Health Division Manager or his/her
Program Designee
HIV/STD Program Community Health Division Manager or his/her
Pro ram Desi nee
Tuberculosis Services Program Community Health Division Manager or his/her
Program Designee
Maternal, Child, and Adolescent Health Program Public Health Nursing Division Manager or his/her
Program Designee
California Children's Services Program Children's Medical Services Division Manager or
his/her Program Designee
17
Exhibit C. Non-Contracted LHD Services.
This Exhibit C governs LHD's provision of any of the services listed below only to the
extent that such services are provided by LHD as a non-contracted Provider of MCP
Covered Services. If LHD has a Network Provider Agreement with MCP pursuant to
which any of these services are covered, such Network Provider Agreement governs.
a. Immunizations. MCP is responsible for providing all immunizations to
Members recommended by the Centers for Disease Control and Prevention ("CDC")
Advisory Committee on Immunization Practices ("ACIP") and Bright Futures/American
Academy of Pediatrics ("AAP") pursuant to the Medi-Cal Managed Care Contract and
must allow Members to access immunizations through LHD regardless of whether LHD
is in MCP's provider network, and MCP must not require prior authorization for
immunizations from LHD.
i. MCP must reimburse LHD for immunization services provided
under this MOU at no less than the Medi-Cal FFS rate.
ii. MCP must reimburse LHD for the administration fee for
immunizations given to Members who are not already immunized as of the date of
immunization, in accordance with the terms set forth in APL 18-004.
b. Sexually Transmitted Infections ("STI") Services, HIV Testing and
Counseling. MCP must ensure Members have access to STI testing and treatment
and HIV testing and counseling services, including access through LHD pursuant to
42 United States Code Sections 1396a(a)(23) and 1396n(b) and 42 Code of Federal
Regulations Section 431 .51.
i. MCP must not require prior authorization or referral for Members to
access STI or HIV testing services.
ii. MCP must reimburse LHD for STI services under this MOU at a
rate no less than the Medi-Cal FFS rate for the diagnosis and treatment of an STI
episode, as defined in Policy Letter No. 96-09.
iii. If LHD provides HIV testing and counseling services to Members,
MCP, in accordance with the Medi-Cal Managed Care Contract and federal law,
including, but not limited to, 42 U.S.C. §§ 1396a(a)(23) and 1396n(b) and 42 Code of
Federal Regulations Section 431.51, must reimburse LHD at a rate no less than the
Medi-Cal FFS rate for such services as defined in PL § 96-09.
c. Reimbursement. MCP must reimburse the aforementioned STI testing
and treatment, and HIV testing and counseling services only if LHD submits to MCP
the appropriate billing information and either treatment records or documentation of
a Member's refusal to release medical records to MCP.
Exhibit D. Tuberculosis ("TB") Screening, Diagnosis, Treatment, and Care
Coordination.
1. Parties' Obligations.
a. MCP must ensure access to care for latent tuberculosis infection ("LTBI")
and active TB disease and coordination with LHD TB Control Programs for Members
with active tuberculosis disease, as specified below.
b. MCP must arrange for and coordinate outpatient diagnostic and treatment
services to all Members with suspected or active TB disease to minimize delays in
initiating isolation and treatment of infectious patients. These outpatient services include
physical examination, drug therapy, laboratory testing, and radiology.
c. MCP must consult with LHD to assess the risk of noncompliance with drug
therapy for each Member who requires placement on anti-TB drug therapy, in
accordance with the Medi-Cal Managed Care Contract.
2. Care Coordination.
a. LTBI Testing and Treatment.
i. TB Risk Assessment. MCP must provide screening through
Network Providers for LTBI in all Members with risk factors for TB infection as
recommended by the U.S. Preventive Services Task Force ("USPSTF") and the AAP.4
The CDPH TB Risk Assessment Tools5 should be used to identify adult and pediatric
patients at risk for TB.
ii. TB Testing. MCP should encourage Network Providers to offer TB
testing to Members who are identified with risk factors for TB infection and should
recommend the Interferon Gamma Release Assay ("IGRA") blood test for Members
when screening for LTBI in order to comply with current standards outlined by the CDC,
CDPH, the California TB Controllers Association,6 and/or the American Thoracic Society
("ATS")7 for conducting TB screening.
iii. Other Diagnostic Testing and Treatment. MCP must arrange for
and coordinate outpatient diagnostic and treatment services to all Members with LTBI.
These outpatient services include physical examination, drug therapy, laboratory
testing, and radiology.
4 AAP, Red Book Report of the Committee on Infectious Diseases, 32nd Ed., available at:
https:Hpublications.aap.org/redbook/book/347/chapter/5748923/l ntroduction
5 CDPH, TB Risk Assessment Tools, available at:
https://www.cdph.ca.gov/Programs/CID/DCDC/Pages/TB-Risk-Assessment.aspx
6 California Tuberculosis Controllers Association ("CTCA"), Latent Tuberculosis Infection
Guidance for Preventing Tuberculosis in California, available at:
https:Hctca.org/guidelines/guidelines-latent-tuberculosis-infection-guideline/
ATS/Infectious Diseases Society of America/CDC Clinical Practice Guidelines: Diagnosis of
Tuberculosis in Adults and Children, available at:
https://www.thoracic.org/statements/resources/tb-opi/diagnosis-of-tuberculosis-in-adults-and-
children.PDF
19
iv. LTBI Treatment. MCP should instruct Network Providers to ensure
Members have access to LTBI treatment in accordance with the updated 2023 USPSTF
Recommendation$ and CDC LTBI Treatment Guidelines9, which recommend treating
individuals diagnosed with LTBI.
b. Reporting of Known or Suspected Active TB Cases.
i. MCP must require Network Providers to report to LHD by electronic
transmission, phone, fax, and/or the Confidential Morbidity Report10 known or
suspected cases of active TB disease for any Member residing in Fresno County within
one day of identification in accordance with Cal. Code Regs. tit. 17 Section 2500.
ii. MCP must obtain LHD's Health Officer (or designee's) approval in
the jurisdiction where the hospital is located, prior to hospital discharge or transfer of
any patients with known or suspected active TB disease.11
c. Active TB Disease Testing and Treatment.
i. MCP is encouraged to ensure Members are referred to specialists
with TB experience (e.g., infectious disease specialist, pulmonologist) or to LHD's TB
clinic, when needed or applicable.
ii. Treatment Monitoring. MCP must provide Medically Necessary
Covered Services to Members with TB, such as treatment monitoring, physical
examinations, radiology, laboratory, and management of drug adverse events, including
but not limited to the following:
1. Requiring Network Providers to obtain at least monthly
sputum smears and cultures for acid-fast bacillus until there is a documented
conversion to negative culture and referring patients unable to spontaneously produce
sputum specimens to sputum induction or BAL, as needed.
2. Promptly submitting initial and updated treatment plans to
LHD at least every three (3) months until treatment is completed.
3. Reporting to LHD when the patient does not respond to
treatment or misses an appointment.
4. Promptly reporting drug susceptibility results to LHD and
ensuring access to rapid molecular identification and drug resistance testing during
diagnosis and treatment as recommended by LHD.
8 US Preventive Services Task Force, Screening for Latent Tuberculosis Infection in Adults
(May 2, 2023):
https:Hmamanetwork.com/journals/lama/fullarticle/2804319?utm campaign=articlePDF&utm me
dium=articlePDFlink&utm source=articlePDF&utm content=iama.2023.3954
9 CTCA, Latent Tuberculosis Infection Guidance for Preventing Tuberculosis in California,
available at: https:Hctca.org/guidelines/guidelines-latent-tuberculosis-infection-guideline/.
10 CDPH, TB Confidential Morbidity Report, available at:
https://www.cdph.ca.gov/CDPH%20Document%2OLibrarV/ControlledForms/cdphl 10b.pdf.
11 Cal. Health & Safety Code Sections 121365 and 121367 grant local health officers with the
authority to issue any orders deemed necessary to protect the public health which may include
authorizing the removal to, detention in, or admission into, a health facility or other treatment
facility.
20
iii. Treatment.
1. LHD and MCP must coordinate the provision of medication
prescriptions for each Member to fill at an MCP-approved pharmacy.
2. LHD should coordinate the provision of TB treatment and
related services, including for the provision of a treatment plan, with the Member's
primary care physician ("PCP") or other assigned clinical services provider.
3. LHD and MCP will coordinate the inpatient admission of
Members being treated by LHD for TB.
iv. Case Management.
1. LHD is encouraged to refer Members to MCP for ECM and
Community Supports when LHD assesses the Member and identifies a need. MCP is
encouraged to require its Network Providers to refer all Members with suspected or
active TB disease, to the LHD Health Officer (or designee) for Directly Observed
Therapy ("DOT") evaluation and services.
2. MCP must continue to provide all Medically Necessary
Covered Services to Members with TB receiving DOT.
3. MCP must assess Members with the following conditions or
characteristics for potential noncompliance and for consideration for DOT: substance
users, persons with mental illness; the elderly, child, and adolescent Members; persons
with unmet housing needs; persons with complex medical needs (e.g., end-stage renal
disease, diabetes mellitus); and persons with language and/or cultural barriers. If a
Member's Network Provider believes that a Member with one or more of these risk
factors is at risk for noncompliance, MCP must refer the Member to LHD for DOT.
4. LHD is responsible for assigning a TB case manager to
notify the Member's PCP of suspected and active TB cases, and the TB case manager
must be the primary LHD contact for coordination of care with the PCP or a TB
specialist, whomever is managing the Member's treatment.
5. MCP should provide LHD with the contact information for the
MCP-LHD Liaison to assist with coordination between the Network Provider and LHD
for each diagnosed TB patient, as necessary.
6. LHD is responsible for assigning a TB case manager to
notify the designated Network Provider of suspected and active cases, and the TB case
manager must be the primary LHD contact for coordination of care with Network
Providers.
d. Case and Contact Investigations.
i. As required by Cal. Health & Safety Code Sections 121362 and
121363, MCP must ensure that Network Providers share with LHD any testing,
evaluation, and treatment information related to LHD's contact and/or outbreak
investigations. The Parties must cooperate in conducting contact and outbreak
investigations.
ii. LHD is responsible for conducting contact investigation activities for
all persons with suspected or confirmed active TB in accordance with Cal. Health &
Safety Code Sections 121363 and 121365 and CDPH/CTCA contact investigations
guidelines,12 including:
1. Identifying and ensuring recommended testing, examination,
and other follow-up investigation activities for contacts with suspected or confirmed
active cases;
2. Communicating with MCP's Network Providers about
guidance for examination of contacts and chemoprophylaxis; and
3. Working with Network Providers to ensure completion of TB
evaluation and treatment.
iii. MCP is responsible for ensuring its Network Providers cooperate
with LHD in the conduct of contact investigations,13 including:
1. Providing medical records as requested and specified within
the time frame requested;
2. Ensuring that its case management staff will be available to
facilitate or coordinate investigation activities on behalf of MCP and its Network
Providers, including requiring its Network Providers to provide appropriate examination
of Members identified by LHD as contacts within seven (7) days;
3. Ensuring Member access to LTBI testing and treatment and
following LTBI Treatment Guidelines published by the CDC.14
4. Requiring that its Network Providers to provide the
examination results to LHD within one day for positive TB results, including:
(a) Results of IGRA or tuberculin tests conducted by
Network Providers;
(b) Radiographic imaging or other diagnostic testing, if
performed; and
(c) Assessment and diagnostic/treatment plans, following
evaluation by the Network Provider.
3. Quality Assurance and Quality Improvement. MCP must consult regularly with
LHD to develop outcome and process measures for care coordination as required by
this Exhibit D for the purpose of measurable and reasonable quality assurance and
improvement.
12 CDPH/CTCA Guidelines for the Assessment of Tuberculosis Patient Infectiousness and
Placement into High and Lower Risk Settings, available at: https://ctca.org/wp-
content/uploads/2018/11/ctcaciquidelines117 2.pdf; CDPH TB Control Branch, Resources for
Local Health Departments, available at:
https://www.cdph.ca.gov/Programs/CID/DCDC/Pages/TB-Resources-for-LH Ds.aspx
13 Cal. Health & Safety Code Section 121350-121460 (standards for tuberculosis control).
14 CDC, Latent Tuberculosis Infection Resources, available at:
https://www.cdc.gov/tb/publications/Itbi/itbiresources.htm
22
Exhibit E. Maternal Child and Adolescent Health.
This Exhibit E governs the coordination between LHD Maternal, Child and Adolescent
Health Programs ("MCAH Programs") and MCP for the delivery of care and services to
Members who reside in LHD's service area and may be eligible for one or more MCAH
Program to the extent such programs are offered by LHD. These MCAH programs
include, but are not limited to, the Black Infant Health Program, the Adolescent Family
Life Program, the California Home Visiting Program, and/or the Children and Youth with
Special Health Care Needs Program.
1. Parties' Obligations.
a. Per service coverage requirements under Medi-Cal for Kids and Teens,
previously known as Early and Periodic Screening, Diagnostic, and Treatment
("EPSDT"),15 MCP must ensure the provision of all screening, preventive, and Medically
Necessary diagnostic and treatment services for Members under twenty-one (21) years
of age.
b. The MCP Responsible Person serves, or may designate a person at MCP
to serve, as the day-to-day liaison with LHD specifically for MCAH Programs (e.g., the
MCP-MCAH Liaison); the MCP-MCAH Liaison is listed in Exhibit A (the designated
person may be the same as the MCP-LHD Liaison). MCP must notify LHD of any
changes to the MCP-MCAH Liaison in accordance with Section 4 of this MOU.
c. To the extent that programs are offered by LHD and to the extent LHD
resources allow, LHD must administer MCAH Programs, funded by CDPH, in
accordance with CDPH guidance set forth in the Local MCAH Programs Policies and
Procedures manual16 and other guidance documents.
d. The LHD Responsible Person may also designate a person to serve as
the day-to-day liaison with MCP specifically for one or more MCAH Programs (e.g., LHD
Program Liaison(s)); the LHD Program Liaison(s) is listed in Exhibit B. LHD must notify
MCP of changes to the LHD Program Liaison in accordance with Section 5 of this MOU.
2. Referrals to, and Eligibility for and Enrollment in, MCAH Programs.
a. MCP must coordinate, as necessary, with the Network Provider, Member,
and MCAH Program to ensure that the MCAH Program receives any necessary
information or documentation to assist the MCAH Program with performing an eligibility
assessment or enrolling a Member in an MCAH Program.
b. MCP must collaborate with LHD to update referral processes and policies
designed to address barriers and concerns related to referrals to and from MCAH
Programs.
15 Additional guidance available in APL 23-005:
https://www.dhcs.ca.gov/formsandpubs/Documents/MMCDAPLsandPolicyLetters/APL2023/APL
23-005.pdf
16 CDPH, Local MCAH Programs Policies and Procedures (updated May 2023), available at:
23
https://www.cdph.ca.gov/Programs/CFH/DMCAH/LocaiMCAH/CDPH%2ODocument%2OLibrary/
MCAH-Policies-and-Procedures.pdf
24
c. LHD is responsible for providing MCP with information regarding how
MCP and its Network Providers can refer to an MCAH Program, including, as
applicable, referral forms, links, fax numbers, email addresses, and other means of
making and sending referrals to MCAH Programs. LHD is responsible for working with
MCP, as necessary, to revise referral processes and to address barriers and concerns
related to referrals to MCAH Programs.'
d. LHD is responsible for the timely enrollment of, and follow-up with,
Members eligible for MCAH Programs in accordance with MCAH Programs' enrollment
practices and procedures and to the extent LHD resources allow. LHD must assess
Member's eligibility for MCAH Programs [and/or enrolling Members, as applicable in
MCAH Programs within five (5) Working Days of receiving a referral.
e. LHD is responsible for coordinating with MCAH Programs to conduct the
necessary screening and assessments to determine Members' eligibility for and the
availability of one or more MCAH Programs and coordinate with MCP and/or its
Network Providers as necessary to enroll Members.18
f. LHD MCAH Programs are not entitlement programs and may deny or
delay enrollment if programs are at capacity.
3. Care Coordination and Collaboration.
a. MCP and LHD must coordinate to ensure Members receiving services
through MCAH Programs have access to prevention and wellness information and
services. LHD is encouraged to assist Members with accessing prevention and wellness
services covered by MCP, by sharing resources and information to with Members about
services for which they are eligible, to address needs identified by MCAH Programs'
assessments.
b. MCP must screen Members for eligibility for care management programs
such as CCM and ECM, and must, as needed, provide care management services for
Members enrolled in MCAH Programs, including for comprehensive perinatal services,
high-risk pregnancies, and children with special health care needs. MCP must engage
LHD, as needed, for care management and care coordination.
c. MCP should collaborate with MCAH Programs on perinatal provider
technical support and communication regarding perinatal issues and service delivery
and to monitor the quality of care coordination.
" CDPH, Local MCAH Programs Policies and Procedures, available at:
https://www.cdph.ca.gov/Programs/CFH/DMCAH/LocaIMCAH/CDPH%2ODocument%2OLibrary/
MCAH-Policies-and-Procedures.pdf
Local Programs Policies and Procedures, available at
https://www.cdph.ca.gov/Programs/CFH/DMCAH/LocaIMCAH/CDPH%2ODocument%2OLibrary/
MCAH-Policies-and-Procedures.pdf
25
4. Coordination of Medi-Cal for Kids and Teens (formerly EPSDT) Services.19
i. Where MCP and LHD have overlapping responsibilities to provide
services to Members under twenty-one (21) years of age, MCPs must do the
following:
1. Assess the Member's need for Medically Necessary EPSDT
services, including mental, behavioral, social, and/or developmental services, utilizing
the AAP Periodicity Table20 and the CDC's ACIP child vaccination schedule", the
required needs assessment tools.
2. Determine what types of services (if any) are being provided
by MCAH Programs, or other third-party programs or services.
3. Coordinate the provision of services with the MCAH
Programs to ensure that MCP and LHD are not providing duplicative services and that
the Member is receiving all Medically Necessary EPSDT services within sixty (60)
calendar days following the preventive screening or other visit identifying a need for
treatment regardless of whether the services are Covered Services under the Medi-Cal
Managed Care Contract.
5. Quarterly Meetings.
a. MCP must invite the LHD Responsible Person and LHD Program
Liaison(s) for MCAH Programs to participate in MCP quarterly meetings as needed to
ensure appropriate committee representation, including a local presence, and in order
to discuss and address care coordination and MOU-related issues. Other MCAH
Program representatives may be permitted to participate in quarterly meetings.
b. MCP must participate, as appropriate, in meetings or engagements to
which MCP is invited by LHD, such as local county meetings, local community forums,
and county engagements, to collaborate with LHD for MCAH Programs on equity
strategy and prevention activities.
c. MCP and LHD may collaborate to collect feedback from Members in
MCAH Programs on topics of interest to Parties through surveys, focus groups, or
other agreed-upon methods, and in accordance with this MOU.
6. Quality Improvement. MCP and LHD must ensure issues related to MCAH
Program coordination and collaboration are included when addressing barriers to
carrying out the obligations under this MOU.
19 Additional guidance available in APL 23-005:
https://www.dhcs.ca.gov/formsandpubs/Documents/M MCDAPLsand PolicVLetters/APL2023/APL
23-005.pdf
20 AAP Periodicity Table available at:
https:HdownIoads.aaP.org/AAP/PDF/periodicity schedule.pdf
21 CDC ACIP Child Vaccination Schedule available at: https://www.cdc.gov/vaccines/hcp/acip-
recs/index.html
26
7. Data Information and Exchange.
The Parties agree to the following additional requirements:
a. MCP and LHD must exchange data and Member enrollment information
in MCAH Programs and Member information related to prevention, wellness, and
home visiting activities, or services designed to minimize health disparities, to ensure
Members are receiving all Medically Necessary services
b. LHD will seek authorization from MCAH Program participants eligible to
enroll in MCP services or programs such as ECM or Community Supports so LHD
can provide MCP with participants' information regarding their needs for MCP
Covered Services.
c. MCP shall provide LHD with reports that includes a list of pregnant
and/or postpartum members with demographic information, race, ethnicity, and zip
codes on an agreed upon cadence.
Exhibit F. California Children's Services.
This Exhibit F governs LHD's provision of the California Children's Services ("CCS")
Program only to the extent that such services are provided by LHD. MCP and LHD will
collaborate to coordinate care, conduct administrative activities, and exchange
information required for the effective and seamless delivery of services to MCP's
Members enrolled, or eligible to enroll, in the CCS Program. This Exhibit F does not
apply to an LHD or MCP that operates the Whole Child Model ("WCM").
This Exhibit delineates the roles and responsibilities of MCP and LHD for coordinating
care and ensuring the non-duplication of services for Members eligible for or enrolled in
the CCS Program.
1. Party Obligations.
a. MCP Obligations.
i. MCP must ensure all Medically Necessary Covered Services
related to the CCS condition are provided until a determination of CCS Program
eligibility is made. MCP must continue to provide all Medically Necessary Covered
Services to the Member if the CCS Program determines the referred Member is not
eligible for the CCS Program and for services not provided through the CCS Program.
ii. MCP must provide all Medically Necessary Covered Services not
authorized by the CCS Program for CCS-enrolled Members, including, without
limitation, Medi-Cal for Kids and Teens (previously known as EPSDT) services,
pediatric preventive services, and immunizations unless determined to be medically
contraindicated in accordance with the Medi-Cal Managed Care Contract and APL 23-
005.
iii. It is MCP's responsibility to provide case management (arranging
PDN hours) in accordance with APL 20-012 and any superseding APL or other, similar
guidance.
iv. MCP must provide to the CCS Program, in a timely manner, all
medical utilization and other clinical data necessary for the CCS Program to complete
annual medical determinations and redeterminations, as well as other medical
determinations, as needed, for CCS-eligible Members.
b. LHD Obligations.
i. LHD must ensure that its CCS Program authorizes and provides
medical case management services for the medical conditions outlined and authorized
in Cal. Code Regs. tit. 22 Sections 41410-41518.9 for Members who have CCS-covered
conditions (referred to as "CCS-Eligible Condition(s)").22
ii. LHD is responsible for making all CCS Program medical, financial,
and residential eligibility determinations for potential CCS-eligible Members, including
responding to and tracking appeals relating to CCS Program eligibility determinations
and annual redeterminations.
2. Training and Education.
a. The training and education that MCP is required to provide under Section
6 of this MOU must include information about LHD's CCS Program, how to refer
Members to the CCS Program, and how to assist Members with accessing CCS
Program services.
b. The training MCP is required to provide under Section 6 of this MOU must
include:
i. Instructions on how to complete the appropriate baseline health
assessments and diagnostic evaluations, which provide sufficient clinical detail to
establish or raise a reasonable suspicion that a Member has a CCS-Eligible Condition;
ii. Instructions on how to refer Members with a suspected CCS-
Eligible Condition on the same day the evaluation is completed, using methods
accepted by LHD (the initial referral must be followed by the submission of supporting
medical documentation sufficient to allow for CCS Program eligibility determination by
LHD);
iii. A statement that the CCS Program reimburses only CCS-paneled
providers and CCS-approved hospitals;
22 Covered conditions and regulations applicable to the CCS Program are described by CCS
Numbered Letters ("NU) located on the CCS website, available at:
httos://www.dhcs.ca.gov/services/ccs/Pages/CCSNL.aspx
29
iv. A statement that the Network Provider must continue to provide all
Medically Necessary Covered Services to the Member until the Member's CCS
Program eligibility is confirmed;
v. Information on how to refer Members in LHD's CCS Program to
community resources; and
vi. Information on how the PCP can assist with accessing CCS
Program authorized services and can coordinate such services with other services
Members may receive.
3. Referrals and Eligibility Determinations.
a. MCP Referrals. MCP is responsible for assisting Network Providers with
identifying potentially CCS-eligible Members for whom there is diagnostic evidence that
such Members have a CCS-Eligible Condition in accordance with Cal. Code Regs. tit.
22 Section 41515.1 and referring such Members to LHD to determine whether the
Members are eligible for the CCS Program.
i. MCP must include with its Member referrals documentation of the
Member's medical and residential information to enable LHD to make an eligibility
determination for the CCS Program.
ii. MCP must refer, or assist Network Providers with referring, to
LHD's CCS Program for CCS initial eligibility determinations a Member who:
1. Has a medical diagnosis, records, or history suggesting
potential CCS-Eligible Condition(s) as outlined in the CCS medical eligibility regulations;
2. Presents at a hospital emergency room, a provider office, or
another health care facility for a non-CCS condition, and for whom the medical
evaluation identifies a potential CCS-Eligible Condition(s);
3. Is an infant with a potential CCS-Eligible Condition at the
time of discharge from the neonatal intensive care unit (such Member must be
assessed for eligibility and, if eligible, referred to the CCS Program's HRIF program); or
4. Has diagnostic evidence that the Member has a condition
eligible for Medical Therapy Program services from the CCS Program's Medical
Therapy Unit; or
5. May have a newly identified potential CCS-Eligible
Condition(s) as determined by a Network Provider.23
23 Additional information about the MTP is available at
https://www.dhcs.ca.gov/services/ccs/Documents/CCS-N L-Whole-Child-Model-Revised.pdf
30
iii. In accordance with Chapter 1, Section 1.13 of the California
Children's Services Program Administrative Case Management Manua124, LHD must
ensure that within five (5) calendar days from the receipt of a referral from MCP the
CCS Program staff review the information provided and take one of the following
actions:
1. Accept the referral as complete as defined in the CCS
Program Administrative Case Management Manual Case Management Manual; or
2. Reject the referral as incomplete and forward a transmittal
notice to MCP as required by the CCS Program Administrative Case Management
Manual Case Management Manual.
b. LHD Eligibility Determination.
i. LHD must determine Members' medical, financial, and residential
eligibility, initially and on an annual basis in accordance with Cal. Code Regs. tit. 22
Section 41515.1, for CCS-Eligible Conditions based on evaluation of documentation
provided by MCP or by a CCS paneled provider.
ii. LHD must assist its CCS Program with obtaining, and may request
from MCP, any additional information required (e.g., medical reports) to determine CCS
Program eligibility.
iii. LHD must ensure its CCS Program informs the Member and their
family (or designated legal caregiver) of the CCS eligibility determination.
iv. LHD must create and send the Notice of Action ("NOX) to a
Member who is determined to be ineligible for or is denied CCS Program services. Each
NOA must notify the Member of their ineligibility in accordance with Cal. Code Regs. tit.
22 Sections 42131 and 42132 and must refer the Member back to MCP, which remains
responsible for providing the Medically Necessary Covered Services to correct or
ameliorate Members' physical conditions and/or mental illnesses
24 CCS Program Administrative Case Management Manual: Chapter One, available at
https://www.dhcs.ca.gov/services/ccs/Documents/CCSAdminCaseManManual.pdf
31
v. If LHD receives a Member referral through an Inter-County
Transfer, the CCS Program must complete applicable activities as set forth in the DHCS
CCS Inter-county Transfer NL.
c. Enhanced Care Management Referrals.
i. The CCS Program should work with MCP to create a referral
pathway for ECM for ECM-eligible Members.
ii. MCP must identify eligible Members for ECM through analysis of
CCS Program enrollment and additional data available to MCPs, including utilizing
Social Drivers of Health ("SDOH")-related ICD-10 Z-codes and identifying SDOH and
high measures on adverse childhood experiences screenings.
iii. In cases where a Member is enrolled in the CCS Program and such
CCS Program provider becomes a contracted ECM Provider, MCP must assign that
Member to that CCS Program for ECM unless the Member or their parent, designated
legal caregiver, or Authorized Representative prefers otherwise.
iv. If LHD's CCS Program is an ECM Provider, LHD's CCS Program
must provide ECM services pursuant to that separate agreement between MCP and the
CCS Program; this MOU does not govern the CCS Program's provision of ECM
services.
4. Care Coordination and Collaboration.
a. Care Coordination.
i. MCP must coordinate with the CCS Program to ensure that
Members enrolled in the CCS Program or eligible for CCS Program services receive all
Medically Necessary Covered Services required for CCS-Eligible Condition(s) through
the CCS Program and receive all Medically Necessary Covered Services that are not
related to the CCS-Eligible Condition(s) through MCP.
ii. Until the Member's CCS eligibility is confirmed by the CCS Program
and the CCS Program begins providing the Medically Necessary Covered Services for
the CCS-Eligible Condition(s), MCP must continue to provide all Medically Necessary
Covered Services for the CCS-Eligible Condition(s).
iii. Once the Member is enrolled in the CCS Program, the CCS
Program is responsible for the Member's case management and care coordination for
the CCS-Eligible Condition(s).
iv. MCP must develop and implement policies and procedures for
coordination activities, joint case management, and communication requirements
between the Member's PCP, specialty providers, hospitals, CCS providers, and CCS
case manager(s).
v. MCP and LHD must have policies and procedures for coordination
with LHD's CCS MTP to ensure appropriate access to MTP services and other services
provided for the coordination of CCS Program services.
b. CCS HRIF Program. The CCS Program must coordinate and
authorize HRIF services for eligible Members and must ensure access to, or arrange
for the provision of, HRIF case management services.
c. PDN Case Management Responsibilities. MCP and LHD must
coordinate the provision of case management services for Members who are receiving
PDN services to ensure that Members receive case management services and that the
Parties do not duplicate the services as set forth in APL 20-012, CCS NL 04-0520, and
any superseding APL or other, similar guidance.25
i. If the CCS Program approves PDN services for CCS-eligible
Members under the age of 21, the CCS Program is primarily responsible for providing
case management to arrange for all approved PDN service hours to treat the CCS-
Eligible Condition. When arranging for the CCS-eligible Members to receive authorized
PDN services, the CCS Program must document all efforts to locate and collaborate
with PDN service providers and MCP.
ii. If MCP approves PDN services for an eligible Member under the
age of 21, MCP is primarily responsible for providing case management to arrange for
the PDN service hours.
iii. MCP must, in collaboration with the CCS Program, continue to
provide case management to Members receiving PDN authorized by the CCS Program,
including, at the Member's request or the request of the Member's Authorized
Representative, arranging for all approved PDN services.
d. Transportation Services.
i. CCS Maintenance and Transportation services related to CCS-
Eligible Conditions are provided and covered by the CCS Program, as determined by
the CCS Program and as resources allow, in accordance with Cal. Health & Safety
Code Section 1238400). MCP must communicate regularly with the CCS Program to
ensure Members' needs are continuously met and must arrange for transportation for
Members' Medi-Cal for Kids and Teens services when the Members' needs are not met
in accordance with APL 22-008.
ii. Emergency Medical Transportation related to the CCS-Eligible
Condition is the responsibility of the CCS Program.
iii. MCP must provide NEMT for all Medically Necessary Covered
Services and pharmacy services, which may include services provided through the CCS
Program, as outlined in the Medi-Cal Managed Care Contract and APL 22-008. MCP
must refer and coordinate NEMT for services not covered under the Medi-Cal Managed
Care Contract.
iv. MCP and the CCS Program must establish policies and procedures
for determining whether NEMT is provided pursuant to a CCS-Eligible Condition(s) and
when such services must be paid for by the CCS Program or MCP.
25 Additional information for PDN services is available in APL 20-012 at
https://www.dhcs.ca.gov/services/Documents/APL-20-012.pdf.
v. If a Member requests NMT, MCP must authorize the NMT if
necessary for the Member to obtain Medically Necessary Covered Services.
e. Emergency Services.
i. The CCS Program must coordinate with MCP for Members who
need to be transferred to emergency services as set forth in NL10-0806 or any
superseding NL, including:
1. Ensuring the CCS Program coordinates with the appropriate
MCP-LHD Liaison confirm the suitable provision of emergency services related to
trauma;
2. Requiring the CCS Program to notify the MCP-LHD Liaison
as soon as possible of the need to transfer a CCS-eligible Member to the appropriate
hospital; and
3. In the event families receive bills for services, contacting the
provider to request they become a CCS-paneled provider and thus bill the CCS
Program rather than the Member.
ii. The CCS Program must notify the MCP-LHD Liaison and DHCS if
these efforts do not resolve the problem.
f. Continuity of Care for Transitioning Members.
i. MCP must maintain policies and procedures for identifying CCS-
Eligible Members who are aging out of the CCS Program.
ii. MCP must follow the Continuity of Care requirements stated in APL
22-032 or any superseding APL.
iii. MCP must develop a care coordination plan to assist a Member
with transitioning out of the CCS Program within twelve (12) months prior to the
Member's aging out, including:
1. Identifying the Member's CCS-Eligible Condition(s);
2. Planning for the needs of the Member to transition from the
CCS Program;
3. Developing a communication plan with the Member in
advance of the transition;
4. Identifying and coordinating primary care and specialty care
providers appropriate for the Member's CCS-Eligible Condition(s); and
5. Continuing to assess the Member through the first
twelve (12) months after the Member's 21 st birthday.
g. Major Organ Transplants.
i. To ensure the appropriate referral and care coordination for CCS-
eligible or enrolled Members requiring a Major Organ Transplant ("MOT"), MCP and
LHD must comply with guidance set forth in Blood, Tissue, and Solid Organ Transplants
NL and APL 21-015 or any superseding NL and APL or other, similar guidance, and
MCP must comply with the requirements set forth in the Medi-Cal Managed Care
Contract.
ii. MCP will not be required to pay for costs associated with
transplants that qualify as a CCS-Eligible Condition if MCP does not participate in the
WCM program.
iii. MCP must refer CCS-eligible Members to a CCS-approved Special
Care Center for an evaluation within 72 hours of the Member's PCP or specialist
identifying the CCS-eligible Member as a potential candidate for a MOT.
iv. If the Member is not eligible for the CCS Program, MCP must
authorize a MOT if Medically Necessary.
h. Quarterly Meetings.
i. MCP must invite LHD Responsible Person and the LHD Program
Liaison(s) for the CCS Program to attend the quarterly meetings with LHD, to discuss
any needed improvements and address barriers to care coordination or referral
processes. Other LHD CCS Program representatives may be permitted to participate in
quarterly meetings.
ii. The CCS Program must designate a medical director or other
designee to actively participate in MCP's quarterly meetings with LHD. The CCS
Program medical director or designee must attend meetings and provide feedback and
recommendations on clinical issues relating to CCS conditions and treatment
authorization guidelines and must serve as a clinical advisor on other clinical issues
relating to CCS conditions.
5. Data Information and Exchange.
a. MCP must timely provide the following information to the CCS Program:
the necessary documentation, medical records, case notes, medical utilization
information, clinical data, and reports to enable the CCS Program to conduct the
Member's initial residential and medical eligibility determination for the CCS Program
and to provide services to the Member for treatment of their CCS-Eligible Condition.
b. Each of the Parties must notify the other Party upon learning that a
Member has lost Medi-Cal eligibility.
Exhibit G.
a. MCP and LHD must share the following data elements:
i. Member demographic information;
ii. Behavioral, dental, and physical health information;
iii. Diagnoses, progress notes, and assessments;
iv. Medications prescribed;
V. Laboratory results;
vi. Known changes in condition that may adversely impact the Member's
health and/or welfare and that are relevant to the services.
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