The DMHC is taking action to protect consumers’ health care rights and ensure a stable health care delivery system during this pandemic. The Department is working closely with state and local leaders, health plans, providers and other stakeholders in supporting actions to mitigate the spread and severity of COVID-19.
If you are a health plan enrollee experiencing a problem with your health plan, please visit the DMHC Help Center online or by calling 1-888-466-2219.
DMHC Fact Sheets:
Consumer Fact Sheet
on COVID-19 Testing, Vaccine & Treatment
(English, Spanish)
State Resources & Actions:
California COVID-19 Response
CDPH COVID-19 Updates
DHCS COVID‑19 Response
Health Care Coverage Options
If you do not have a source of health care coverage or have recently lost your employer-sponsored health care coverage, this fact sheet provides and an explanation of some options to gain health care coverage. Contact the specific programs for more information.
Coverage Options Fact Sheet in English
Coverage Options Fact Sheet in Spanish
Governor Newsom Issues Executive Order to Expand Telehealth Services
Governor Gavin Newsom signed an executive order to expand protections to medical providers as they amplify the use of video chats and similar applications to provide routine and non-emergency medical appointments in an effort to minimize patient exposure to COVID-19. The executive order allows health care providers to use video chats and applications to provide health services without risk of penalty, and aligns with federal Health and Human Services guidelines and waivers issued in response to COVID-19.
DMHC Actions:
DMHC Issues Guidance on Coverage of COVID-19 Therapeutics
The DMHC issued an All Plan Letter (APL) regarding commercial health plan coverage of COVID-19 therapeutics, steps plans can take to encourage providers to use therapeutics, when appropriate, and directs plans to submit a description of how the plan is ensuring enrollees who need and are eligible for therapeutics have ready access to such treatment. Health plans must ensure enrollees for whom a COVID-19 therapeutic is medically necessary have access to these treatments within 48 hours if the plan does not require prior authorization or 96 hours if the plan requires prior authorization. Given treatment should be started as soon as possible after symptoms start, the DMHC strongly urges plans to waive any prior authorization requirements with respect to therapeutics and to ensure enrollees can receive needed treatment as quickly as possible.
DMHC APL 22-017 – Coverage of COVID-19 Therapeutics
DMHC APL Reminds Health Plans of Federal Requirement to Cover At-Home COVID-19 Tests
Beginning January 15, 2022, health plans must cover at least eight (8) over-the-counter (OTC) COVID-19 tests per enrollee per month. Health plans can arrange with a network of distributors (e.g., pharmacies and retailers) to provide direct coverage of the tests, in which case enrollees would be able to obtain the tests from an in-network source without paying out-of-pocket and then seeking reimbursement from the plan. Alternatively, enrollees may purchase the tests themselves and seek reimbursement up to the amount allowed by the federal guidance. Plans may not impose any prior authorization or cost-sharing requirements as a prerequisite for an enrollee obtaining OTC COVID-19 tests. Likewise, an enrollee does not need to first have an order or individualized clinical assessment from a provider to obtain coverage for OTC COVID-19 tests.
DMHC APL 22-005 - Federal Requirement to Cover At-Home COVID-19 Tests Purchased Over-the-Counter
DMHC APL Reminds Health Plans of Enrollee Transfer Obligations
The DMHC issued an All Plan Letter (APL) reminding health plans of their obligations to comply with California Code of Regulations, title 28, section 1300.67.02. That section directs plans to remove certain barriers to enrollee transfers between hospitals when such transfers are made pursuant to a public health order. Section 1300.67.02 also specifies how plans must reimburse for the transfer and continued hospitalization of enrollees transferred pursuant to a public health order.
DMHC APL 21-021 - Transfer of Hospitalized Enrollees per Regulation Section 1300.67.02
DMHC APL on Continued Coverage of COVID-19 Diagnostic Testing
The DMHC issued an All Plan Letter (APL) reminding health plans that federal law continues to require them to cover COVID-19 testing for their enrollees when the testing provides an individualized assessment of whether the enrollee has a COVID-19 infection. Health plans must cover the testing whether it is performed in or out of network and may impose no prior authorization or cost-sharing requirements on such testing. Health plans must cover the testing whether the person is symptomatic or asymptomatic and regardless of whether the person has had recent known or suspected exposure to COVID-19.
DMHC APL 21-020 – Continued Coverage of COVID-19 Diagnostic Testing
DMHC Guidance to Health Plans on Continued Coverage of COVID-19 Testing
Health plans must continue to cover certain COVID-19 testing for their enrollees pursuant to federal law. The Families First Coronavirus Response Act (FFCRA) and Coronavirus Aid, Relief, and Economic Security Act (CARES Act) continue to require plans to cover COVID-19 diagnostic testing, regardless of whether enrollees access such tests through in- or out-of-network providers. Health plans may not require any type of prior authorization for testing and may not impose medical management/utilization management criteria on testing.
DMHC APL 21-016 – Continued coverage of COVID-19 diagnostic testing
DMHC Guidance to Health Plans for COVID-19 Vaccines for Homebound Enrollees, Transportation Assistance
All individuals 16 years or older are now eligible to be vaccinated against COVID-19. Vaccinating individuals who lack transportation or who are homebound is a priority for the state. However, some enrollees may have difficulty accessing the vaccine because they lack transportation to a vaccination site. Other enrollees may not be able to access the vaccine because they are homebound due to a health care condition or a disability. For homebound enrollees, traveling to access a vaccine may be very difficult, not feasible or could jeopardize their life or health. The DMHC issued an All Plan Letter (APL) reminding plans they must arrange for vaccines for individuals receiving “home health services,” and providing information for enrollees requesting transportation assistance to a vaccination site.
DMHC APL 21-014 - COVID-19 Vaccinations for Homebound Enrollees; Transportation Assistance to Obtain COVID-19 Vaccines
DMHC Guidance to Health Plans on COVID-19 Vaccine Prioritization
Following guidance issued by the California Department of Public Health (CDPH), the DMHC issued an All Plan Letter (APL) to ensure health plans take all appropriate steps to help enrollees at the very highest risk receive COVID-19 vaccinations in a timely and efficient manner. Health plans should coordinate with their contracted health care providers to engage in outreach to enrollees at the very highest risk to ensure those enrollees are aware they are eligible to receive COVID-19 vaccinations and how the enrollees can obtain vaccinations.
On February 12, 2021, CDPH issued a Provider Bulletin (“Provider Bulletin”) regarding vaccine prioritization for individuals deemed to be at the very highest risk to get very sick from COVID-19 either because the individual has one or more enumerated severe health conditions and/or a developmental or other significant, high-risk disability. On March 11, 2021, the CDPH issued guidance to the public regarding how people at the very highest risk, as described in the Provider Bulletin, can gain access to COVID-19 vaccinations beginning March 15, 2021.
DMHC APL 21-012 - COVID-19 Vaccine Prioritization for Individuals with High-Risk Health Conditions and/or Disabilities
DMHC Guidance to Health Plans on COVID-19 Testing
On February 26, 2021, the federal Centers for Medicare & Medicaid Services (CMS), in conjunction with the Department of Labor and the Department of the Treasury, issued new guidance making it easier for enrollees to obtain diagnostic COVID-19 testing and clarifying when health plans must cover such testing for their enrollees.
The new federal guidance clarifies that health plans must cover COVID-19 diagnostic testing for all health plan enrollees by any provider with no cost-sharing. The DMHC issued an All Plan Letter (APL) to health plans providing an overview of the new federal guidance, and explaining how the federal guidance and the DMHC’s emergency regulation regarding COVID-19 testing work together to ensure enrollees have ready access to COVID-19 testing at no cost to the enrollee.
Additionally, the DMHC issued a Consumer Fact Sheet on COVID-19 Testing to help clarify the requirements under the new federal guidance.
Consumer Fact Sheet on COVID-19 Testing (March 10, 2021)
DMHC APL 21-011 – New Federal Guidance Regarding COVID-19 Testing (March 10, 2021)
DMHC APL 20-028 - Emergency Regulation Regarding COVID-19 Diagnostic Testing
DMHC APL 20-033 - Implementation of Emergency Regulation Regarding COVID-19 Diagnostic Testing
DHCS COVID-19 Virus and Antibody Testing Guidance
DMHC Extends Special Enrollment Period in Response to COVID-19
As the state of California is taking action to respond to the COVID-19 pandemic, the Department of Managed Health Care (DMHC) joined with Covered California to make sure Californians have a ready path to health care coverage.
The DMHC provided guidance on January 28, 2021 to health plans on opening a special enrollment period from February 1, 2021 through May 15, 2021. This will ensure consumers enrolling in the entire individual market in California will have access to coverage during the pandemic emergency. The DMHC previously issued guidance creating a special enrollment period in 2020.
DMHC APL 21-008 - Special Enrollment Period; Coverage Effective Dates
DMHC Reminds Health Plans of Obligations Under Enrollee Transfers
The DMHC issued guidance reminding health plans of their continuing obligations under Health and Safety Code section 1371.4 to cover emergency services and care provided to plan enrollees. Such coverage includes reimbursement for appropriate transfers of unstable enrollees between hospitals in conformance with the requirements of the federal Emergency Medical Treatment and Labor Act (EMTALA).
DMHC APL 21-004 – Transfers of unstable or destabilized enrollees
DMHC Notifies Health Plans to NOT Prevent or Delay Enrollee Transfers under Public Health Order
The State of California is experiencing a surge in COVID-19 positive cases and hospitalizations. This surge is causing many hospitals in the state to meet or exceed their usual capacity to serve patients, which can jeopardize the health and lives of the patients and staff. Accordingly, to provide care to all patients in need, it is imperative to maximize the capacity of hospitals in the state by allowing for the expeditious transfer of patients from the most highly impacted hospitals to hospitals with more available capacity. This regional approach is central to an ethical and equitable response to the COVID-19 pandemic. Health plan prior authorization requirements for transfers between hospitals can cause unnecessary delays in effectuating such transfers.
On December 28, 2020, the California Department of Public Health (CDPH) issued “All Facilities Letter 20-91” to California hospitals. That letter outlines crisis care continuum guidelines with which California hospitals must abide during the COVID-19 surge. On January 5, 2021, CDPH issued a State Public Health Officer Order (Order) to help ensure California hospitals and other health care facilities can prioritize services to those who are the sickest and priorities resources for the providers delivering direct care to them.
The DMHC issued guidance notifying health plans they may not prevent or delay the transfer of a plan enrollee and must cover the medically necessary costs associated with the transfer of their enrollees per the Order.
DMHC APL 21-003 - Transfer of Enrollees Per State Public Health Officer Order
DMHC Directs Health Plans to Remove Administrative Burdens on Hospitals During COVID-19 Surge
The California Department of Managed Health Care (DMHC) today directed health plans regulated by the Department to remove administrative burdens on hospitals during the COVID-19 surge. This includes directing plans to take immediate steps to reduce or remove unnecessary barriers to the efficient admission, transfer, and/or discharge of health plan enrollees. The DMHC has also enacted new reporting requirements for health plans to ensure plans are sufficiently supporting providers to acquire COVID-19 supplies, such as Personal Protective Equipment (PPE), to safely deliver services to plan enrollees.
Press Release
DMHC APL 20-042 - Removal of Administrative Burdens on Hospitals
DMHC APL 20-043 - Health Plan Reporting Regarding PPE and Related Support to Providers
DMHC APL 21-007 – Dental Plan Reporting re PPE and Related Supports to Providers
DMHC Directs Health Plans to Cover COVID-19 Vaccines with No Cost-Sharing to Enrollees
The California Department of Managed Health Care (DMHC) issued guidance reminding health plans that all qualified, approved COVID-19 vaccines must be provided with no cost-sharing for health plan enrollees, regardless of whether the enrollee receives the vaccine from an in-network or out-of-network provider.
"As we begin to enter this new phase of the pandemic with vaccines becoming available, the DMHC is reminding health plans they must cover the cost of COVID-19 vaccines," said DMHC Director Mary Watanabe. "It is critical that all Californians have access to a safe COVID-19 vaccine to help protect their health. Financial challenges should not and will not get in the way of getting protection from COVID-19."
Press Release
Fact Sheet
DMHC APL 20-039 – Health Plan Coverage of COVID-19 Vaccines
DMHC Directs Plans to Ensure Continued Network Adequacy, Encourages Removing Burdens on Providers
The DMHC directed health plans with commercial lines of business to submit an informational filing explaining the steps the plan has taken, and/or will take, to ensure continued network adequacy. Health plans have an on-going duty to ensure they have adequate networks to provide enrollees with all medically necessary services in a timely and geographically appropriate manner. Providers, including medical and dental clinics and hospitals, report experiencing significant financial difficulties due to COVID-19, as patients have delayed receiving all but emergency and urgent medical services.
DMHC APL 20-020 – Ensuring Continued Network Adequacy and Removing Unnecessary Burdens on Providers
DMHC APL 21-006 - Dental Plan Reporting Regarding Network Stability
DMHC Extends Phase-Out Period Related to Association Health Plans
Due to the COVID-19 state of emergency the DMHC is extending the end of the phase-out period through October 31, 2020. Beginning November 1, 2020, health plans may not renew large group coverage for small employers or individuals, regardless of the arrangement by which the small employer or individual purchased the coverage.
DMHC APL 20-019 – Association Health Plans: Extension of “Phase-Out” Period
DMHC Modifies 2020 Timely Access PAAS Start Date Due to COVID-19
The DMHC has modified the start date for the Timely Access Provider Appointment Availability Surveys (PAAS) for Measurement Year (MY) 2020 due to the COVID-19 pandemic. Health plans shall begin administration of the MY 2020 PAAS no earlier than August 1, 2020.
DMHC APL 20-018 – COVID-19 (OPM) Modification of Timely Access Provider Appointment Availability Surveys (PAAS) Timeframes
DMHC Extends Phase-In Period for General Licensure Regulation
The DMHC has extended the phase-in period under the General Licensure Regulation, adopted in 2019. The All Plan Letter extends the phase-in period through December 31, 2020 due to the uncertainty caused by the COVID-19 pandemic. The DMHC has also updated the guidance document to reflect the extended phase-in period.
DMHC APL 20-017 – General Licensure Regulation: Extension of Phase-In Period For Expedited Exemption Requests
Revised General Licensure Guidance (updated April 16, 2020)
DMHC, CDA Provide Guidance on Supporting Older and At-Risk Enrollees During COVID-19
The DMHC and California Department of Aging (CDA) issued an All Plan Letter (APL) to offer reminders and resources to help health plans serve enrollees who are aged 60 and older, or have high-risk health conditions during the COVID-19 emergency response. During California’s stay-at-home order, older Californians and other at-risk adults will likely need the help of their health plans, as well as family, friends, neighbors and community, to help them maintain basic needs like groceries and prescriptions, and much-needed social interaction and connection.
DMHC APL 20–016 — Preventing Isolation and Supporting Older and other At-Risk Individuals to Stay Home and Stay Healthy During COVID-19 Efforts
DMHC Provides Temporary Extension for Health Plan Filing Deadlines
In light of the COVID-19 State of Emergency, the DMHC has determined that select deadlines and requirements may be temporarily extended to give health plans additional time to comply. The extensions enumerated in the DMHC All Plan Letter (APL) shall be in effect until the California Governor declares the COVID-19 State of Emergency no longer exists or the DMHC notifies health care service plans that the extensions permitted in this APL are no longer in effect.
DMHC APL 20-015 – COVID-19 Temporary Extension of Plan Deadlines
DMHC and OSG Offer Resources to Health Plans to Help Mitigate Negative Health Outcomes
DMHC and the Office of the Surgeon General (OSG) offer reminders and resources to help health care service plans serve enrollees and mitigate negative health outcomes to members due to the COVID-19 emergency. To mitigate negative secondary health outcomes, it is crucial that health care service plans and their providers continue to provide high-quality care to enrollees.
DMHC APL 20-014 – Mitigating Negative Outcomes
DMHC Directs Health Plans to Ensure Californians Can Access Necessary Medical Care Through Telehealth
The DMHC issued an All Plan Letter (APL) in March directing health plans to ensure Californians can access necessary medical care through telehealth when medically appropriate. This includes directing health plans to reimburse providers for care provided through telehealth at the same rate as in-person care and ensuring enrollee cost-sharing is not changed for telehealth services. Following several questions from plans and providers, the DMHC issued All Plan Letter (APL) 20-013 - Billing for Telehealth Services; Telehealth for the Delivery of Services with a Frequently Asked Questions (FAQ) document. This includes information on provider billing during the COVID-19 State of Emergency to decrease administrative burdens on providers and plans.
DMHC APL 20-013 – Billing for Telehealth Services; Telehealth for the Delivery of Services
DMHC FAQ – Telehealth During the COVID-19 State of Emergency
DMHC APL 20-009 – Reimbursement for Telehealth Services
DMHC APL 20-032 – Continuation of Telehealth All Plan Letters
DMHC Reminds Health Plans to Comply with California Nondiscrimination Requirements
The DMHC remains committed to protecting the health care rights of all Californians, regardless of their gender identity, sexual orientation, or English proficiency. The Department issued an All Plan Letter (APL) reminding health plans licensed in California that they must continue to comply with California law, which protects all Californians from discrimination based on, among other things, gender identity and sexual orientation. Likewise, California-licensed health plans must continue to comply with California’s requirements to provide enrollees with notice of the availability of free language assistance services in English and the top 15 languages spoken by Limited English Proficiency individuals in California.
DMHC APL 20-022 - Compliance with California nondiscrimination requirements
Guidance Relating to Non-Discrimination in Medical Treatment for Novel Coronavirus 2019 (COVID-19)
The Departments of Health Care Services (DHCS), Public Health (CDPH), and Managed Health Care (DMHC) continue to closely monitor and assess appropriate next steps as well as release guidance to ensure the safety of Medi-Cal beneficiaries, health plan enrollees, medical providers, and California communities in general.
The State of California understands that people with disabilities are concerned that medical providers might consider an individual’s disability status when determining which patients to treat if hospitals or other health care facilities experience a surge of patients needing life-saving care. This joint bulletin reminds health care providers and payers that rationing care based on a person’s disability status is impermissible and unlawful under both federal and state law.
DMHC Encourages Health Plans Practice “Social Distancing” Measures in Response to COVID-19
The Department of Managed Health Care (DMHC) issued an All Plan Letter encouraging health plans take actions to facilitate the delivery of health care services in a manner that decreases the need for in-person visits and practices “social distancing” measures to help slow the spread of COVID-19. This includes expanding health care delivery via telehealth and decreasing the need for in-person pharmacy visits.
DMHC APL 20-007 - “Social Distancing” Measures in Response to COVID-19