Skip to Main Content

25-800 Stay Compliant With Contracts, Laws and Regulations

Date: 07/31/25

Meet these expectations to avoid corrective action plans

The Department of Health Care Services’ (DHCS’) All Plan Letter (APL) 25-0071 (PDF), issued April 25, 2025, reminds Medi-Cal managed care plans (MCPs) of their responsibility to ensure compliance with MCP contractual provisions, DHCS APLs, Policy Letters, and applicable state and federal laws and regulations.

MCPs are responsible for ensuring that all subcontractors comply with all contract requirements related to the delegated functions undertaken by each delegate and subcontractor.

When these expectations are not met, DHCS is authorized to take enforcement actions, including imposing corrective action plans (CAPs), and imposing administrative and monetary sanctions on MCPs that violate applicable state and federal laws and regulations or violate their contractual obligations.

Expectations used to monitor compliance

To stay in good standing with DHCS, the Plan and all MCP delegated entities are expected to:

  • Comply with state and federal regulations and laws.
  • Ensure timely access and availability to care.
  • Maintain network adequacy.
  • Meet CAP requirements.
  • Meet contractual obligations.
  • Meet data quality and reporting requirements.
  • Meet quality metrics or benchmarks, including Managed Care Accountability Set.
  • Provide adequate delivery of health care services.
  • Timely and accurately process member grievances or appeals.

Note: The above list is not all inclusive.

Provider oversight can help meet expectations

The Plan measures and monitors provider compliance and requires corrective actions when deficiencies are identified. Delegation may be revoked and the provider's contract terminated if the corrective action process does not resolve
the deficiency.

In addition to routine data collection, monitoring, evaluation and analysis, the Plan’s Delegation Oversight staff is available to assist providers with:

  • Alerting the delegated entity regarding possible areas of below standard performance.
  • Sharing information regarding regulations – available in the Delegation Oversight Interactive Tool.
  • Developing corrective action plans (CAPs) – managed within the Delegation Oversight Interactive Tool.
  • Sharing best practices.
  • Offering guidance regarding on-site review by outside agencies.
  • On-going training upon request.

Information about the Delegation Oversight Interactive Tool is available in the Medi-Cal Provider Operations Manual.

What happens when a CAP is required

If a CAP is necessary, the delegate is notified of the deficiency and is requested to submit a CAP to address the deficiency and apply monitoring measures to prevent repeating the deficiency.

The delegation oversight compliance auditor reviews the CAP for appropriateness and completeness and notifies the delegate whether the CAP is approved.

Unapproved CAP

If the Plan does not approve the CAP, the delegate is notified and asked to revise and resubmit the CAP to
the Plan.

Incomplete or late submission

If the delegate does not submit a CAP or complete the actions in their CAP in a timely manner, the deficiency may be escalated to the Delegation Oversight Workgroup, Compliance and Network Management Leadership and/or at a joint operations meeting to discuss deficiencies or to recommend further actions.

If the delegate remains deficient, it may be escalated to the Delegation Oversight Committee to take formal actions up to and including de-delegation.

Additional information

If you have questions regarding the information contained in this update, contact CalViva Health at 888-893-1569. Behavioral Health providers can call 844-966-0298.

1 See DHCS APL 25-007, Enforcement Actions Regarding Corrective Action Plans, Administrative and Monetary Sanctions (PDF).

 

This information applies to Physicians, Participating Physician Groups (PPGs), Hospitals, Ancillary Providers, Community Supports (CS) Providers, Enhanced Care Management (ECM) Providers, and Behavioral Health Providers.

This information applies to Medi-Cal in Fresno, Kings and Madera counties.



Last Updated: 07/31/2025