HomeMy WebLinkAbout32850Agreement No. 18-361
1 AGREEMENT
2 THIS AGREEMENT is made and entered into this 10th day of __ J=u=ly'------
3 2018, by and between the COUNTY OF FRESNO, a Political Subdivision of the State of California,
4 hereinafter referred to as "COUNTY", and the FRESNO-KINGS-MADERA REGIONAL HEAL TH
5 AUTHORITY (RHA), a California Joint Powers Authority and Medi-Cal Managed Care Health Plan dba
6 CAL VIVA HEAL TH, whose address is 7625 N. Palm Avenue, Suite 109, Fresno, California, 93711,
7 hereinafter referred to as "CALVIVA HEALTH", (collectively the "parties").
8 WITNESS ETH:
9 WHEREAS, COUNTY, through its Department of Behavioral Health, is a Mental Health
10 Plan "MHP" as defined in Title 9 of the California Code of Regulations (CCR), section 1810.226; and
11 WHEREAS, CALVIVA HEALTH, is the Local Initiative Plan for the Counties of Fresno,
12 Kings, and Madera (the "Service Area") and has contracted with the California Department of Health
13 Care Services (DHCS) to arrange and coordinate services for the provision of specialty mental health
14 and/or alcohol and substance use disorder treatment services to those Medi-Cal Members who are
15 assigned to or enrolled with CALVIVA HEALTH in the Service Area. CALVIVA HEALTH may also
16 subcontract with other organizations to provide or arrange services for Medi-Cal members assigned to
17 or enrolled with CALVIVA HEALTH in the Service Area; and
18 WHEREAS, CALVIVA HEALTH, is a prepaid full-service health care service plan licensed
19 under the Knox-Keene Health Care Service Plan Act of 1975, as amended (the "Knox-Keene Act"),
20 which has entered into an agreement with the California Department of Health Care Services under the
21 Medi-Cal Managed Care Program to arrange and coordinate services for the provision of specialty
22 mental health and/or alcohol and substance use disorder treatment services to persons who enroll in
23 the Local Initiative Medi-Cal Plan for Fresno County; and
24 WHEREAS, COUNTY contracts with the California Department of Health Care Services
25 (DHCS) to provide medically necessary specialty mental health services to the Medi-Cal beneficiaries
26 of Fresno County. The COUNTY and DHCS work collaboratively to ensure timely and effective access
27 to specialty mental health and/or alcohol and substance use disorder treatment services; and
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WHEREAS, CALVIVA HEALTH and COUNTY desire to identify responsibilities and
protocols in the delivery of specialty mental health and/or alcohol and substance use disorder treatment
services to Medi-Cal Members served by both.
NOW, THEREFORE, in consideration of their mutual covenants and conditions, the
parties hereto agree as follows:
1. DEFINITIONS
Many words and terms are capitalized throughout this Agreement to indicate that they are
defined as set forth in this Section.
A. CalViva Health Medi-Cal Plan – is the CALVIVA HEALTH benefit plan covering the
provision of Health Care and Behavioral Health Services to CALVIVA HEALTH Members pursuant to
the Medi-Cal Agreement. The benefits of the CalViva Health Medi-Cal Plan are set forth in the Medi-
Cal Agreement.
B. Health Care Services – are all medical, behavioral health and ancillary services,
including emergency services, which are covered benefits under the CalViva Health Medi-Cal Plan.
C. Medi-Cal Fee-for Service (“FFS”) Rate – is the applicable fee-for-service rate
determined by the California Department of Health Care Services for the service under the Medi-Cal
Program. All services to be provided by COUNTY and compensated by CALVIVA HEALTH pursuant to
this Agreement shall be billed by COUNTY, and compensated by CALVIVA HEALTH, at the then current,
applicable Medi-Cal FFS Rate.
D. Member – is a Medi-Cal beneficiary who is eligible and enrolled in the CALVIVA
HEALTH Medi-Cal Plan for Fresno County.
E. Primary Care Physician (PCP) – is a physician responsible for supervising,
coordinating, and providing initial and primary care to patients and serves as the Medical Home for
Members. The PCP is a general practitioner, internist, pediatrician, family practitioner, or
obstetrician/gynecologist (OB/GYN). For SPD beneficiaries, a PCP may also be a Specialist or clinic in
accordance with W & I Code 14182 (b)(11).
F. Primary Care Provider - is a person responsible for supervising, coordinating, and
providing initial and primary care to patients; for initiating referrals; and for maintaining the continuity of
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patient care. A Primary Care Provider may be a Primary Care Physician (PCP) or Non-Physician
Medical Practitioner.
2. RESPONSIBILITIES
A. JOINT RESPONSIBILITIES
1. The parties understand that CALVIVA HEALTH arranges for the provision
of health care for its Members through contracts with independent health care providers (“Contracting
Providers”). The parties understand and agree that all references in this Agreement to the provision of
Health Care Services by CALVIVA HEALTH are deemed to refer to services provided by its Contracting
Providers.
2. Notwithstanding any provision in this Agreement to the contrary, the parties
understand and agree that CALVIVA HEALTH’s responsibilities under this Agreement are subject to,
and limited to the requirements under the Medi-Cal Agreement.
3. The parties understand and agree that responsibility for performance of
certain services under this Agreement will be shared by the parties as explained in detail in Exhibit A,
attached hereto and by this reference incorporated herein.
4. The parties understand and agree to coordinate or arrange for the provision
of specialty mental health services in accordance with MMCD Policy Letter No. 00-01 REV, Exhibit B,
attached hereto and by this reference incorporated herein.
5. The parties understand and agree to coordinate or arrange for the provision
of substance use disorder services in accordance with ASAM levels of care as described in Exhibit C,
attached hereto and by this reference incorporated herein.
B. RESPONSIBILITIES OF CALVIVA HEALTH
1. CALVIVA HEALTH shall arrange for the provision of health care for its
Members through contracts with Contracting Providers. CALVIVA HEALTH covers Health Care
Services, but it does not provide Health Care Services.
2. CALVIVA HEALTH shall require that its Contracting Providers comply with
all laws requiring the reporting of certain diseases. CALVIVA HEALTH will disseminate to its Contracting
Providers the information provided by the COUNTY regarding local community resources.
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3. CALVIVA HEALTH shall require that its PCP provide behavioral health
services limited PCP training and scope of practice.
4. CALVIVA HEALTH shall promote organized managed care systems that
reduce fragmentation in case management and which improve quality of care.
5. CALVIVA HEALTH shall refer its Members to local agencies and
organizations providing health services and health programs for low-income persons where such
services are not provided by CALVIVA HEALTH and its Contracting Providers.
6. CALVIVA HEALTH shall assist COUNTY to determine the membership
status of its Members and to which PCP they have been assigned.
7. CALVIVA HEALTH and COUNTY shall make every reasonable effort to
provide linguistic services for non-English speaking and limited English speaking Members. In the event
that a Member seeks services from COUNTY and COUNTY has exhausted all reasonable resources for
providing linguistic services to the Member, CALVIVA HEALTH agrees to provide linguistic services to
that Member.
8. In accordance with Exhibit A, all responsibilities of CALVIVA HEALTH are
outlined.
C. RESPONSIBILITIES OF COUNTY
1. COUNTY shall continue to provide such Federal and State mandated
public and community programs subject to available funding, as required; and shall further provide such
other non-mandated public and community programs subject to available funding, as the COUNTY shall,
in its unfettered discretion, determine.
2. Upon request, COUNTY shall maintain and make available to the California
Department of Health Care Services and CALVIVA HEALTH copies of all executed COUNTY
subcontracts for the performance of Health Care Services under this Agreement. All COUNTY
subcontracts shall be in writing and shall be consistent with the terms and provisions of this Agreement
and in compliance with applicable State and Federal Laws. Each COUNTY subcontract shall contain
the amount of compensation that the COUNTY subcontractor will receive under the term of the COUNTY
subcontract.
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3. COUNTY shall require all its specialty mental health and/or alcohol and
substance abuse disorder treatment service providers to assist COUNTY and CALVIVA HEALTH in the
orderly transfer of the medical care of Members in the event of termination of the Medi-Cal Agreement,
including, without limitation, making available to the California Department of Health Care Services
copies of medical records and any other pertinent information necessary for efficient case management
of Members, as determined by the California Department of Health Care Services, subject to compliance
with Federal, State and local confidentiality laws.
4. Neither COUNTY nor any of its specialty mental health and/or alcohol and
substance abuse disorder treatment services providers shall in any event, including, without limitation,
non-payment by CALVIVA HEALTH, insolvency of CALVIVA HEALTH, or breach of this Agreement, bill,
charge, collect and deposit, or attempt to bill, charge, collect or receive form of payment from any
Member for specialty mental health and/or alcohol and substance abuse disorder treatment services
provided pursuant to this Agreement. Neither COUNTY nor any COUNTY specialty mental health and/or
alcohol and substance abuse disorder treatment services provider shall maintain any action at law or
equity against a Member to collect sums owed by CALVIVA HEALTH to COUNTY. However, COUNTY
may collect against a person receiving services from the COUNTY who is determined to be ineligible
under the Medi-Cal Program at the time of service. In addition, COUNTY may bill the California
Department of Health Care Services under the Medi-Cal Fee-For-Services Program for services
provided by the COUNTY to a Medi-Cal beneficiary who is determined to not be a Member at the time
of service. Upon notice of any violation of this section, CALVIVA HEALTH may terminate this Agreement
pursuant to Paragraph 4 of this Agreement and take all other appropriate action consistent with the
terms of this Agreement to eliminate such charges, including, without limitation, requiring COUNTY and
COUNTY specialty mental health and/or alcohol and substance abuse disorder treatment services
providers to return all sums improperly collected from Members or their representatives. COUNTY and
CALVIVA HEALTH’s obligations under this paragraph shall survive the termination of this Agreement
with respect to specialty mental health and/or alcohol and substance abuse disorder treatment services
provided during the term of this Agreement without regard to cause of termination of this Agreement.
5. A detailed description of COUNTY’s responsibilities is located in Exhibit A.
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3. TERM
This Agreement shall become effective upon execution by all parties and shall terminate
on the 30th day of June 2019.
This Agreement shall automatically be extended for an unlimited number of one (1) year
extensions upon the same terms and conditions herein set forth, unless written notice of non-renewal is
given by CALVIVA HEALTH or COUNTY or COUNTY’s Department of Behavioral Health (DBH)
Director, or designee, not later than thirty (30) days prior to the close of the current Agreement term.
4. TERMINATION
A. Non-Allocation of Funds - the terms of this Agreement, and the services to be
provided thereunder, are contingent on the approval of funds by the appropriating government agency.
Should sufficient funds not be allocated, the services provided may be modified, or this Agreement
terminated at any time by giving COUNTY and CALVIVA HEALTH thirty (30) days advance written
notice.
B. Breach of Contract - COUNTY and CALVIVA HEALTH may immediately suspend
or terminate this Agreement in whole or in part, where in the determination of COUNTY or CALVIVA
HEALTH there is:
1. An illegal or improper use of funds;
2. A failure to comply with any term of this Agreement;
3. A substantially incorrect or incomplete report submitted to COUNTY or
CALVIVA HEALTH;
4. Improperly performed service: and/or
5. Failure by COUNTY or CALVIVA HEALTH to obtain and maintain a license
under the Knox-Keene Act.
C. Without Cause - Under circumstances other than those set forth above, this
Agreement may be terminated by CALVIVA HEALTH or COUNTY or COUNTY’s DBH Director or
designee upon the giving of thirty (30) days advance written notice of an intention to terminate.
5. COMPENSATION
Services pursuant to the terms and conditions of the Agreement shall be performed
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without the payment of any monetary consideration by CALVIVA HEALTH or COUNTY, one to the other.
6. INDEPENDENT CONTRACTOR
A. In performance of the work, duties, and obligations assumed by CALVIVA
HEALTH under this Agreement, it is mutually understood and agreed that CALVIVA HEALTH, including
any and all of CALVIVA HEALTH’s officers, agents, and employees will at all times be acting and
performing as an independent contractor, and shall act in an independent capacity and not as an officer,
agent, servant, employee, joint venturer, partner, or associate of the COUNTY. Furthermore, COUNTY
shall have no right to control or supervise or direct the manner or method by which CALVIVA HEALTH
shall perform its work and function. However, COUNTY shall retain the right to administer this
Agreement so as to verify that CALVIVA HEALTH is performing its obligations in accordance with the
terms and conditions thereof. CALVIVA HEALTH and COUNTY shall comply with all applicable
provisions of law and the rules and regulations, if any, of governmental authorities having jurisdiction
over matters which are directly or indirectly the subject of this Agreement.
B. Because of its status as an independent contractor, CALVIVA HEALTH shall have
absolutely no right to employment rights and benefits available to COUNTY employees. CALVIVA
HEALTH shall be solely liable and responsible for providing to, or on behalf of, its employees all
legally-required employee benefits. In addition, CALVIVA HEALTH shall be solely responsible and save
COUNTY harmless from all matters relating to payment of CALVIVA HEALTH’s employees, including
compliance with Social Security, withholding, and all other regulations governing such matters. It is
acknowledged that during the term of this Agreement, CALVIVA HEALTH may be providing services to
others unrelated to the COUNTY or to this Agreement.
C. In performance of the work, duties, and obligations assumed by COUNTY under
this Agreement, it is mutually understood and agreed that COUNTY, including any and all of COUNTY’s
officers, agents, and employees will at all times be acting and performing as an independent contractor,
and shall act in an independent capacity and not as an officer, agent, servant, employee, joint venturer,
partner, or associate of the CALVIVA HEALTH. Furthermore, CALVIVA HEALTH shall have no right to
control or supervise or direct the manner or method by which COUNTY shall perform its work and
function. However, CALVIVA HEALTH shall retain the right to administer this Agreement so as to verify
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that COUNTY is performing its obligations in accordance with the terms and conditions thereof.
COUNTY and CALVIVA HEALTH shall comply with all applicable provisions of law and the rules and
regulations, if any, of governmental authorities having jurisdiction over matters which are directly or
indirectly the subject of this Agreement.
D. Because of its status as an independent contractor, COUNTY shall have
absolutely no right to employment rights and benefits available to CALVIVA HEALTH employees.
COUNTY shall be solely liable and responsible for providing to, or on behalf of, its employees all
legally-required employee benefits. In addition, COUNTY shall be solely responsible and save CALVIVA
HEALTH harmless from all matters relating to payment of COUNTY’s employees, including compliance
with Social Security, withholding, and all other regulations governing such matters. It is acknowledged
that during the term of this Agreement, COUNTY may be providing services to others unrelated to the
CALVIVA HEALTH or to this Agreement.
7. MODIFICATION
Any matters of this Agreement may be modified from time to time by the written consent
of all the parties without, in any way, affecting the remainder.
8. NON-ASSIGNMENT
Neither party shall assign, transfer or subcontract this Agreement nor their rights or duties
under this Agreement without the prior written consent of the other party.
9. HOLD-HARMLESS
A. CALVIVA HEALTH agrees to indemnify, save, hold harmless, and at COUNTY's
request, defend the COUNTY, its officers, agents and employees from any and all costs and expenses,
including attorney fees and court costs, damages, liabilities, claims and losses occurring or resulting to
COUNTY in connection with the performance, or failure to perform, by CALVIVA HEALTH, its officers,
agents or employees under this Agreement, and from any and all costs and expenses, including attorney
fees and court costs, damages, liabilities, claims and losses occurring or resulting to any person, firm or
corporation who may be injured or damaged by the performance, or failure to perform, of CALVIVA
HEALTH, its officers, agents or employees under this Agreement.
B. COUNTY agrees to indemnify, save, hold harmless, and at CALVIVA HEALTH's
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request, defend CALVIVA HEALTH, its officers, agents and employees from any and all costs and
expenses, including attorney fees and court costs, damages, liabilities, claims and losses occurring or
resulting to CALVIVA HEALTH in connection with the performance, or failure to perform, by COUNTY,
its officers, agents or employees under this Agreement, and from any and all costs and expenses,
including attorney fees and court costs, damages, liabilities, claims and losses occurring or resulting to
any person, firm or corporation who may be injured or damaged by the performance, or failure to perform,
of COUNTY, its officers, agents or employees under this Agreement.
10. CONFIDENTIALITY
All services performed by COUNTY and CALVIVA HEALTH under this Agreement shall
be in strict conformance with all applicable Federal, State of California and/or local laws and regulations
relating to confidentiality.
11. NON-DISCRIMINATION
During the performance of this Agreement, COUNTY and CALVIVA HEALTH shall not
unlawfully discriminate against any employee or applicant for employment, or recipient of services,
because of race, religion, color, national origin, ancestry, physical disability, medical condition, sexual
orientation, marital status, age or gender, pursuant to all applicable State of California and Federal
statutes and regulations.
12. NOTICES
The persons having authority to give and receive notices under this Agreement and their
addresses include the following:
COUNTY CALVIVA HEALTH
Director, County of Fresno CEO, Fresno, Kings, Madera Regional Department of Behavioral Health Health Authority (RHA) 4441 E. Kings Canyon Road 7625 N. Palm Avenue, Suite 109, Fresno, CA 93702 Fresno, California 93711
Any and all notices between the COUNTY and the CALVIVA HEALTH provided for or
permitted under this Agreement or by law shall be in writing and shall be deemed duly served when
personally delivered to one of the parties, or in lieu of such personal service, when deposited in the
United States Mail, postage prepaid, addressed to such party.
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13. GOVERNING LAW
The parties agree that for the purposes of venue, performance under this Agreement is to
be in Fresno County, California.
The rights and obligations of the parties and all interpretation and performance of this
Agreement shall be governed in all respects by the laws of the State of California.
14. COVERED SERVICES AND POPULATIONS
The Mental Health Services Description Chart for Medi-Cal Managed Care Members
included with APL 17-018 as developed by DHCS and identified as Exhibit D, is attached hereto and
incorporated herein.
15. OVERSIGHT RESPONSIBILITIES OF CALVIVA HEALTH AND THE COUNTY
A. CALVIVA HEALTH will oversee a subcontracted behavioral health provider
network, which will provide the above additional behavioral health services to the extent they are not
provided by the COUNTY under the Specialty Mental Health Services Waiver to its Medi-Cal Members
and under the Drug Medi-Cal Organized Delivery System Waiver (herein after referred to as “DMC-ODS
Waiver”) to its Drug Medi-Cal Members.
B. CALVIVA HEALTH has the responsibility to work with the COUNTY to ensure that
oversight is coordinated and comprehensive and that the Member’s healthcare is at the center of all
oversight. Specific processes and procedures will be developed cooperatively with COUNTY, as well
as any actions required to identify and resolve any issues or problems that arise.
C. CALVIVA HEALTH and COUNTY will configure a behavioral health Medi-Cal
oversight team comprised of representatives from CALVIVA HEALTH and COUNTY that are responsible
for program oversight, quality improvement, problem and dispute resolution, and ongoing management
of this MOU.
D. CALVIVA HEALTH and COUNTY will formulate a multidisciplinary clinical team
oversight process for clinical operations: screening, assessment, referrals, care management, care
coordination, and exchange of medical information. CALVIVA HEALTH and COUNTY will determine
the final composition of the multidisciplinary teams to conduct this oversight function.
E. CALVIVA HEALTH and the COUNTY will designate as appropriate and when
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possible the same staff to conduct tasks associated within the oversight and multidisciplinary clinical
teams.
16. SPECIFIC ROLES AND RESPONSIBLITIES
A. Screening, Assessment and Referral
1. Determination of Medical Necessity
a. COUNTY will follow the medical necessity criteria for Medi-Cal
specialty mental health 1915(b) waiver services described in Title 9, California Code of Regulations
(CCR), Sections 1820.205, 1830.205, and 1830.210.
b. COUNTY will follow the medical necessity criteria outlined for the
DMC-ODS described in the 1115 Waiver Standard Terms and Conditions. DMC-ODS Substance Use
Disorder (SUD) Services shall be available as a Medi-Cal benefit for individuals who meet the medical
necessity criteria and reside in a county that opts into the Pilot program.
c. CALVIVA HEALTH will be responsible for determining medical
necessity as it relates to covered health care benefits, as outlined in 22 CCR 51303(a).
2. Assessment Process
a. CALVIVA HEALTH and COUNTY shall develop and agree to
written policies and procedures regarding screening, assessment and referral processes, including
screening and assessment tools for use in determining if CALVIVA HEALTH or COUNTY will provide
behavioral health services within a reasonable period that allows for timely access to services for
Members.
b. CALVIVA HEALTH will conduct a behavioral health assessment for
Members with a potential behavioral health condition using an assessment tool mutually agreed upon
with the COUNTY to determine the appropriate care needed.
c. For SUD Services CALVIVA HEALTH and COUNTY will distribute
to their providers the current version of the American Society of Addiction Medicine (ASAM) Patient
Placement Criteria (PPC Adult and Adolescent) crosswalk that identifies the criteria utilized to assist
with determining the appropriate treatment level of care to ensure providers are aware of SUD levels of
care for referral purposes.
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d. CALVIVA HEALTH providers shall ensure a comprehensive
substance use, physical, and mental health screening, including ASAM Level 0.5 Screening, Brief
Intervention, and Referral to Treatment (SBIRT) services for Members, is available.
3. Referrals
a. CALVIVA HEALTH and COUNTY shall develop and agree to
written policies and procedures regarding referral processes and tracking referrals, including the
following:
i. The COUNTY agrees to accept referrals from CALVIVA
HEALTH staff, providers, and Members’ self-referral for determination of medical necessity for specialty
mental health services and/or alcohol and substance use disorder treatment services.
ii. CALVIVA HEALTH Primary Care Provider agrees to refer
the Member to the CALVIVA HEALTH’s behavioral health network provider for initial assessment and
treatment (except in emergency situations or in cases when the Member clearly has a significant
impairment that the Member can be referred directly to the COUNTY). If it is determined by CALVIVA
HEALTH behavioral health provider that the Member may meet specialty mental health services and/or
alcohol and substance use disorder treatment services medical necessity criteria, the CALVIVA
HEALTH behavioral health network provider agrees to refer the Member to the COUNTY for further
assessment and treatment.
iii. CALVIVA HEALTH agrees to accept referrals from
COUNTY staff, providers, and Members’ self-referral for assessment; make a determination of medical
necessity for outpatient services; and provide referrals within CALVIVA HEALTH behavioral health
provider network. The COUNTY agrees to refer to CALVIVA HEALTH when the service needed is one
provided by CALVIVA HEALTH and not the COUNTY, and when it has been determined by the
COUNTY that the Member does not meet the specialty mental health medical necessity criteria and/or
when SUD medical necessity suggests that the member needs Early Intervention, ASAM Level 3.7 –
Medically Monitored Intensive Inpatient Services, ASAM Level 4.0 – Medically Managed Intensive
Inpatient Services, ASAM Level 3.7 Withdrawal Management – Medically Monitored Inpatient
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Withdrawal Management and ASAM Level 4.0 Withdrawal Management – Medically Managed Intensive
Inpatient Withdrawal Management not supported by Fresno County contracted providers.
B. Care Coordination
CALVIVA HEALTH and COUNTY agree to develop policies and procedures for
coordinating inpatient and outpatient medical and behavioral health care for Members enrolled with
CALVIVA HEALTH and receiving Medi-Cal specialty mental health and/or alcohol and substance use
disorder treatment services through the COUNTY. These policies and procedures shall include:
1. An identified point of contact from each party to serve as a liaison and
initiate, provide, and maintain ongoing care coordination as mutually agreed upon in CALVIVA HEALTH
and COUNTY protocols.
2. Coordination of care for inpatient behavioral health treatment provided by
the COUNTY, including a notification process between the COUNTY and CALVIVA HEALTH within 24
hours of admission and discharge to arrange for appropriate follow-up services. A process for reviewing
and updating the care plan of Members, as clinically indicated (i.e., following crisis intervention or
hospitalization). The process must include triggers for updating care plans and coordinating with
outpatient behavioral health providers.
3. Coordination of care for alcohol and substance use disorder treatment
provided by COUNTY shall occur in accordance with all applicable federal, state and local regulations.
A process for shared development of care plans by the beneficiary, caregivers and all providers and
collaborative treatment planning activities will be developed to ensure clinical integration between DMC-
ODS and managed care providers.
4. CALVIVA HEALTH shall arrange for the provision of non-emergency
medical transportation as outlined in APL 17-010, Exhibit E, attached hereto and by this reference
incorporated herein.
5. CALVIVA HEALTH and COUNTY will promote availability of clinical
consultation for shared clients receiving physical health, mental health or substance use disorder
services, including consultation on medications when appropriate.
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6. Transition of care for Members transitioning to or from CALVIVA HEALTH
or COUNTY services.
7. Regular meetings to review referral, care coordination, and information
exchange protocols and processes will occur with COUNTY and CALVIVA HEALTH representatives.
8. The delineation of case management responsibilities will be outlined.
C. Information Exchange
The COUNTY and CALVIVA HEALTH will develop and agree to information
sharing policies and procedures and agreed upon roles and responsibilities for sharing protected health
information (“PHI”) for the purposes of medical and behavioral health care coordination pursuant to Title
9, CCR, Section 1810.370(a)(3) and other pertinent state and federal laws and regulations, including
the Health Insurance Portability and Accountability Act and 42 CFR part 2, governing the confidentiality
of mental health and alcohol and substance abuse disorder treatment information.
D. Reporting and Quality Improvement Requirements
The COUNTY and CALVIVA HEALTH will have policies and procedures to
address quality improvement requirements and reports.
1. Hold regular meetings, as agreed upon by the COUNTY and CALVIVA
HEALTH, to review the referral and care coordination process and monitor Member engagement and
utilization.
2. Hold quarterly meetings and review referral and care coordination
processes to improve quality of care; and provide quarterly meeting minutes summarizing quality
findings which will be available to the DHCS upon request. The minutes summarizing findings of the
review must address the systemic strengths and barriers to effective collaboration between CALVIVA
HEALTH and COUNTY.
3. COUNTY and CALVIVA HEALTH will track cross-system referrals,
beneficiary engagement, service utilization and, have such data available to the DHCS upon request.
Data captured include but not limited to: 1) the number of disputes between CALVIVA HEALTH and
COUNTY, 2) the dispositions/outcomes of those disputes, 3) the number of grievances related to
referrals and network access, and 4) the dispositions/outcomes of those grievances. The data captured
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shall address utilization of behavioral health services by Members receiving such services from
CALVIVA HEALTH and the COUNTY, as well as quality strategies to address duplication of services.
4. The performance measures and quality improvement initiatives will be
determined by DHCS.
E. Dispute Resolution Process
CALVIVA HEALTH and COUNTY agree to follow the resolution of dispute process
in accordance to Title 9, Section 1850.505, and the contract between Medi-Cal Managed Care Plans
and DHCS and Centers for Medicare & Medicaid Services (“CMS”). A dispute will not delay member
access to medically necessary services and the referenced process above is outlined in Exhibit A of the
signed MOU.
F. Telephone Access
CALVIVA HEALTH shall ensure that Members will be able to assess urgent or
emergency behavioral health services 24 hours per day, 7 days a week. The approach will be the “no
wrong door” to service access. There will be multiple entry paths for Members to access behavioral
health services. Referrals may come from primary care physicians, providers, CALVIVA HEALTH staff,
County Departments, and self-referral by calling the COUNTY’s toll-free number that will be available
24 hours per day, 7 days a week for service access, service authorization, and referral.
G. Provider and Member Education
CALVIVA HEALTH and COUNTY shall determine the requirements for
coordination of Member and provider information about access to CALVIVA HEALTH and COUNTY
covered services to increase navigation support for beneficiaries and caregivers. CALVIVA HEALTH
and COUNTY may develop a “Quick Guide” that will assist for referrals and access to services.
H. Point of Contact for the MOU Amendment
The Point of Contact for the MOU will be a designated liaison from both the
COUNTY and CALVIVA HEALTH.
17. HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT
COUNTY and CALVIVA HEALTH each consider and represent themselves as covered
entities as defined by the U.S. Health Insurance Portability and Accountability Act of 1996, Public Law
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104-191 (“HIPAA”) and agree to use and disclose PHI as required by law. COUNTY and CALVIVA
HEALTH acknowledge that the exchange of PHI between them is only for treatment, payment, and
health care operations. COUNTY and CALVIVA HEALTH intend to protect the privacy and provide for
the security of PHI pursuant to the Agreement in compliance with HIPAA, the Health Information
Technology for Economic and Clinical Health Act, Public Law 111-005 (“HITECH”), and regulations
promulgated thereunder by the U.S. Department of Health and Human Services (HIPAA Regulations)
and other applicable laws.
18. SEVERABILITY
The provisions of this Agreement are severable. The invalidity or unenforceability of any
one provision in the Agreement shall not affect the other provisions.
19. ENTIRE AGREEMENT
This Agreement, including all exhibits, constitutes the entire agreement between CALVIVA
HEALTH and COUNTY with respect to the subject matter hereof and supersedes all previous
Agreement negotiations, proposals, commitments, writings, advertisements, publications, and
understanding of any nature whatsoever unless expressly included in this Agreement.
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1 IN WITNESS WHEREOF, the parties hereto have executed this Agreement as of the day
2 and year first hereinabove written .
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CALVIVA HEALTH:
FRESNO, KINGS, MADERA
REGIONAL HEAL TH AUTHORITY
dba CAL VIVA HEAL TH
1 (R~5 µ. ?~i <V\ i\va.-:1oq
fre o 10 CA °l 2JJ \ \
Mailing Add~ess
FOR ACCOUNTING USE ONLY:
Fund/Subclass: 0001/10000
Account No .: 7295 ($0)
Org No.: 56302666 ($0)
COUNTY OF FRESNO
ATTEST:
Bernice E. Seidel
Clerk of the Board of Supervisors
County of Fresno, State of California
17
MEMORANDUM OF UNDERSTANDING (MOU)
DEPARTMENT OF BEHAVIORAL HEALTH (COUNTY)
AND
CALVIVA HEALTH
CATEGORY COUNTY CALVIVA HEALTH
A. Liaison 1. COUNTY’s Administrative Staff
is the liaison to coordinate
activities with CALVIVA
HEALTH and to notify COUNTY
providers and relevant staff of
their roles and responsibilities
2. COUNTY Liaison will provide
CALVIVA HEALTH with an
updated list of approved
COUNTY providers, specialists
and behavioral health care
centers in the county.
3. Information for mental health is
also available on the
COUNTY’s managed care
website and is updated at a
minimum on a quarterly basis.
4. Information for Substance Use
Disorder is also available on the
COUNTY’s Substance Use
Disorders Services Webpage
and is updated at a minimum on
a 30 day basis.
1. CALVIVA HEALTH has a liaison that
coordinates activities with the COUNTY
and COUNTY Liaison.
2. The Liaison will notify CALVIVA HEALTH
staff and CALVIVA HEALTH providers of
their responsibilities to coordinate
services with the COUNTY.
3. A printable downloadable CALVIVA
HEALTH Provider Directory is available
on line and updated at a minimum on a
monthly basis. CALVIVA HEALTH also
maintains an online searchable provider
directory that is updated at least weekly.
4. The CALVIVA HEALTH Provider
Operations Manual is available on line.
B. Behavioral
Health Service
1. COUNTY will credential and
contract with sufficient numbers
of licensed behavioral health
professionals to maintain a
COUNTY provider network
sufficient to meet the needs of
Members.
2. COUNTY will assist with
identification of COUNTY
providers who have the
capacity and willingness to
accept Medi-Cal Fee for
Service reimbursement to serve
Members in need of mental
health services who do not
meet the COUNTY medical
necessity criteria and require
services outside the scope of
practice of the Primary Care
Physicians (PCP) per Exhibit B,
attached hereto.
3. For Substance Use Disorder,
1. CALVIVA HEALTH will utilize the
COUNTY to identify COUNTY providers
who are willing to accept Medi-Cal fee for
service reimbursement to provide
services for mental health services to
Members who do not meet COUNTY
medical necessity criteria for COUNTY
services and require services outside the
scope of practice of the PCP per Exhibit
B, attached hereto.
2. CALVIVA HEALTH will coordinate care
with the appropriate COUNTY provider or
provider organization as recommended
by the COUNTY for those services that
do not meet the COUNTY medical
necessity criteria.
3. For Substance Use Disorder services,
CALVIVA HEALTH will screen and offer
brief intervention. For clients who appear
to need further assessment and more
intensive services, a referral to COUNTY
centralized intake or a provider on the list
Exhibit A
Page 1 of 27
CATEGORY COUNTY CALVIVA HEALTH
COUNTY will provide a
centralized intake function that
will screen clients using the
ASAM criteria and determine a
presumptive level of care.
Once the client attends an
intake at a COUNTY contracted
provider, they will be assessed
for medical necessity including
diagnosis. COUNTY
centralized intake will approve
services through a Treatment
Authorization Request process.
4. COUNTY will continually
monitor the COUNTY provider
network to ensure Member
access to quality behavioral
health care. COUNTY will
assist CALVIVA HEALTH in
arranging for a specific
COUNTY provider or
community service.
5. COUNTY will assist CALVIVA
HEALTH to develop and update
a list of providers or provider
organizations to be made
available to Members. For
mental health services this list
is available on the COUNTY’s
managed care website. Any
updates to the list will be
forwarded to the CALVIVA
HEALTH liaison quarterly and
upon request. For Substance
Use Disorder services, this list
is available on the COUNTY’s
Substance Use Disorder
Services Webpage. Any
updates to the list will be
forwarded to the CALVIVA
HEALTH liaison quarterly and
upon request.
will be required.
4. CALVIVA HEALTH will collaborate with
COUNTY to maintain a list of COUNTY
providers or provider organizations to be
made available to Members upon
request.
5. Any updates to the list will be provided to
CALVIVA HEALTH liaison quarterly and
upon request.
C. Medical
Records
Exchange of
Information
1. COUNTY will follow all
applicable laws pertaining to the
use and disclosure of protected
health information including but not
limited to:
HIPAA / 45 C.F.R. Parts 160 and
164
LPS / W & I Code Sections 5328-
1. CALVIVA HEALTH and contracted
providers are allowed to release medical
information under HIPAA regulations specific
to the HIPPA Privacy Rule (45 C.F.R. Part
164.)
Exhibit A
Page 2 of 27
CATEGORY COUNTY CALVIVA HEALTH
5328.15
45 C.F.R. Part 2
HITECH Act (42. U.S.C. Section
17921 et. seq.
CMIA (Ca Civil Code 56 through
56.37)
D. Scope of
Service
1. COUNTY has a toll-free
telephone number available 24
hours a day, seven days a
week for access to emergency,
specialty mental health and
Substance Use Disorder
services for Members who meet
the medical necessity criteria as
identified in Exhibit B, attached
hereto.
2. COUNTY maintains
responsibility for:
a. Medication treatment for
behavioral health
conditions that would
not be responsive to
physical healthcare-
based treatment and the
condition meets
COUNTY medical
necessity criteria.
b. All other outpatient
specialty mental health
and Substance Use
Disorder services
covered by the
COUNTY when the
Member’s behavioral
health condition meets
COUNTY medical
necessity criteria, such
as individual and group
therapies, case
management, crisis
intervention, treatment
plan, assessment, and
linkage with community
resources.
c. Consultation and
training services to
PCPs, particularly
related to specialty
mental health and
Substance Use Disorder
1. CALVIVA HEALTH PCPs will be
responsible for providing 24 hours a day,
seven days a week, access to health care
services for Members as specified in the
CALVIVA HEALTH contract with
Department of Health Care Services
(DHCS).
2. PCP will refer to the COUNTY for
assessment and appropriate services.
PCP’s will refer Members for:
a. An assessment to confirm or
arrive at a diagnosis
b. Behavioral health services other
than medication management are
needed for a Member with a
diagnosis included in the
responsibilities of the COUNTY.
c. For identification of conditions not
responsive to physical healthcare-
based treatment.
3. PCP’s will provide primary care
behavioral health treatment which
includes:
a. Basic education, assessment
(mental health services only),
counseling (mental health services
only) and referral and linkage to
other services for all Members
b. Medication and treatment for
i. Behavioral health
conditions that would be
responsive to physical
healthcare-based
treatment
ii. Behavioral health
disorders due to a general
medical condition
c. Medication-induced reactions from
medications prescribed by
physical health care providers.
4. PCPs will provide or arrange for:
a. Covered medical services
b. Primary behavioral health
intervention for Member with
Exhibit A
Page 3 of 27
CATEGORY COUNTY CALVIVA HEALTH
issues and treatments,
including medication
consultation.
3. To receive behavioral health
services, the Member must
meet the criteria for each of the
following categories for mental
health services:
a. Category A—Included
Diagnosis
b. Category B—
Impairment Criteria
c. Category C—
Intervention Related
Criteria
Per Enclosure 1a of Exhibit
A.
4. To receive behavioral health
services, the Member must
meet the criteria for each of the
following categories for
Substance Use Disorder
services:
a. Early Intervention Services
b. Outpatient/Intensive
Outpatient
c. Residential Services (ASAM
Levels 3.1, 3.3, 3.5, 3.7 and
4.0)
d. Withdrawal Management
e. Opioid Treatment
f. Recovery Services
For further details on SUD
ASAM levels of care please see
Exhibit C. For SUD ICD-10
Diagnostic Codes see
Enclosure 1b.
5. COUNTY providers will refer
Members back to their identified
PCP for medical and non-
specialty behavioral health
conditions that would be
responsive to appropriate
physical health care.
“Excluded Diagnosis” as identified
in Specialty Mental Health
Services identified in
ATTACHMENT A, Page 17 of this
Exhibit A.
c. Screening and brief intervention
for behavioral health services
within the PCP’s scope of practice
5. CALVIVA HEALTH and COUNTY
recognize that the PCP’s ability to treat
behavioral health disorders will be limited
to each provider’s training and scope of
practice.
6. When the Member does not meet mental
health medical necessity, CALVIVA
HEALTH and PCP will be responsible for
coordinating a referral in accordance with
Category B2 “Mental Health Services” or
an CALVIVA HEALTH contracted
provider.
7. When the member meets Substance Use
Disorder medical necessity for COUNTY
contracted services, CALVIVA HEALTH
and PCP will refer client to a county
provider or coordinate care with inpatient
facilities and out-of-county facilities
accepting Fresno County clients as
appropriate.
E. Ancillary
Behavioral Health
Services
1. When medical necessity criteria
are met and services are
approved by the COUNTY, the
COUNTY and its contracted
providers will provide hospital
based specialty mental health
1. CALVIVA HEALTH must cover and pay
for medically necessary laboratory,
radiological, and radioisotope services
described in Title 22, CCR, Section
51311. CALVIVA HEALTH will cover and
pay for related services for
Exhibit A
Page 4 of 27
CATEGORY COUNTY CALVIVA HEALTH
ancillary services, which
include, but are not limited to
Electroconvulsive therapy
(ECT) and magnetic resonance
imaging (MRI) that are received
by a Member admitted to a
psychiatric inpatient hospital
other than routine services, per
Exhibit B, attached hereto.
2. When Substance Use Disorder
medical necessity criteria is met
and services are approved by
the COUNTY for ASAM levels
3.7 and 4.0 and medical detox,
COUNTY will refer Member to
CALVIVA HEALTH.
3. COUNTY will make training
available for community based
physicians interested in
providing Medically Assisted
Treatment (MAT) services,
including an eight hour
Buprenorphine Waiver Training
required to become a
community based MAT
provider.
Electroconvulsive Therapy (ECT),
anesthesiologist services provided on an
outpatient basis, per Exhibit B, attached
hereto.
2. CALVIVA HEALTH will cover and pay for
all medically necessary professional
services to meet the physical health care
needs of the Members who are admitted
to the psychiatric ward of a general acute
care hospital or to a freestanding licensed
psychiatric inpatient hospital or
Psychiatric Health Facility (PHF). These
services include the initial health history
and physical assessment required within
24 hours of admission and any medically
necessary physical medicine consultation,
per Exhibit B, attached hereto.
3. CALVIVA HEALTH is not required to
cover room and board charges or
behavioral health services associated
with a Member’s admission to a hospital
or inpatient psychiatric facility for
psychiatric inpatient services, per Exhibit
B, attached hereto.
4. CALVIVA HEALTH will provide
Substance Use Disorder treatment for
Members who meet medical necessity for
Medically Monitored Intensive Inpatient
Services (ASAM Level 3.7) which
includes 24 hour nursing care with
physician availability for significant
problems with acute intoxication and/or
withdrawal potential, biomedical
conditions and emotional, behavioral or
cognitive conditions and complications
and 16 hour/day counselor availability.
5. CALVIVA HEALTH will provide
Substance Use Disorder treatment for
Members who meet medical necessity for
Medically Managed Intensive Inpatient
Services (ASAM Level 4.0) which
includes 24 hour nursing care and daily
physician care for severe, unstable
problems with acute intoxication and/or
withdrawal potential, biomedical
conditions and emotional, behavioral or
cognitive conditions and complications
with counseling available to engage
Member in treatment.
6. CALVIVA HEALTH will provide
Substance Use Disorder treatment for
Exhibit A
Page 5 of 27
CATEGORY COUNTY CALVIVA HEALTH
Members who meet medical necessity for
Medically Monitored Inpatient Withdrawal
Management (ASAM Level 3.7 – WM)
which includes severe withdrawal needing
24-hour nursing care and physician visits.
7. CALVIVA HEALTH will provide
Substance Use Disorder treatment for
Members who meet medical necessity for
Medically Managed Intensive Inpatient
Withdrawal Management (ASAM Level 4
– WM) which includes severe, unstable
withdrawal needing 24-hour nursing care
and daily physician visits to modify
withdrawal management regimen and
manage medical instability. Once the
client has stabilized CALVIVA HEALTH
will refer to a lower level of care to
increase the likelihood of successful
recovery.
8. CALVIVA HEALTH will prescribe, dose
and/or refer Members with an Opioid Use
Disorder to Medication Assisted
Treatment (MAT) when appropriate.
CALVIVA will encourage its physicians to
complete an eight hour Buprenorphine
Waiver Training course required to
prescribe and dispense Buprenorphine.
This training is available through
SAMHSA.
9. CALVIVA HEALTH shall coordinate with
COUNTY Narcotic Treatment Program
providers when medically indicated for
MAT services.
E1. Emergency
Room Urgent
Behavioral Health
Care
1. The COUNTY toll free 24 hour
line is available to Members.
2. The COUNTY shall cover and
pay for the professional
services of a behavioral health
specialist provided in an
emergency room to a Member
whose condition meets
COUNTY medical necessity
criteria or when behavioral
health specialist services are
required to assess whether
COUNTY medical necessity is
met, per Exhibit B, attached
hereto.
3. The COUNTY is responsible for
the facility charges resulting
1. CALVIVA HEALTH will maintain a 24
hour member service and Nurse Advice
Line.
2. CALVIVA HEALTH shall cover and pay
for all professional services, except the
professional services of a behavioral
health specialist when required for the
emergency services and care of a
member whose condition meets COUNTY
medical necessity criteria.
3. CALVIVA HEALTH shall cover and pay
for the facility charges resulting from the
emergency services and care of a
Member whose condition meets COUNTY
medical necessity criteria when such
services and care do not result in the
admission of the member for psychiatric
Exhibit A
Page 6 of 27
CATEGORY COUNTY CALVIVA HEALTH
from the emergency services
and care of a Member whose
condition meets COUNTY
medical necessity criteria when
such services and care do
result in the admission of the
Member for psychiatric and/or
Substance Use Disorder
inpatient hospital services at the
same facility. The facility charge
is not paid separately, but is
included in the per diem rate for
the inpatient stay, per Exhibit B,
attached hereto.
4. The COUNTY is responsible for
facility charges directly related
to the professional services of a
behavioral health specialist
provided in the emergency
room when these services do
not result in an admission of the
member for psychiatric and/or
Substance Use Disorder
inpatient hospital services at
that facility or any other facility,
per Exhibit B, attached hereto.
and/or Substance Use Disorder inpatient
hospital services or when such services
result in an admission of the member for
psychiatric and/or Substance Use
Disorder inpatient hospital services at a
different facility.
4. CALVIVA HEALTH shall cover and pay
for the facility charges and the medical
professional services required for the
emergency services and care of a
Member with an excluded diagnosis or a
Member whose condition does not meet
COUNTY medical necessity criteria and
such services and care do not result in
the admission of the Member for
psychiatric and/or Substance Use
Disorder inpatient hospital services.
5. Payment for the professional services of a
behavioral health specialist required for
the emergency services and care of a
Member with an excluded diagnosis is the
responsibility of CALVIVA.
E2. Home Health
Agency Services
1. COUNTY shall cover and pay
for medication support services,
case management, crisis
intervention services, or any
other specialty mental health
services as provided under
Section 1810.247, which are
prescribed by a psychiatrist and
are provided to a Member who
is homebound. COUNTY will
collaborate with CALVIVA
HEALTH on any specialty
mental health services being
provided to a Member.
1. CALVIVA HEALTH will cover and pay for
prior authorized home health agency
services as described in Title 22, CCR,
Section 51337 prescribed by an CALVIVA
HEALTH provider when medically
necessary to meet the needs of
homebound Members. CALVIVA
HEALTH is not obligated to provide home
health agency services that would not
otherwise be authorized by the Medi-Cal
program.
2. CALVIVA HEALTH will refer Members
who may be at risk of institutional
placement to the Home and Community
Based services (HCBS) Waiver Program
(CALVIVA/DHCS Contract 6.7.3.8) if
appropriate.
E3. Nursing and
Residential
Facility Services
1. COUNTY will arrange and
coordinate payment for nursing
facility services, i.e.,
Augmented Board and Care
(ABC), Skilled Nursing Facility
(SNF), Institution for Mental
1. CALVIVA HEALTH will arrange and pay
for nursing facility services for Members
who meet the medical necessity criteria
for the month of admission plus one
month, per Title 22, CCR, Section 51335.
2. CALVIVA HEALTH will arrange for
Exhibit A
Page 7 of 27
CATEGORY COUNTY CALVIVA HEALTH
Disease (IMD), etc., for
Members who meet medical
necessity criteria and who
require a special treatment
program [Title 22, California
Code of Regulations (CCR),
Section 51335(k)].
2. COUNTY’s provide medically
necessary specialty mental
health services, typically visits
by psychiatrists and
psychologists.
disenrollment from managed care if
Member needs nursing services for a
longer period of time.
3. CALVIVA HEALTH will pay for all
medically necessary DHCS contractually
required Medi-Cal covered services until
the disenrollment is effective.
E4. Emergency
Transportation,
Non-Emergency
Medical
Transportation
(NEMT and Non-
Medical
Transportation
(NMT)
1. Medical transportation services
as described in Title 22, Section
51323 are not the responsibility
of the COUNTY except when
the purpose of the medical
transportation service is to
transport a Medi-Cal beneficiary
from a psychiatric inpatient
hospital to another psychiatric
inpatient hospital or another
type of 24 hour care facility
because the services in the
facility to which the beneficiary
is being transported will result in
lower costs to the COUNTY.
1. CALVIVA HEALTH will arrange and pay
for transportation of Members needing
medical transportation from:
a. The emergency room for medical
evaluation.
b. A psychiatric inpatient hospital to
a medical inpatient hospital
required to address the Member’s
change in medical condition.
c. A medical inpatient hospital to a
psychiatric inpatient hospital
required to address the Member’s
change in psychiatric condition.
2. CALVIVA HEALTH will cover and pay for
all medically necessary emergency
transportation (per CCR Title 22, 51323).
Ambulance services are covered when
the Member’s medical condition
contraindicates the use of other forms of
medical transportation.
3. Emergency medical transportation is
covered, without prior authorization, to the
nearest facility capable of meeting the
medical needs of the Member as per
CCR Title 22, 51323.
4. Ambulance, litter van and wheelchair van
medical transportation services are
covered when the Member’s medical and
physical condition is such that transport
by ordinary means of public or private
conveyance is medically contraindicated,
and transportation is required for the
purpose of obtaining needed medical
care. Ambulance services are covered
when the member’s medical condition
contraindicates the use of other forms of
medical transportation
5. CALVIVA HEALTH will cover all
Exhibit A
Page 8 of 27
CATEGORY COUNTY CALVIVA HEALTH
nonemergency medical transportation,
necessary to obtain program covered
services. A completed, signed CALVIVA
HEALTH Physician Certification
Statement (PCS) Form must be submitted
to CALVIVAHEALTH for the NEMT
services to be arranged.
6. CALVIVA HEALTH will cover and pay for
medically necessary non-emergency
medical transportation services when
prescribed for a Member by a Medi-Cal
behavioral health provider outside the
COUNTY when a PCS is submitted.
7. CALVIVA HEALTH will maintain a policy
of non-discrimination regarding Members
with behavioral health disorders who
require access to any other transportation
services provided by CALVIVA.
8. CALVIVA HEALTH shall/will provide Non-
Medical Transport (NMT) for all Medi-Cal
services including services not covered
by the CALVIVA HEALTH contract. These
services include but are not limited to;
Specialty Mental Health, Substance Use
Disorder, dental and any other benefits
delivered through the Medi-Cal delivery
system.
9. NMT does not include transportation of
the sick, injured, invalid, convalescent,
infirm or otherwise incapacitated
members who need to be transported by
ambulance, litter vans, or wheelchair vans
licensed, operated and equipped in
accordance with the State and Local
statutes, ordinance, or regulations.
Physicians may authorize NMT for
members if they are currently using a
wheelchair but the limitation is such that
the member is able to ambulate without
assistance from the driver. The NMT
requested must be the least costly
method of transportation that meets the
member’s needs.
10. CALVIVA HEALTH may use prior
authorization processes for NMT
services. The member’s needs for NMT
or NEMT services do not relieve
CALVIVA HEALTH from complying with
their timely access standards obligation.
11. CALVIVA HEALTH will assure that
Substance Use Disorder clients receive
Exhibit A
Page 9 of 27
CATEGORY COUNTY CALVIVA HEALTH
Non-Emergency medical transportation
services when prescribed for a Member
as described in APL 17-010, Attached as
Exhibit E. These transportation services
will be provided when the SUD services
are medically necessary and a PCS is
submitted.
E5.
Developmentally
Disabled Services
1. COUNTY will refer Members
with developmental disabilities
to the Central Valley Regional
Center for non-medical services
such as respite, out-of-home
placement, supportive living,
etc., if such services are
needed.
2. COUNTY has a current list of
names, addresses and
telephone numbers of local
providers, provider
organizations, and agencies
that is available to a Member
when that Member has been
determined to be ineligible for
COUNTY covered services
because the Member’s
diagnosis is not included in
Exhibit B Pages 32 to 36.
1. CALVIVA HEALTH PCP will refer
Members with developmental disabilities
to the Central Valley Regional Center for
non-medical services such as respite,
out-of-home placement supportive living,
etc., if such services are needed.
2. CALVIVA HEALTH will maintain a current
MOU with Central Valley Regional Center
E6. History and
Physical for
Psychiatric
Hospital
Admission
1. COUNTY will utilize CALVIVA
HEALTH network providers to
perform medical histories and
physical examinations required
for behavioral health
examinations required for
behavioral health and
psychiatric hospital admissions
for CALVIVA HEALTH
members.
1. CALVIVA HEALTH will cover and pay for
all medically necessary professional
services to meet the physical health care
needs of Members who are admitted to
the psychiatric ward of a general acute
care hospital or freestanding licensed
psychiatric inpatient hospital. These
services include the initial health history
and physical assessment required within
24 hours of admission and any necessary
physical medicine consultations, per
Exhibit B attached hereto.
E7. Hospital
Outpatient
Department
Services
(Electroconvulsive
Therapy)
1. COUNTY will cover and pay for
all psychiatric professional services
associated with electroconvulsive
therapy. Per Title 9, CCR Section
1810.350
1. CALVIVA HEALTH is responsible for
separately billable outpatient services
related to electroconvulsive therapy, such
as anesthesiologist services, per Exhibit
B, attached hereto.
2. CALVIVA HEALTH will cover and pay for
professional services and associated
room charges for hospital outpatient
Exhibit A
Page 10 of 27
CATEGORY COUNTY CALVIVA HEALTH
department services consistent with
medical necessity and CALVIVA‘s
contract with its contractors and DHCS,
per Exhibit B, attached hereto.
F. Diagnostic
Assessment and
Triage
3. COUNTY or COUNTY provider
will screen and apply ASAM
criteria for level of care
placement. When Member is
determined to meet medical
necessity for a level of care not
provided by COUNTY Member
will be referred to CALVIVA.
4. COUNTY will arrange and pay
for specialty COUNTY provider
services for Members whose
psychiatric condition may not be
responsive to physical health
care.
a. Initial access and
availability will be via the
COUNTY Access Unit (a
twenty-four hour toll free
telephone triage system)
b. Crisis/emergency triage
via COUNTY provider is
available 24 hours a
day.
5. COUNTY provider will assess
and diagnose Member’s
symptoms, level of impairment
and focus of intervention.
Included ICD-9 Diagnoses
codes are identified in
Enclosure 1a, attached hereto
and incorporated herein.
6. COUNTY provider assessments
will:
c. Determine if Member
meets medical necessity
criteria (See Attachment
B, attached hereto and
incorporated herein by
reference.)
d. Provide a resolution of
diagnostic dilemmas not
resolved by
consultations (e.g.,
multiple interacting
syndromes, patient’s
symptoms interfere with
1. CALVIVA HEALTH will provide Members
with Substance Use Disorder screenings,
brief intervention (SBIRT), referral and
assessment. If it is found that a Member
preliminarily meets medical necessity for
COUNTY provided services CALVIVA
HEALTH will refer the Member to an
appropriate COUNTY access point (24/7
Access Line, Urgent Care Wellness
Center or COUNTY provider) for further
assessment and treatment.
2. CALVIVA HEALTH will arrange and pay
for assessments of CALVIVA HEALTH
members by PCPs to:
a. Rule out general medical
conditions causing psychiatric
and/or Substance Use Disorder
symptoms.
b. Rule out behavioral health
disorders caused by a general
medical condition.
3. The PCP will identify those general
medical conditions that are causing or
exacerbating psychiatric and/or
Substance Use Disorder symptoms.
4. The PCP will be advised to identify and
treat non-disabling psychiatric conditions
which may be responsive to primary care,
i.e., mild to moderate anxiety and/or
depression.
5. When medically necessary CALVIVA
HEALTH will cover and pay for physician
services provided by specialists such as
neurologists, per Exhibit B, attached
hereto.
Exhibit A
Page 11 of 27
CATEGORY COUNTY CALVIVA HEALTH
the diagnostic
conclusion and has a
bearing on the primary
care physician’s
treatment plan or if the
diagnostic conclusion is
needed to determine
appropriateness for
specialized mental
health care.
e. Identify stability level, if
the result is needed to
determine
appropriateness for
specialty mental health
services.
G. Referrals 1. COUNTY will accept referrals
from CALVIVA HEALTH staff
and providers. CALVIVA
HEALTH providers and
Members will be referred to
determine medical necessity for
specialty mental health
services. For Substance Use
Disorder members, screening
will be completed to determine
if further assessment is
necessary. If so clients will be
referred to the 24/7 Access
Line.
2. COUNTY will coordinate with
CALVIVA HEALTH Customer
Care Center to facilitate
appointment and referral
verification assistance as
needed.
3. When all medical necessity
criteria are met, COUNTY will
arrange for specialty mental
health and/or Substance Use
Disorder services by COUNTY
provider.
4. When Member is appropriately
treated and/or stabilized,
Member may be referred back,
if appropriate to PCP for
maintenance care. The
COUNTY and CALVIVA
HEALTH will coordinate
services as necessary in such
1. Following the PCP assessment, CALVIVA
HEALTH staff and/or PCP will refer those
Members whose psychiatric condition or
Substance Use Disorder would not be
responsive to physical health care to the
COUNTY to determine if specialty mental
health and/or Substance Use Disorder
services medical necessity criteria are
met.
2. CALVIVA HEALTH and PCP will
coordinate and assist the COUNTY and
Member to keep their appointments and
referrals back to their PCP as appropriate
for all other services not covered by the
COUNTY.
a. CALVIVA HEALTH may request
assistance from the COUNTY
Liaison to facilitate removal of
barriers to a successful referral
such as transportation difficulties,
resistance to treatment or delays
to access.
3. Members not meeting COUNTY medical
necessity guidelines will be referred by
CALVIVA HEALTH to appropriate
community resources for assistance in
identifying programs available for low
income Medi-Cal beneficiaries.
Exhibit A
Page 12 of 27
CATEGORY COUNTY CALVIVA HEALTH
cases
5. COUNTY and COUNTY
provider will track referrals to
PCP to verify that Member has
access to appointment and
assistance to keep appointment
as needed.
a. COUNTY provider will
have the option of
contacting the CALVIVA
HEALTH Health Services
for information and
assistance concerning a
referred Member.
6. The COUNTY will refer the
Member to a source of
treatment or a source of referral
for treatment outside the
COUNTY when the COUNTY
determines that the Member’s
diagnosis is not included in Title
9, CCR, Section 1830.205.
7. Per Welfare & Institution Code,
Section 5777.5 (b)(1) for
behavioral health services the
COUNTY will designate a
process or entity to receive
notice of actions, denials, or
deferrals from CALVIVA
HEALTH, and to provide any
additional information requested
in the deferral notice as
necessary for a medical
necessity determination.
8. Per Welfare & Institution Code,
Section 5777.5(b) (2) for
behavioral health services the
COUNTY will respond by the
close of business day following
the day the deferral notice is
received.
H. Service
Authorizations
1. For mental health services,
COUNTY will authorize
assessment and/or treatment
services by COUNTY providers
who are credentialed and
contracted with COUNTY for
services that meet specialty
mental health services medical
necessity criteria.
1. CALVIVA HEALTH will authorize medical
assessment and/or treatment services by
CALVIVA HEALTH network providers
who are credentialed and contracted with
CALVIVA HEALTH for covered medically
necessary services.
2. CALVIVA HEALTH will inform PCPs that
they may refer Members to the COUNTY
for initial diagnosis and assessment of the
Exhibit A
Page 13 of 27
CATEGORY COUNTY CALVIVA HEALTH
2. For Substance Use Disorder
services, COUNTY will perform
screening and referral to
treatment. Once the provider
assessment is complete
COUNTY will authorize a
Treatment Authorization
Request (TAR) for level of care
to receive treatment by
COUNTY providers who are
Drug Medi-Cal certified and
contracted with the COUNTY
for Substance Use Disorder
services that meet medical
necessity criteria.
Member.
I. Consultation
1. COUNTY encourages
consultations between
COUNTY providers, specialty
providers and CALVIVA
HEALTH PCP providers as it
relates to specialty mental
health and/or Substance Use
Disorder issues including but
not limited to medication issues,
linkage with community
resources, etc., in accordance
with HIPAA federal and state
regulations regarding
confidentiality per HIPPA
Privacy Rule 45 C.F.R. Part
164.
2. For those Members who are
excluded from COUNTY
services, COUNTY will provide
clinical consultation and training
to the CALVIVA HEALTH
PCPs, other behavioral health
providers and/or CALVIVA
HEALTH staff on the following
topics:
a. Recommended physical
healthcare-based
treatment for diagnosed
conditions
b. Complex diagnostic
assessment of
behavioral health
disorders (e.g., multiple
co-occurring diagnosis,
atypical symptom
1. PCP providers will be available to consult
with COUNTY and COUNTY providers
regarding Members who are treated by
both, in accordance with HIPAA federal
and state regulations regarding
confidentiality, per HIPPA Privacy Rule 45
C.F.R. Part 164.
2. For those Members who meet COUNTY
medical necessity criteria and whose
psychiatric symptoms and/or Substance
Use Disorder will be treated by a
COUNTY provider, CALVIVA HEALTH
and/or PCP will provide consultation to
COUNTY providers and/or COUNTY staff
on the following topics:
a. Acquiring access to covered
CALVIVA HEALTH medical
services.
b. Treatment of physical symptoms
precipitated by medications used
to treat behavioral health
disorders.
c. Treatment of complicated sub-
syndrome medical symptoms.
d. Complex medication interactions
with medications prescribed by
PCP not commonly used in
psychiatric or Substance Use
Disorder specialty practice.
Exhibit A
Page 14 of 27
CATEGORY COUNTY CALVIVA HEALTH
patterns)
c. Treatment of stabilized
but serious and
debilitating mental
disorders
d. Complex psychotropic
medications practices
(medication interactions,
polypharmacy, use of
novel psychotropic
medication)
e. Treatment of
complicated sub-
syndrome psychiatric
symptoms
f. Treatment of psychiatric
symptoms precipitated
by medications used to
treat medical conditions
g. Treatment of outpatient
behavioral health
services that are within
the CALVIVA HEALTH
PCP’s scope of practice.
3. For those Members who are
excluded from COUNTY
services, COUNTY will provide
clinical consultation and training
to the CALVIVA HEALTH
PCPs, and/or CALVIVA
HEALTH staff on the following
topics:
a. ASAM Multidimensional
Assessment
b. From Assessment to
Service Planning and
Level of Care
c. Title 22/Documentation
d. Evidence Based
Practices
e. DSM-5
f. Co-occurring Disorders
g. Medication Assisted
Treatment
J. Early Periodic
Screening,
Diagnosis and
treatment
(EPSDT)
Supplemental
1. COUNTY will utilize Medi-Cal
medical necessity criteria
established for EPSDT
supplemental services to
determine if a child, 21 years of
age and under, meets those
1. When CALVIVA HEALTH determines that
EPSDT supplemental services criteria are
not met and the Member child’s condition
is not CCS eligible, CALVIVA HEALTH
will refer the Member child to the PCP for
treatment of conditions within the PCP’s
Exhibit A
Page 15 of 27
CATEGORY COUNTY CALVIVA HEALTH
Services. criteria.
2. When EPSDT supplemental
criteria are met, COUNTY is
responsible for arranging and
paying for EPSDT supplemental
services provided by COUNTY
specialty mental health and
Substance Use Disorder
providers.
3. When EPSDT supplemental
criteria are not met, COUNTY
will refer Member children as
follows:
a. For mental health
services, Referral to
California Children’s
Services (CCS)- for
those children who have
a CCS medically eligible
condition and require
behavioral health
provider services related
to the eligible condition
b. For Substance Use
Disorder services,
ASAM criteria will be
applied, level of care will
be determined and a
referral to treatment will
be made.
c. When a referral is made,
the COUNTY will notify
CALVIVA HEALTH of
the referral.
scope of practice.
2. Referrals to the COUNTY for an
appropriate linked program will be made
for treatment of conditions outside the
PCP’s scope of practice. CALVIVA
HEALTH will assist the COUNTY and
Members by providing links to known
community providers of supplemental
services.
3. CALVIVA HEALTH will cover all medically
necessary professional services to meet
the physical health care needs of
Members admitted to a general acute
care hospital ward or to a freestanding
licensed psychiatric inpatient hospital.
K.
Pharmaceutical
Services and
Prescribed Drugs
1. COUNTY providers will
prescribe and monitor the
effects and side effects of
psychotropic medications for
Members under their treatment.
2. COUNTY will coordinate with
CALVIVA HEALTH
representatives to ensure that
psychotropic drugs prescribed
by COUNTY providers are
included in the CALVIVA
HEALTH formulary and/or
available for dispensing by
CALVIVA HEALTH network
pharmacies unless otherwise
stipulated by state regulation.
1. CALVIVA HEALTH will:
a. Allow COUNTY credentialed
providers access to pharmacy and
laboratory services as specialty
providers.
b. Will make available a list of
participating pharmacies and
laboratories on the internet.
c. Will make available the formulary
and information regarding drug
formulary procedures on the
internet.
d. Consider recommendations from
COUNTY for utilization
management standards for
behavioral health, pharmacy and
Exhibit A
Page 16 of 27
CATEGORY COUNTY CALVIVA HEALTH
3. COUNTY will inform COUNTY
providers regarding process
and procedure for obtaining
prescribed medications for
Members.
4. COUNTY providers will utilize
CALVIVA HEALTH contracted
laboratories for laboratory tests
required for medication
administration and
management of psychotropic
medications.
5. COUNTY will assist CALVIVA
HEALTH in the utilization
review of psychotropic drugs
prescribed by out-of-network
psychiatrists.
6. COUNTY will share with
CALVIVA HEALTH a list of non-
contracted psychiatrist
COUNTY providers contracted
to provide behavioral health
services in areas where access
to psychiatrists is limited, on a
quarterly basis.
laboratory services.
e. Provide the process for obtaining
timely authorization and delivery
of prescribed drugs and laboratory
services to the COUNTY.
2. CALVIVA HEALTH will coordinate with
COUNTY to ensure that covered
psychotropic drugs prescribed by
COUNTY providers are available through
the authorization process or formulary for
dispensing by CALVIVA HEALTH network
pharmacies unless otherwise stipulated
by state regulation. (See Enclosure2,
“Drugs Excluded from Plan Coverage” of
Exhibit B)
3. CALVIVA HEALTH will apply utilization
review procedures when prescriptions are
written by out-of-network psychiatrists for
the treatment of psychiatric conditions.
a. Covered psychotropic drugs
written by out-of-network
psychiatrists will be filled by
CALVIVA HEALTH network
pharmacies.
b. CALVIVA HEALTH will provide
Members with the same drug
accessibility written by out-of-
network psychiatrists as in-
network providers.
c. CALVIVA HEALTH will not cover
and pay for behavioral health
drugs written by out-of-network
physicians who are not
psychiatrists unless these
prescriptions are written by non-
psychiatrists contracted by the
COUNTY to provide behavioral
health services in areas where
access to psychiatrists is limited
per Exhibit B, attached hereto.
4. CALVIVA HEALTH PCPs will monitor the
effects and side effects of psychotropic
medications prescribed for those
members whose psychiatric conditions
are under their treatment.
5. Reimbursement to pharmacies for new
psychotropic drugs classified as
antipsychotics and approved by the FDA
will be made through the Medi-Cal FFS
system whether these drugs are provided
by a pharmacy contracting with CALVIVA
Exhibit A
Page 17 of 27
CATEGORY COUNTY CALVIVA HEALTH
HEALTH or by a FFS pharmacy, per
Enclosure 2 of this Exhibit A, attached
hereto and incorporated herein.
L. Laboratory,
Radiological and
Radioisotope
Services
1. COUNTY or a Medi-Cal FFS
behavioral health services
provider needing laboratory,
radiological, or radioisotope
services for a Member when
necessary for the diagnosis,
treatment or monitoring of a
behavioral health condition will
utilize the list of CALVIVA
HEALTH contract providers.
1. CALVIVA HEALTH will cover and pay for
medically necessary laboratory,
radiological and radioisotope services
when ordered by a COUNTY or a Medi-
Cal FFS behavioral health services
provider for the diagnosis, treatment or
monitoring of a behavioral health
condition (and side effects resulting from
medications prescribed to treat the
behavioral health diagnosis) as described
in Title 22, CCR Section 51311 and
Exhibit B, attached hereto.
2. CALVIVA HEALTH will coordinate and
assist the COUNTY or Medi-Cal FFS
behavioral health provider in the delivery
of laboratory radiological or radioisotope
services.
3. A list of CALVIVA HEALTH contracted
providers is available on-line.
4. Provide the process for obtaining timely
authorization and delivery of prescribed
drugs and laboratory services.
M. Grievances
and Complaints
1. COUNTY will share with
CALVIVA HEALTH its
established processes for the
submittal, processing and
resolution of all member and
provider grievances and
complaints regarding any
aspect of the behavioral health
care services in accordance
with CFR 42 Part 438. These
processes include
timelines/deadlines and
member information that must
be provided.
2. COUNTY and CALVIVA
HEALTH will work
collaboratively to resolve any
formal grievance or complaint
brought to the attention of either
plan.
1. CALVIVA HEALTH has in place a written
process for the submittal, processing and
resolution of all member and provider
grievances and complaints which is
inclusive of any aspect of the health care
services or provision of services.
2. CALVIVA HEALTH liaison will coordinate
and share the established complaint and
grievance process for its Members with
the COUNTY
N. Appeal
Resolution
Process
1. COUNTY will ensure that the
Members and providers are
given an opportunity for
1. CALVIVA HEALTH will ensure that
Members and providers are given an
opportunity for reconsideration and an
Exhibit A
Page 18 of 27
CATEGORY COUNTY CALVIVA HEALTH
reconsideration and appeal for
denied, modified or delayed
services.
2. COUNTY will ensure that the
Members receive specialty
mental health and/or Substance
Use Disorder services and
prescription drugs while the
dispute is being resolved.
appeal for denied, modified or delayed
services
2. CALVIVA HEALTH will ensure that
medically necessary services continue to
be provided to Members while the dispute
is being resolved. CALVIVA’s appeal
process will be shared with the COUNTY.
O. Conflict
Resolution/MOU
Monitoring
1. COUNTY Liaison will meet with
the CALVIVA HEALTH Liaison
to monitor this MOU quarterly
and/or upon request.
a. Within two weeks of a
formal request,
COUNTY Liaison will
meet with CALVIVA
HEALTH Liaison when
COUNTY or CALVIVA
HEALTH management
identifies problems
requiring resolution
through the MOU.
b. COUNTY Liaison will be
responsible for
coordinating, assisting
and communicating
suggestions for MOU
changes to the
COUNTY leadership
and CALVIVA.
c. COUNTY Liaison will
communicate and
coordinate MOU
changes to the State
Department of Health
Care Services (DHCS),
COUNTY service
providers and to
CALVIVA HEALTH and
its providers.
2. COUNTY Liaison will participate
in an annual review, update
and/or renegotiations with
CALVIVA, as mutually agreed.
3. COUNTY management will
provide 60 days advance
written notice to CALVIVA
HEALTH should the COUNTY
decide to modify this MOU.
1. Local CALVIVA HEALTH liaison will meet
with the COUNTY Liaison to monitor this
MOU quarterly and/or upon request.
a. Within two weeks of a formal
request, CALVIVA HEALTH
Liaison will meet with the
COUNTY Liaison when the
COUNTY or CALVIVA HEALTH
management identifies problems
requiring resolution through the
MOU.
b. CALVIVA HEALTH Liaison will be
responsible for coordinating,
assisting and communicating
suggestions for MOU changes for
to CALVIVA HEALTH and the
COUNTY leadership.
c. CALVIVA HEALTH will coordinate
and communicate MOU changes
to the California Department of
Health Care Services (DHCS),
COUNTY providers and CALVIVA
HEALTH network services
providers.
d. CALVIVA HEALTH Liaison will
make a good faith effort to agree
to resolutions that are in the best
interest of Members and are
agreeable to all parties involved.
2. CALVIVA HEALTH Liaison will conduct
an annual review, update and/or
renegotiations of this MOU, as mutually
agreed.
3. CALVIVA HEALTH management will
provide 60 day advance written notice to
COUNTY should CALVIVA HEALTH
decide to modify this MOU.
Exhibit A
Page 19 of 27
CATEGORY COUNTY CALVIVA HEALTH
[Unless mandated by the
Department of Behavioral
Health directives, Department
of Health Care Services
mandated requirements and/or
Federal guidelines.]
P. Protected
Health
Information
1. COUNTY will comply with all
applicable laws pertaining to use
and disclosure of PHI including but
not limited to:
HIPAA / 45 C.F.R. Parts 160 and
164
LPS / W & I Code Sections 5328-
5328.15
45 C.F.R. Part 2
HITECH Act (42. U.S.C. Section
17921 et. seq.
CMIA (Ca Civil Code 56 through
56.37)
2. COUNTY will train its workforce
in policies and procedures
regarding Protected Health
Information (PHI) as necessary and
appropriate to perform processes
and functions within the scope of
duties under this MOU.
3. Only encrypted PHI as specified
in the HIPAA Security Rule will be
transmitted via email. Unsecured
PHI will not be transmitted via
email.
4. COUNTY will notify CALVIVA
HEALTH within 24 hours during a
work week of any suspected or
actual breach of security, intrusion
or unauthorized use or disclosure of
PHI and/or any actual or suspected
use of disclosure of data in violation
of any applicable Federal and State
laws and regulations.
1. CALVIVA HEALTH will comply with
Confidentiality of Medical Information Act
[California Civil Code 56 through 56.37] the
Patient Access to Health Records Act
(California Health and Safety Code 123100,
et seq) and the Health Insurance Portability
and Accountability Act (Code of Federal
Regulations Title 45 Parts 160 and 164).
2. CALVIVA HEALTH will train its workforce
in policies and procedures regarding
Protected Health Information (PHI) as
necessary and appropriate to perform
processes and functions within the scope of
duties under this MOU.
3. CALVIVA HEALTH will encrypt any data
transmitted via Electronic Mail (Email)
containing confidential data of Members such
as PHI and Personal Confidential Information
(PCI) or other confidential data to CALVIVA
HEALTH or anyone else including state
agencies.
4. CALVIVA HEALTH will notify COUNTY
within 24 hours during a work week of any
suspected or actual breach of security,
intrusion or unauthorized use or disclosure of
PHI and/or any actual or suspected use or
disclosure of data in violation of any
applicable Federal and State laws or
regulations.
Q. Dispute
Resolution
The COUNTY will provide a
resolution of dispute process in
accordance to Title 9, Section
1810.370.
When the COUNTY has a
dispute with CALVIVA HEALTH
that cannot be resolved to the
satisfaction of the COUNTY, the
CALVIVA HEALTH will provide a
resolution of dispute process in
accordance with CCR Title 9, Section
1810.370, and the Medi-Cal contract
between CALVIVA HEALTH and the
State Department of Health Care
Services (DHCS).
When CALVIVA HEALTH has a dispute
Exhibit A
Page 20 of 27
CATEGORY COUNTY CALVIVA HEALTH
COUNTY may submit a request
for resolution to the State
Department of Mental Health
(DMH)
A request for resolution by either
the COUNTY or the CALVIVA
HEALTH will be submitted to the
respective department within 30
calendar days of the completion
of the dispute resolution process
between both parties.
The request for resolution
will contain the following
information:
1. A summary of the issues and a statement of desired remedy, including any disputed services that have or are expected to be delivered to the beneficiary and the expected rate of payment for each type of service.
2. History of attempts to resolve
the issue.
3. Justification for the desired
remedy.
4. Documentation regarding the
issue.
Upon receipt of a request for
resolution, the department
receiving the request will notify
the other department and the
other party within seven calendar
days. The notice to the other
party will include a copy of the
request and will ask for a
statement of the party's position
on the issues.
The other party will submit the
requested documentation within
21 calendar days or the
departments will decide the
dispute based solely on the
documentation filed by the
initiating party.
A dispute between the COUNTY
with the COUNTY that cannot be
resolved to the satisfaction of the Plan,
CALVIVA HEALTH may submit a
request for resolution to the State
DHCS.
A request for resolution by either the
COUNTY or CALVIVA HEALTH will be
submitted to the respective department
within 30 calendar days of the completion
of the dispute resolution process between
both parties.
The request for resolution will contain
the following information:
1. A summary of the issues and a
statement of the desired remedy
including any disputed services that
have or are expected to be delivered
to the beneficiary and the expected
rate of payment for each type of
service.
2. History of attempts to resolve the
issue.
3. Justification for the desired
remedy.
4. Documentation regarding the
issue.
Upon receipt of a request for resolution,
the agency receiving the request will notify
the other agency and the other party within
seven calendar days. The notice to the
other party will include a copy of the
request and will ask for a statement of the
party's position on the issues.
The other party will submit the requested
documentation within 21 calendar days, or
the agencies will decide the dispute based
solely on the documentation filed by the
initiating party.
A dispute between the CALVIVA HEALTH
and the COUNTY will not
delay medically necessary specialty mental
health services, physical health care
services, or
related prescription drugs and laboratory,
Exhibit A
Page 21 of 27
CATEGORY COUNTY CALVIVA HEALTH
and CALVIVA HEALTH will not
delay medically necessary
specialty mental health services,
physical health care services, or
related prescription drugs and
laboratory, radiological, or
radioisotope services to
beneficiaries, when it is
reasonably foreseeable that
delay in the provision of services
is likely to harm the beneficiary.
Nothing in this section will
preclude a
beneficiary from utilizing the
COUNTY's beneficiary problem
resolution process or any similar
process offered by CALVIVA
HEALTH or to request a fair
hearing.
If a dispute occurs between the
member and the COUNTY or
CALVIVA HEALTH, the member
will continue to receive medically
necessary health care and mental
health care services, including
prescription drugs until the
dispute is resolved.
When the dispute involves
CALVIVA HEALTH continuing to
provide services to a beneficiary
CALVIVA HEALTH believes
requires specialty mental health
services from the COUNTY, the
COUNTY shall identify and
provide CALVIVA HEALTH with
the name and telephone number
of a psychiatrist or other qualified
licensed mental health
professional available to provide
clinical consultation, including
consultation on medications to
CALVIVA HEALTH provider
responsible for the beneficiary's
care.
radiological, or radioisotope services to
beneficiaries, when it is reasonably
foreseeable
that delay in the provision of services is
likely to harm the beneficiary.
Nothing in this section will preclude a
beneficiary from utilizing the Plan's
beneficiary problem resolution process or
any similar process offered by the
COUNTY or to request a fair hearing.
If a dispute occurs between the member
and
CALVIVA HEALTH or COUNTY, the
member will continue to receive medically
necessary health care and mental health
care services, including prescription drugs
until the dispute is resolved.
Exhibit A
Page 22 of 27
Enclosure 1a.
Table 1 - Included ICD-10 Diagnoses - All Places of Services Except Hospital Inpatient
F20.0-F29 F60.0-F60.1 F98.0-F98.4
F30.10-F30.9 F60.3-F68.13 G21.0-G25.9
F31.10-F39 F80.82-F80.9 R15.0-R69
F40.00-F45.1 F84.2-F84.9 Z03.89
F45.22-F50.9 F90.0-F94.1
Exhibit A
Page 23 of 27
Disorder
DSM-5 Recommended ICD-
10-CM Code for use through
September 30, 2017
DSM-5 Recommended ICD-
10-CM Code for use
beginning October 1, 2017
Avoidant/Restrictive Food Intake Disorder F50.89 F50.82
Alcohol Use Disorder, Mild F10.10 F10.10
Alcohol Use Disorder, Mild, in early or sustained
remission F10.10 F10.11
Alcohol Use Disorder, Moderate F10.20 F10.20
Alcohol Use Disorder, Moderate, in early or sustained
remission F10.20 F10.21
Alcohol Use Disorder, Severe F10.20 F10.20
Alcohol Use Disorder, Severe, in early or sustained
remission F10.20 F10.21
Cannabis Use Disorder, Mild F12.10 F12.10
Cannabis Use Disorder, Mild, in early or sustained
remission F12.10 F12.11
Cannabis Use Disorder, Moderate F12.20 F12.20
Cannabis Use Disorder, Moderate, in early or sustained
remission F12.20 F12.21
Cannabis Use Disorder, Severe F12.20 F12.20
Cannabis Use Disorder, Severe, in early or sustained
remission F12.20 F12.21
Phencyclidine Use Disorder, Mild F16.10 F16.10
Phencyclidine Use Disorder, Mild, in early or sustained
remission F16.10 F16.11
Phencyclidine Use Disorder, Moderate F16.20 F16.20
Phencyclidine Use Disorder, Moderate, in early or
sustained remission F16.20 F16.21
Phencyclidine Use Disorder, Severe F16.20 F16.20
Phencyclidine Use Disorder, Severe, in early or
sustained remission F16.20 F16.21
Other Hallucinogen Use Disorder, Mild F16.10 F16.10
Other Hallucinogen Use Disorder, Mild, in early or
sustained remission F16.10 F16.11
Other Hallucinogen Use Disorder, Moderate F16.20 F16.20
Other Hallucinogen Use Disorder, Moderate, in early or
sustained remission F16.20 F16.21
Other Hallucinogen Use Disorder, Severe F16.20 F16.20
Other Hallucinogen Use Disorder, Severe, in early or
sustained remission F16.20 F16.21
Inhalant Use Disorder, Mild F18.10 F18.10
Inhalant Use Disorder, Mild, in early or sustained
remission F18.10 F18.11
Inhalant Use Disorder, Moderate F18.20 F18.20
DSM-5 Diagnoses and New ICD-10-CM Codes
As Ordered in the DSM-5 Classification
Exhibit A
Page 24 of 27
Inhalant Use Disorder, Moderate, in early or sustained
remission F18.20 F18.21
Inhalant Use Disorder, Severe F18.20 F18.20
Inhalant Use Disorder, Severe, in early or sustained
remission F18.20 F18.21
Opioid Use Disorder, Mild F11.10 F11.10
Opioid Use Disorder, Mild, in early or sustained
remission F11.10 F11.11
Opioid Use Disorder, Moderate F11.20 F11.20
Opioid Use Disorder, Moderate, in early or sustained
remission F11.20 F11.21
Opioid Use Disorder, Severe F11.20 F11.20
Opioid Use Disorder, Severe, in early or sustained
remission F11.20 F11.21
Sedative, Hypnotic, or Anxiolytic Use Disorder, Mild F13.10 F13.10
Sedative, Hypnotic, or Anxiolytic Use Disorder, Mild, in
early or sustained remission F13.10 F13.11
Sedative, Hypnotic, or Anxiolytic Use Disorder,
Moderate F13.20 F13.20
Sedative, Hypnotic, or Anxiolytic Use Disorder,
Moderate, in early or sustained remission F13.20 F13.21
Sedative, Hypnotic, or Anxiolytic Use Disorder, Severe F13.20 F13.20
Sedative, Hypnotic, or Anxiolytic Use Disorder, Severe,
in early or sustained remission F13.20 F13.21
Amphetamine-type Substance Use Disorder, Mild F15.10 F15.10
Amphetamine-type Substance Use Disorder, Mild, in
early or sustained remission F15.10 F15.11
Amphetamine-type Substance Use Disorder, Moderate F15.20 F15.20
Amphetamine-type Substance Use Disorder,
Moderate, in early or sustained remission F15.20 F15.21
Amphetamine-type Substance Use Disorder, Severe F15.20 F15.20
Amphetamine-type Substance Use Disorder, Severe, in
early or sustained remission F15.20 F15.21
Cocaine Use Disorder, Mild F14.10 F14.10
Cocaine Use Disorder, Mild, in early or sustained
remission F14.10 F14.11
Cocaine Use Disorder, Moderate F14.20 F14.20
Cocaine Use Disorder, Moderate, in early or sustained
remission F14.20 F14.21
Cocaine Use Disorder, Severe F14.20 F14.20
Cocaine Use Disorder, Severe, in early or sustained
remission F14.20 F14.21
Tobacco Use Disorder, Moderate F17.200 F17.200
Tobacco Use Disorder, Moderate, in early or sustained
remission F17.200 F17.201
Tobacco Use Disorder, Severe F17.200 F17.200
Exhibit A
Page 25 of 27
Tobacco Use Disorder, Severe, in early or sustained
remission F17.200 F17.201
Other (or Unknown) Substance Use Disorder, Mild F19.10 F19.10
Other (or Unknown) Substance Use Disorder, Mild, in
early or sustained remission F19.10 F19.11
Other (or Unknown) Substance Use Disorder,
Moderate F19.20 F19.20
Other (or Unknown) Substance Use Disorder,
Moderate, in early or sustained remission F19.20 F19.21
Other (or Unknown) Substance Use Disorder, Severe F19.20 F19.20
Other (or Unknown) Substance Use Disorder, Severe,
in early or sustained remission F19.20 F19.21
Exhibit A
Page 26 of 27
ATTACHMENT A
Medical Necessity For Specialty Mental Health Services That Are The Responsibility Of Mental
Health Plan
Must have all, A, B and C:
A. Diagnoses
Must have one of the following DSM IV diagnoses, which will be the focus of the intervention being
provided:
Included Diagnosis:
Pervasive Development Disorders, except Autistic Disorder which is excluded.
Attention Deficit and Disruptive Behavior Disorders
Feeding & Eating Disorders of Infancy or Early Childhood
Elimination Disorders
Other Disorders of Infancy, Childhood or Adolescence
Schizophrenia & Other Psychotic Disorder
Mood Disorders
Anxiety Disorders
Somatoform Disorders
Factitious Disorders
Dissociative Disorders
Paraphilias
Gender Identify Disorders
Eating Disorders
Impulse-Control Disorders Not Elsewhere Classified
Adjustment Disorders
Personality Disorders, excluding Antisocial Personality Disorder
Medication-Induced Movement Disorders (related to other
included diagnoses).
B. Impairment Criteria
Must have one of the following as a result of the mental disorder(s)
identified in the diagnostic (“A”) criteria; must have one, 1, 2 or 3:
1 A significant impairment in an important area of life
functioning, or
2 A probability of significant deterioration in an important
area of life functioning, or
3 Children also qualify if there is a probability the child will
not progress developmentally as individually appropriate.
Children covered under EPSDT qualify if they have a mental disorder which can be corrected or
ameliorated (current DHS EPSDT regulations also apply).
C. Intervention Related Criteria
Must have all, 1, 2 and 3 below:
1 The focus of proposed intervention is to address the condition identified in impairment criteria “B”
above and
2 It is expected the beneficiary will benefit from the proposed intervention by significantly diminishing
the impairment, or preventing significant deterioration in an important area of life functioning,
and/or for children it is probable the child will progress developmentally as individually appropriate
(or if covered by EPSDT can be corrected or ameliorated), and
3 The condition would not be responsive to physical health care based treatment.
EPSDT beneficiaries with an included diagnosis and a substance related disorder may receive specialty
mental health services directed at the substance use component. The intervention must be consistent
with, and necessary to the attainment of, the specialty MH treatment goals.
Excluded Diagnosis:
Mental Retardation
Learning Disorder
Motor Skills Disorder
Communications Disorders
Autistic Disorder, Other Pervasive
Developmental Disorders are
included.
Tic Disorders
Delirium, Dementia, and Amnestic
and Other Cognitive Disorders
Mental Disorders Due to a General
Medical Condition
Substance-Related Disorders
Sexual Dysfunctions
Sleep Disorders
Antisocial Personality Disorder
Other Conditions that may be a focus
of clinical attention, except
Medication induced Movement
Disorders which are included.
_________________________________
_
A beneficiary may receive services for an
included diagnosis when an excluded
diagnosis is also present.
Exhibit A
Page 27 of 27
Exhibit B
Page 1 of 36
Exhibit B
Page 2 of 36
Exhibit B
Page 3 of 36
Exhibit B
Page 4 of 36
Exhibit B
Page 5 of 36
Exhibit B
Page 6 of 36
Exhibit B
Page 7 of 36
Exhibit B
Page 8 of 36
Exhibit B
Page 9 of 36
Exhibit B
Page 10 of 36
Exhibit B
Page 11 of 36
Exhibit B
Page 12 of 36
Exhibit B
Page 13 of 36
Exhibit B
Page 14 of 36
Exhibit B
Page 15 of 36
Exhibit B
Page 16 of 36
Exhibit B
Page 17 of 36
Exhibit B
Page 18 of 36
Exhibit B
Page 19 of 36
Exhibit B
Page 20 of 36
Exhibit B
Page 21 of 36
Exhibit B
Page 22 of 36
Exhibit B
Page 23 of 36
Exhibit B
Page 24 of 36
Exhibit B
Page 25 of 36
Exhibit B
Page 26 of 36
Exhibit B
Page 27 of 36
Exhibit B
Page 28 of 36
July 2011
Exhibit B
Page 29 of 36
Enclosure 2
Psychiatric Drugs Drugs Excluded From Plan Coverage:
Psychotropic Drugs Psychotropic
Drugs
Drugs for the Treatment of
HIV/AIDS
Drugs for the Treatment of
HIV/AIDS
Amantadine HCl Olanzapine Fluoxetine
HCl
Abacavir/Lamivudine
Stavudine
Aripiprazole
Asenapine (Saphris)
Olanzapine Pamoate
Monohydrate
(Zyprexa Relprevv)
Abacavir Sulfate
Tenofovir Disoproxil-Emtricitabine
Benztropine Mesylate Paliperidone (Invega) Amprenavir
Tenofovir Disoproxil Fumarate
Biperiden HCl
Biperiden Lactate
Paliperidone Palmitate
(Invega Sustenna)
Atazanavir Sulfate
Tipranavir
Chlorpromazine HCl Perphenazine Darunavir Ethanolate
Zidovudine/Lamivudine
Chlorprothixene Phenelzine Sulfate Delavirdine Mesylate
Zidovudine/Lamivudine/
Abacavir sulfate
Clozapine Pimozide Efavirenz
Fluphenazine Decanoate Proclyclidine HCl Efavirenz/Emtricitabine/Tenofovir
Fluphenazine Enanthate Promazine HCl Disoproxil Fumarate
Fluphenazine HCl Quetiapine Emtricitabine
Haloperidol Risperidone Enfuvirtide
Haloperidol Decanoate Risperidone
Microspheres Etravirine
Haloperidol Lactate Selegiline
(transdermal only)
Fosamprenavir Calcium
Iloperidone (Fanapt) Thioridazine HCl Indinavir Sulfate
Isocarboxazid Thiothixene Lamivudine
Lithium Carbonate Thiothixene HCl Lopinavir/Ritonavir
Lithium Citrate Tranylcypromine
Sulfate
Maraviroc
Loxapine HCl Trifluoperazine HCl Nelfinavir Mesylate
Nevirapine
Loxapine Succinate Triflupromazine HCl Raltegravir Potassium
Lurasidone
Hydrochloride
Trihexyphenidyl Rilpivirine Hydrochloride
Mesoridazine Mesylate Ziprasidone Ritonavir
Molindone HCl Ziprasidone Mesylate Saquinavir
Olanzapine Saquinavir Mesylate
Exhibit B
Page 30 of 36
Exhibit B
Page 31 of 36
Exhibit B
Page 32 of 36
Exhibit B
Page 33 of 36
Exhibit B
Page 34 of 36
Exhibit B
Page 35 of 36
Exhibit B
Page 36 of 36
Exhibit C
1
Drug Medi-Cal Organized Delivery System
SUMMARY
California’s Medi-Cal 2020 Section 1115(a) Demonstration (No. 11-W-00193/9) authorizes the State to
test a new paradigm for the organized delivery of health care services for Medicaid (or “Medi-Cal” in
California) eligible individuals with a SUD.
The amendment includes a five-year demonstration program, the DMC-ODS Pilot that will include a
continuum of care modeled after the American Society of Addiction Medicine (ASAM) Criteria for SUD
treatment services.
The DMC-ODS Pilot services shall be available as a Medi-Cal benefit for Medi-Cal eligible individuals who
meet the SUD medical necessity criteria and reside in a participating county.
The DMC-ODS Pilot is expected to provide the Medi-Cal Beneficiary with access to the care and system
interaction needed in order to achieve sustainable SUD recovery.
Counties participating in the DMC-ODS Pilot shall enter into a Memorandum of Understanding (MOU)
with selected Medi-Cal managed care plans that enroll Beneficiaries served by the DMC-ODS Pilot.
CalViva Health has been selected by the Fresno County Department of Behavioral Health as one of the
managed care plans to ensure collaborative treatment planning, care coordination and effective
communication among providers for DMC-ODS services to eligible Beneficiaries in Fresno County.
The DMC-ODS Pilot is authorized and financed under the authority of California’s Medi-Cal 2020
Demonstration Waiver. Section 1115 of the Social Security Act gives the Secretary of Health and Human
Services authority to approve experimental, pilot, or demonstration projects that promote the
objectives of the Medicaid and Children’s Health Insurance Program (CHIP). The purpose of these
demonstrations, which gives states additional flexibility to design and improve their programs, is to
demonstrate and evaluate policy approaches such as expanding services not typically covered by
Medicaid, and using innovative service delivery systems that improve care, increase efficiency, and
reduce costs. The section 1115 demonstrations, such as the DMC-ODS Pilot, are approved for a five-
year period.
The DMC-ODS is a pilot to test a new paradigm for the organized delivery of health care services for
Medicaid eligible individuals with SUD. The DMC-ODS will demonstrate how organized SUD care
increases the success of DMC Beneficiaries while decreasing other health care costs. Critical elements of
the DMC-ODS Pilot include providing a continuum of care modeled after the ASAM Criteria for SUD
services, increased local control and accountability, greater use of resources, evidence-based practices
in SUD treatment, and increased coordination with other systems of care.
Exhibit C
2
DEFINITIONS
Access Line - A 24-hour, 365 days per year toll-free line operated on behalf of Fresno County
Department of Behavioral Health, that conducts substance use disorder screening interviews with callers
using the standardized adolescent or adult brief triage assessment (based on the ASAM Criteria),
determines the provisional level of care, and schedules an assessment and admission appointment with
a SUD network provider.
ASAM Criteria - Also known as the ASAM patient placement criteria, provides a multi-dimensional
assessment framework for SUD placement determination and the development of comprehensive and
individualized treatment plans tailored to medical necessity. These criteria are used as a comprehensive
set of guidelines for placement, continued stay, and transfer/discharge of patients with SUD and co-
occurring conditions.
Behavioral Health - Refers to both substance use disorder and mental health services/conditions.
Beneficiary - An individual who is eligible for Medi-Cal benefits, receives covered services through
CalViva Health and who is eligible for DMC-ODS Pilot services due to a qualifying SUD condition.
California Department of Health Care Services (DHCS) - The state department that has responsibility for
administering statewide, health care services funded by Medi-Cal.
Care Coordination - The management of physical, mental health, and/or SUD services for Beneficiaries
to help ensure that delivered services are well integrated and provided seamlessly to ensure maximum
benefit, effectiveness, and safety.
Determination of DMC-ODS Medical Necessity Criteria - As described in the DMC-ODS Special Terms
and Conditions (STC), Beneficiaries receiving services through DMC-ODS must be enrolled in Medi-Cal
and meet the following medical necessity criteria:
1. Must have one diagnosis from the Diagnostic and Statistical Manual of Mental Disorders (DSM)
V for Substance-Related and Addictive Disorders with the exception of Tobacco-Related
Disorders and Non-Substance-Related Disorders; or be assessed to be at-risk for developing a
SUD (for youth under 21).
2. Must meet the ASAM Criteria definition of medical necessity for services based on the ASAM
Criteria.
3. If applicable, must meet the ASAM adolescent treatment criteria. Beneficiaries under the age of
21 are eligible to receive Medicaid services pursuant to the Early Periodic Screening, Diagnostic
and Treatment (EPSDT) mandate. Under the EPSDT mandate, Beneficiaries under the age of 21
are eligible to receive all appropriate and medically necessary services needed to correct and
ameliorate health conditions that are covered under section 1905(a) Medicaid authority.
Exhibit C
3
Determination of DMC-ODS Medical Need - All individuals seeking SUD treatment services can access
services by (1) contacting the Access Line which is a dedicated toll-free telephone line, (2) contacting any
network treatment provider, or (3) direct referral from a County partner/referring agency. When
contacting the Access Line, staff will conduct an initial brief triage assessment based on the ASAM
Criteria, and refer the Beneficiary to the identified provisional level of care with a contracted SUD
Provider. The SUD Provider will determine initial medical necessity and conduct a more intensive ASAM
assessment to establish and/or confirm the appropriate SUD level of care.
Diagnostic and Statistical Manual of Mental Disorders (DSM) - The standard classification of mental
disorders used by mental health professionals in the United States which contains a listing of diagnostic
criteria for every psychiatric disorder recognized by the United States healthcare system. Also a
necessary tool for collecting and communicating accurate public health statistics about the diagnosis of
psychiatric disorders, including SUD.
Early and Periodic Screening, Diagnostic and Treatment (EPSDT) - A Medicaid benefit that provides
comprehensive and preventive health care services for children under age 21 who are enrolled in
Medicaid.
Evidence Based Programs (EBP) - Programs that meet the criteria of the National Registry for Evidence
Based Programs and Practices (NREPP) for effectiveness and scientific rigor.
Level of Care - Refers to the SUD treatment services outlined in the ASAM Criteria and offered under
Fresno County’s DMC-ODS benefit package. This includes outpatient (ASAM 1.0, 2.1), residential (ASAM
3.1, 3.3, 3.5) withdrawal management (ASAM 1-WM, 2-WM, 3.2-WM) and opioid treatment program
(ASAM 1-OTP) modalities.
Licensed Practitioner of the Healing Arts (LPHA) - Professional staff who are licensed, registered,
certified, or recognized under California State scope of practice statutes that provide services within
their scope of practice and receive supervision required under their scope of practice laws. LPHA
includes the following professional categories:
Physician
Licensed/waivered Clinical Psychologist
Licensed/waivered/registered Clinical Social Worker
Licensed/waivered/registered Marriage and Family Therapist
Licensed/waivered/registered Professional Clinical Counselor
Registered Nurse
Nurse Practitioner
Physician Assistant
Registered Pharmacist
Licensed eligible practitioner under the supervision of licensed clinicians
Exhibit C
4
Primary Care - A basic level of health care usually rendered in ambulatory setting by general
practitioners, family practitioners, internists, obstetricians, pediatricians, and mid-level practitioners.
Primary care emphasizes caring for the member's general health needs as opposed to a specialist
focusing on specific needs. This means providing care for the majority of health care problems, including,
but not limited to, preventive services, acute and chronic conditions, and psychosocial issues.
Primary Care Provider (PCP) - A person licensed by the applicable State licensing board who has primary
health care responsibility for the Beneficiary, and who is responsible for supervising, coordinating, and
providing initial and primary care to patients, initiating referrals, and maintaining the continuity of patient
care.
Screening, Brief Intervention, and Referral to Treatment (SBIRT) - An evidence-based practice used to
identify, reduce, and prevent problematic use, abuse, and dependence on alcohol and illicit drugs.
Substance Use Disorder (SUD) - SUD occurs when the recurrent use of alcohol and/or drugs causes
clinically and functionally significant impairment, such as health problems, disability and failure to meet
major responsibilities at work, school, or home. The Diagnostic and Statistical Manual of Mental
Disorders, Fifth Edition (DSM-5), defines SUD as mild, moderate, or severe to indicate the level of
severity, by the number of diagnostic criteria met by an individual.
Substance Use Disorder (SUD) Services - SUD services include outpatient, intensive outpatient,
residential, withdrawal management, opioid (narcotic) treatment program, and recovery support services
that are made available to persons with substance use disorders. Types of services include assessment,
screening, evaluation, crisis intervention, individual counseling, group counseling, family counseling, case-
management, medication assisted treatment, and recovery support.
Substance Use Disorder (SUD) Provider - An entity/organization contracted with Fresno County DBH and
certified or licensed to provide SUD treatment services as required. Individuals providing counseling
services must be registered, certified or licensed in accordance with the California Code of Regulations,
Title 9, Division 4, Chapter 8, commencing with Section 13000, California Medi-Cal 2020 Section 1115(a)
Demonstration Special Terms and Conditions, Section X: Drug Medi-Cal Organized Delivery System and
DBH contract requirements.
SUBSTANCE USE DISORD ER ASAM DESCRIPTIONS
Early Intervention Services - (ASAM Level 0.5) Screening, brief intervention and referral to treatment
(SBIRT) services are provided by non-DMC providers to beneficiaries at risk of developing a substance
use disorder. SBIRT services are paid for and provided by the managed care plans or by fee-for-service
primary care providers. The components of Early Intervention are screening, counseling and referral.
Exhibit C
5
Outpatient Services (ASAM Level 1) Counseling services are provided to beneficiaries when determined
by a Medical Director or Licensed Practitioner of the Healing Arts to be medically necessary and in
accordance with an individualized beneficiary plan. Services can be provided in-person, by telephone or
by telehealth. Counseling session types include individual, group, family therapy, patient education,
medication services, collateral services, crisis intervention services, treatment planning and discharge
services.
Adult Services – up to 9 hours per week
Adolescent Services – less than 6 hours per week
Intensive Outpatient Treatment (ASAM Level 2.1) Structured programming services are
provided to beneficiaries when determined by a Medical Director or Licensed Practitioner of the
Healing Arts to be medically necessary and in accordance with an individualized beneficiary plan.
Lengths of treatment can be extended when determined to be medically necessary. Services can be
provided in-person, by telephone or by telehealth. Counseling sessions are the same as Outpatient.
Adult Services – minimum 9 hours per week to a maximum of 19 hours per week
Adolescent Services – minimum of 6 hours per week with a maximum of 19 hours per week
Residential Treatment (ASAM Level 3) is a non-institutional, 24-hour non-medical, short-term
residential program that provides rehabilitation services to beneficiaries with a substance use disorder
diagnosis when determined by a Medical Director or Licensed Practitioner of the Healing Arts as
medically necessary and in accordance with an individualized treatment plan. Residential services are
provided in licensed residential facilities that also have DMC certification and have been designated by
DHCS as capable of delivering care consistent with ASAM treatment criteria.
The length of residential services range from 1 to 90 days unless medical necessity authorizes a one-time
extension of up to 30 days on an annual basis. Only two non-continuous 90-day regimens will be
authorized in a one-year period.
Adult Services – 90 day maximum.
Adolescent Services – 30 day maximum.
Perinatal Services - Perinatal beneficiaries may receive a longer length of stay based on medical
necessity. Perinatal beneficiaries may receive lengths of stay up to the length of the pregnancy
and postpartum period (60 days after the pregnancy ends.)
Criminal Justice Services - up to 6 months residential; 3 months FFP with a one-time 30-day
extension.
Residential levels of treatment include:
ASAM Level 3.1 - Clinically Managed Low-Intensity Residential Services. 24-hour structure with
available trained personnel; at least 5 hours of clinical service/week and prepare for outpatient
treatment.
ASAM Level 3.3 - Clinically Managed Population-Specific High-Intensity Residential Services 24-
hour care with trained counselors to stabilize multidimensional imminent danger. Less intense
Exhibit C
6
milieu and group treatment for those with cognitive or other impairments unable to use full
active milieu or therapeutic community and prepare for outpatient treatment.
ASAM Level 3.5 - Clinically Managed High-Intensity Residential Services. 24-hour care with
trained counselors to stabilize multidimensional imminent danger and prepare for outpatient
treatment. Able to tolerate and use full milieu or therapeutic community.
ASAM Level 3.7 - Medically Monitored Intensive Inpatient Services. 24-hour nursing care with
physician availability for significant problems. 16 hour/day counselor availability.
ASAM Level 4.0 - Medically Managed Intensive Inpatient Services. 24-hour nursing care and
daily physician care for severe, unstable problems. Counseling available to engage patient in
treatment
Withdrawal Management (Levels 1, 2, 3.2, 3.7 and 4 in ASAM) services are provided in a
continuum of five levels of Withdrawal Management in the ASAM Criteria when determined by a
Medical Director or Licensed Practitioner of the Healing Arts as medically necessary and in
accordance with an individualized beneficiary plan. Each beneficiary shall reside at the facility if
receiving a residential service and will be monitored during the detoxification process. Medically
necessary habilitative and rehabilitative services are provided in accordance with an individualized
treatment plan prescribed by a licensed physician or licensed prescriber, and approved and
authorized according to the state of California requirements.
Withdrawal Management levels of treatment include:
1-WM – Ambulatory withdrawal management without extended on-site monitoring. Mild
withdrawal with daily or less than daily outpatient supervision.
2-WM – Ambulatory withdrawal management with extended on-site monitoring. Moderate
withdrawal with all day withdrawal management and support and supervision; at night has
supportive family or living situation.
3.2-WM – Clinically managed residential withdrawal management. Moderate withdrawal,
but needs 24-hour support to complete withdrawal management and increase likelihood of
continuing treatment or recovery.
3.7-WM - Medically monitored inpatient withdrawal management. Severe withdrawal,
needs 24-hour nursing care & physician visits; unlikely to complete withdrawal management
without medical monitoring.
4-WM - Medically managed intensive inpatient withdrawal management. Severe unstable
withdrawal and needs 24-hour nursing care and daily physician visits to modify withdrawal
management regimen and manage medical instability.
Opioid (Narcotic) Treatment Program (ASAM OTP Level 1) services are provided in NTP
licensed facilities. Medically necessary services are provided in accordance with an individualized
treatment plan determined by a licensed physician or licensed prescriber and approved and
Exhibit C
7
authorized according to the State of California requirements. NTPs/OTPs are required to offer and
prescribe medications to patients covered under the DMC-ODS formulary including methadone,
buprenorphine, naloxone and disulfiram. A patient must receive at minimum fifty minutes of
counseling sessions with a therapist or counselor for up to 200 minutes per calendar month,
although additional services may be provided based on medical necessity.
Additional Medication Assisted Treatment (ASAM OTP Level 1) includes the ordering, prescribing,
administering, and monitoring of all medications for substance use disorders. Medically necessary
services are provided in accordance with an individualized treatment plan determined by a licensed
physician or licensed prescriber.
Recovery Services - Treatment must emphasize the patient’s central role in managing their health, use
effective self-management support strategies, and organize internal and community resources to
provide ongoing self-management support to patients. Services are provided as medically necessary.
Recovery services may be provided face-to-face, by telephone, or by telehealth with the beneficiary and
may be provided anywhere in the community. Recovery Services components are outpatient counseling
services, recovery monitoring, substance abuse assistance, education and job skills, family support,
support groups and ancillary services. Recovery services may be utilized when the beneficiary is
triggered, when the beneficiary has relapsed or simply as a preventative measure to prevent relapse.
EDMUND G. BROWN JR.
GOVERNOR
State of California—Health and Human Services Agency
Department of Health Care Services
JENNIFER KENT
DIRECTOR
DATE: October 27, 2017
ALL PLAN LETTER 17-018
SUPERSEDES ALL PLAN LETTER 13-021
TO: ALL MEDI-CAL MANAGED CARE HEALTH PLANS
SUBJECT: MEDI-CAL MANAGED CARE HEALTH PLAN RESPONSIBILITIES FOR
OUTPATIENT MENTAL HEALTH SERVICES
PURPOSE:
The purpose of this All Plan Letter (APL) is to explain the contractual responsibilities of
Medi-Cal managed care health plans (MCPs) for the provision of medically necessary
outpatient mental health services and the regulatory requirements for the Medicaid
Mental Health Parity Final Rule (CMS-2333-F). MCPs must provide specified services
to adults diagnosed with a mental health disorder, as defined by the current Diagnostic
and Statistical Manual of Mental Disorders (DSM),that results in mild to moderate
distress or impairment1 of mental, emotional, or behavioral functioning. MCPs must also
provide medically necessary non-specialty mental health services2 to children under the
age of 21. This APL also delineates MCP responsibilities for referring to, and
coordinating with, county Mental Health Plans (MHPs) for the delivery of specialty
mental health services (SMHS).
This letter supersedes APL 13-021 and provides updates to the responsibilities of the
MCPs for providing mental health services. Mental Health and Substance Use Disorder
Services (MHSUDS) Information Notice 16-0613 describes existing requirements
regarding the provision of SMHS by MHPs, which have not changed as a result of
coverage of non-specialty, outpatient mental health services by MCPs and the fee -for-
service (FFS) Medi-Cal program. The requirements outlined in Information Notice 16-
061 remain in effect.
1 DHCS recognizes that the medical necessity criteria for impairment and intervention for Medi-Cal SMHS differ between children
and adults. For children and youth, under EPSDT, the “impairment” criteria component of SMHS, medical necessity is less
stringent than it is for adults; therefore, children with low levels of impairment may meet medical necessity criteria SMHS (CCR, Title
9 Sections § 1830.205 and §1830.210).
2 The term “non-specialty” in this context is used to differentiate the mental health services covered and provided by MCPs and the
FFS Medi-Cal program from the SMHS covered and provided by MHPs. It is not intended to describe the providers of these services
as non-specialist providers.
3 MHSUDS Information Notices are available at: http://www.dhcs.ca.gov/formsandpubs/Pages/MHSUDS-Information-Notices.aspx
Managed Care Quality and Monitoring Division
1501 Capitol Avenue, P.O. Box 997413, MS 4400
Sacramento, CA 95899-7413
Phone (916) 449-5000 Fax (916) 449-5005
www.dhcs.ca.gov
Exhibit D
APL 17-018
Page 2
BACKGROUND:
The federal Section 1915(b) Medi-Cal SMHS Waiver4 requires Medi-Cal beneficiaries
needing SMHS to access these services through MHPs. To qualify for these services,
beneficiaries must meet SMHS medical necessity criteria regarding diagnosis,
impairment, and expectations for intervention, as specified below. Medical necessity
criteria differ depending on whether the determination is for :
1.Inpatient services;
2.Outpatient services; or
3.Outpatient services (Early and Periodic Screening, Diagnostic, and Treatment
(EPSDT)).
The medical necessity criteria for SMHS can be found in Title 9, California Code of
Regulations (CCR), Sections (§) 1820.205 (inpatient)5; 1830.205 (outpatient)6; and
1830.210 (outpatient EPSDT)7.
DHCS recognizes that the medical necessity criteria for impairment and intervention for
Medi-Cal SMHS differs between children and adults. For children and youth, under
EPSDT, the “impairment” criteria component of SMHS medical necessity is less
stringent than it is for adults, therefore children with low levels of impairment may meet
medical necessity criteria for SMHS (Title 9, CCR, §1830.205 and §1830.210), whereas
adults must have a significant level of impairment. To receive SMHS, Medi-Cal children
and youth must have a covered diagnosis and meet the following criteria:
1.Have a condition that would not be responsive to physical health care based
treatment; and
2.The services are necessary to correct or ameliorate a mental illness and
condition discovered by a screening conducted by the MCP, the Child Health
and Disability Prevention Program, or any qualified provider operating within
the scope of his or her practice, as defined by state law regardless of whether
or not that provider is a Medi-Cal provider.
Consistent with Title 9, CCR, §1830.205, an adult beneficiary must meet all of the
following criteria to receive outpatient SMHS:
4 SHMS Waiver Information can be found at:
http://www.dhcs.ca.gov/services/MH/Pages/1915(b)_Medi-cal_Specialty_Mental_Health_Waiver.aspx
5 Medical necessity criteria for inpatient specialty mental health services (Title 9, CCR, §1820.205) are not described in detail in this
APL, as this APL is primarily focused on outpatient mental health services.
6 Title 9, CCR, §1830.205
7 Title 9, CCR, §1830.210
Exhibit D
APL 17-018
Page 3
1.The beneficiary has one or more diagnoses covered by Title 9, CCR,
§1830.205(b)(1), whether or not additional diagnoses, not included in Title 9,
CCR, §1830.205(b)(1) are also present.
2.The beneficiary must have at least one of the following impairments as a result
of the covered mental health diagnosis:
a.A significant impairment in an important area of life functioning; or
b.A reasonable probability of significant deterioration in an important area of
life functioning.
3.The proposed intervention is to address the impairment resulting from the
covered diagnosis, with the expectation that the proposed intervention will
significantly diminish the impairment, prevent significant deterioration in an
important area of life functioning, In addition, the beneficiary’s condition would
not be responsive to physical health care based treatment.
Prior to January 1, 2014, adult MCP beneficiaries who had mental health conditions but
did not meet the medical necessity criteria for SMHS had only limited access to
outpatient mental health services, which were delivered by primary care providers
(PCPs) or by referral to Medi-Cal FFS mental health providers. DHCS paid MCPs a
capitated rate to provide those outpatient mental health services that were within the
PCP’s scope of practice (unless otherwise excluded by contract). Since January 1,
2014, DHCS adjusted MCP capitation payments to account for expanded outpatient
mental health services.
DHCS requires MCPs to cover and pay for mental health services conducted by
licensed mental health professionals (as specified in the Psychological Services Medi-
Cal Provider Manual8) for MCP beneficiaries with potential mental health disorders, in
accordance with Sections 29 and 30 of Senate Bill X1 1 of the First Extraordinary
Session (Hernandez & Steinberg, Chapter 4, Statutes of 2013), which added §14132.03
and §14189 to the Welfare and Institutions Code. This requirement, which was in
addition to the previously-existing requirement that PCPs offer mental health services
within their scope of practice, remains in effect, along with the requirement to cover
outpatient mental health services to adult beneficiaries with mild to moderate
impairment of mental, emotional, or behavioral functioning (as assessed by a licensed
mental health professional through the use of a Medi-Cal-approved clinical tool or set of
tools agreed upon by both the MCP and MHP) resulting from a mental health disorder
(as defined in the current DSM).
8 The Psychological Services Provider Manual can be found at:
http://files.medi-cal.ca.gov/pubsdoco/publications/masters-mtp/part2/psychol_a07.doc
Exhibit D
APL 17-018
Page 4
On March 30, 2016, the Centers for Medicare and Medicaid Services (CMS) issued a
final rule (CMS-2333-F) that applied certain requirements from the Mental Health Parity
and Addiction Equity Act of 2008 (Pub. L. 110-343, enacted on October 3, 2008) to
coverage offered by Medicaid Managed Care Organizations. This included the addition
of Subpart K – Parity in Mental Health and Substance Use Disorder Benefits to the
Code of Federal Regulations (CFR). The general parity requirement (Title 42, CFR,
§438.910(b)) stipulates that treatment limitations for mental health benefits may not be
more restrictive than the predominant treatment limitation s applied to medical or
surgical benefits. This precludes any restrictions to a beneficiary’s access to an initial
mental health assessment. Therefore, MCPs shall not require prior authorization for an
initial mental health assessment. DHCS recognizes that while many PCPs provide initial
mental health assessments within their scope of practice, not all do. If a beneficiary’s
PCP cannot perform the mental health assessment because it is outside of their scope
of practice, they may refer the beneficiary to the appropriate provider.
POLICY:
MCPs continue to be responsible for the delivery of non-SMHS for children under age
21 and outpatient mental health services for adult beneficiaries with mild to moderate
impairment of mental, emotional, or behavioral functioning resulting from a mental
health disorder, as defined by the current DSM. MCPs shall continue to deliver the
outpatient mental health services specified in their Medi-Cal Managed Care contract
and listed in Attachment 1 whether they are provided by PCPs within their scope of
practice or through the MCP’s provider network.
MCPs also continue to be responsible for the arrangement and payment of all medically
necessary, Medi-Cal-covered physical health care services, not otherwise excluded by
contract, for MCP beneficiaries who require SMHS. The eligibility and medical necessity
criteria for SMHS provided by MHPs have not changed pursuant to this policy; SMHS
continue to be available through MHPs.
MCPs must be in compliance with Mental Health Parity requirements on October 1,
2017, as required by Title 42, CFR, §438.930. MCPs shall also ensure direct access to
an initial mental health assessment by a licensed mental health provider within the
MCP’s provider network. MCPs shall not require a referral from a PCP or prior
authorization for an initial mental health assessment performed by a network mental
health provider. MCPs shall notify beneficiaries of this policy, and MCPs informing
materials must clearly state that referral and prior authorization are not required for a
beneficiary to seek an initial mental health assessment from a network mental health
provider. An MCP is required to cover the cost of an initial mental health assessment
Exhibit D
APL 17-018
Page 5
completed by an out-of-network provider only if there are no in-network providers that
can complete the necessary service.
If further services are needed that require authorization, MCPs are required to follow
guidance developed for mental health parity, as follows:
MCPs must disclose the utilization management or utilization review policies and
procedures that the MCP utilizes to DHCS, its contracting provider groups, or any
delegated entity, uses to authorize, modify, or deny health care services via prior
authorization, concurrent authorization or retrospective authorizations, under the
benefits included in the MCP contract.
MCP policies and procedures must ensure that authorization determinations are based
on the medical necessity of the requested health care service in a manner that is
consistent with current evidence-based clinical practice guidelines. Such utilization
management policies and procedures may also take into consideration the following:
Service type
Appropriate service usage
Cost and effectiveness of service and service alternatives
Contraindications to service and service alternatives
Potential fraud, waste and abuse
Patient and medical safety
Other clinically relevant factors
The policies and procedures must be consistently applied to medical/surgical, mental
health and substance use disorder benefits. The plan shall notify contracting health care
providers of all services that require prior authorization, concurrent authorization or
retrospective authorization and ensure that all contracting health care providers are
aware of the procedures and timeframes necessary to obtain authorization for these
services.
The disclosure requirements for MCPs include making utilization management criteria
for medical necessity determinations for mental health and substance use disorder
benefits available to beneficiaries, potential beneficiaries and providers upon request in
accordance with Title 42, CFR §438.915(a). MCPs must also provide to beneficiaries,
the reason for any denial for reimbursement or payment of services for mental health or
substance use disorder benefits in accordance with Title 42, CFR, §438.915(b). In
addition, all services must be provided in a culturally and linguistically appropriate
manner.
Exhibit D
APL 17-018
Page 6
MCP Responsibility for Outpatient Mental Health Services
Attachment 1 summarizes mental health services provided by MCPs and MHPs. MCPs
must provide the services listed below when medically necessary and provided by
PCPs or by licensed mental health professionals in the MCP provider network within
their scope of practice:
1.Individual and group mental health evaluation and treatment (psychotherapy);
2.Psychological testing, when clinically indicated to evaluate a mental health
condition;
3.Outpatient services for the purposes of monitoring drug therapy;
4.Outpatient laboratory, drugs, supplies, and supplements (excluding medications
listed in Attachment 2); and,
5.Psychiatric consultation.
Current Procedural Terminology (CPT) codes that are covered can be found in the
Psychological Services Medi-Cal Provider Manual (linked in footnote 8 above).
Laboratory testing may include tests to determine a baseline assessment before
prescribing psychiatric medications or to monitor side effects from psychiatric
medications. Supplies may include laboratory supplies. Supplements may include
vitamins that are not specifically excluded in the Medi-Cal formulary and that are
scientifically proven effective in the treatment of mental health disorders (although none
are currently indicated for this purpose).
For mild to moderate mental health MCP covered services for adults, medically
necessary services are defined as reasonable and necessary services to protect life,
prevent significant illness or significant disability, or to alleviate severe pain through the
diagnosis and treatment of disease, illness, or injury. These include services to:
1.Diagnose a mental health condition and determine a treatment plan;
2.Provide medically necessary treatment for mental health conditions (excluding
couples and family counseling for relational problems) that result in mild or
moderate impairment; and,
3.Refer adults to the county MHP for SMHS when a mental health diagnosis
covered by the MHP results in significant impairment;
For beneficiaries under the age of 21, the MCP is responsible for providing medically
necessary non-SMHS listed in Attachment 1 regardless of the severity of the
impairment. The number of visits for mental health services is not limited as long as the
MCP beneficiary meets medical necessity criteria.
Exhibit D
APL 17-018
Page 7
At any time, beneficiaries can choose to seek and obtain a mental health assessment
from a licensed mental health provider within the MCP’s provider network. Each MCP is
still obligated to ensure that a mental health screening of beneficiaries is conducted by
network PCPs. Beneficiaries with positive screening results may be further assessed
either by the PCP or by referral to a network mental health provider. The beneficiary
may then be treated by the PCP within the PCP’s scope of practice. When the condition
is beyond the PCP’s scope of practice, the PCP must refer the beneficiary to a mental
health provider within the MCP network. For adults, the PCP or mental health provider
must use a Medi-Cal-approved clinical tool or set of tools mutually agreed upon with the
MHP to assess the beneficiary’s disorder, level of impairment, and appropriate care
needed. The clinical assessment tool or set of tools must be identified in the MOU
between the MCP and MHP, as discussed in APL 13-018.
Pursuant to the EPSDT benefit, MCPs are required to provide and cover all medically
necessary services. For adults, medically necessary services include all covered
services that are reasonable and necessary to protect life, prevent significant illness or
significant disability, or to alleviate severe pain through the diagnosis or treatment of
disease, illness, or injury. For children under the age 21, MCPs must provide a broader
range of medically necessary services that is expanded to include standards set forth
under Title 22, CCR Sections 51340 and 51340.01 and “[s]uch other necessary health
care, diagnostic services, treatment, and other measures described in [Title 42, United
States Code (US Code), Section 1396d(a)] to correct or ameliorate defects and physical
and mental illnesses and conditions discovered by the screening services, whether or
not such services or items are covered under the state plan” (Title 42, US Code, Section
1396d(r)(5)). However for children under the age 21, MCPs are required to provide and
cover all medically necessary service, except for SMHS listed in CCR, Title 9, Section
1810.247 for beneficiaries that meet the medical necessity criteria for SMHS as
specified in to CCR, Title 9, Sections 1820.205, 1830.205, or 1830.210 that must be
provided by a MHP.
If an MCP beneficiary with a mental health diagnosis is not eligible for MHP services
because they do not meet the medical necessity criteria for SMHS, then the MCP is
required to ensure the provision of outpatient mental health services as listed in the
contract and Attachment 1 of this APL, or other appropriate services within the scope of
the MCP’s covered services.
Each MCP must ensure its network providers refer adult beneficiaries with significant
impairment resulting from a covered mental health diagnosis to the county MHP. Also,
when the adult MCP beneficiary has a significant impairment, but the diagnosis is
uncertain, the MCP must ensure that the beneficiary is referred to the MHP for further
assessment.
Exhibit D
APL 17-018
Page 8
The MCPs must also cover outpatient laboratory tests, medications (excluding carved-
out medications that are listed in the MCP’s relevant Medi-Cal Provider Manual9),
supplies, and supplements prescribed by the mental health providers in the MCP
network, as well as by PCPs, to assess and treat mental health conditions. The MCP
may require that mild to moderate mental health services to adults are provided through
the MCP's provider network, subject to a medical necessity determination.
The MCP may contract with the MHP to provide these mental health services when the
MCP covers payment for these services.
MCPs continue to be required to provide medical case management and cover and pay
for all medically necessary Medi-Cal-covered physical health care services for an MCP
beneficiary receiving SMHS. The MCP must coordinate care with the MHP. The MCP is
responsible for the appropriate management of a beneficiary’s mental and physical
health care, which includes, but is not limited to, the coordination of all medically
necessary, contractually required Medi-Cal-covered services, including mental health
services, both within and outside the MCP's provider network.
MCPs are responsible for ensuring that their delegates comply with all applicable state
and federal law and regulations, as well as other contract requirements and DHCS
guidance, including applicable APLs and Duals Plan Letters. These requirements must
be communicated by each MCP to all delegated entities and subcontr actors.
If you have any questions regarding this APL, please contact your Contract Manager.
Sincerely,
Original signed by Nathan Nau
Nathan Nau, Chief
Managed Care Quality and Monitoring Division
Department of Health Care Services
Attachments
9 The provider manual for the Two Plan Model can be found at:
http://files.medi-cal.ca.gov/pubsdoco/publications/masters-mtp/part1/mcptwoplan_z01.doc
The provider manual for the Geographic Managed Care Model can be found at:
http://files.medi-cal.ca.gov/pubsdoco/publications/masters-mtp/part1/mcpgmc_z01.doc
The provider manual for the County Organized Health Systems can be found at:
https://files.medi-cal.ca.gov/pubsdoco/publications/masters-mtp/.../mcpcohs_z01.doc
The provider manual for Imperial, San Benito, and Regional Models can be found at:
http://files.medi-cal.ca.gov/pubsdoco/publications/masters-mtp/part1/mcpimperial_z01.doc
Exhibit D
APL 17-018
Page 9
Attachment 1
Mental Health Services Description Chart for Beneficiaries Enrolled in an MCP
DIMENSION MCP MHP10 OUTPATIENT MHP INPATIENT
ELIGIBILITY Mild to Moderate
Impairment in Functioning
A beneficiary is covered by
the MCP for services if he or
she is diagnosed with a
mental health disorder, as
defined by the current
DSM11, resulting in mild to
moderate distress or
impairment of mental,
emotional, or behavioral
functioning:
At an initial health
screening, a PCP may
identify the need for a
thorough mental health
assessment and refer a
beneficiary to a licensed
mental health provider
within the MCP’s network.
The mental health
provider can identify the
mental health disorder
and determine the level of
impairment.
A beneficiary may seek
and obtain a mental health
assessment at any time
directly from a licensed
mental health provider
within the MCP network
without a referral from a
PCP or prior authorization
from the MCP.
The PCP or mental health
provider should refer any
beneficiary who meets
medical necessity criteria
Significant Impairment in
Functioning
An adult beneficiary is eligible
for services if he or she meets
all of the following medical
necessity criteria:
1.Has an included mental
health diagnosis;12
2.Has a significant
impairment in an important
area of life function, or a
reasonable probability of
significant deterioration in
an important area of life
function;
3.The focus of the proposed
treatment is to address the
impairment(s), prevent
significant deterioration in
an important area of life
functioning.
4.The expectation is that the
proposed treatment will
significantly diminish the
impairment, prevent
significant deterioration in
an important area of life
function, and
5.The condition would not be
responsive to physical
health care based
treatment.
Note: For beneficiaries
under age 21, specialty
mental health services
must be provided for a
range of impairment levels
Emergency and Inpatient
A beneficiary is eligible for
services if he or she meets
the following medical
necessity criteria:
1.An included diagnosis;
2.Cannot be safely treated
at a lower level of care;
3.Requires inpatient
hospital services due to
one of the following which
is the result of an
included mental disorder:
a.Symptoms or behaviors
which represent a
current danger to self or
others, or significant
property destruction;
b.Symptoms or behaviors
which prevent the
beneficiary from
providing for, or utilizing,
food, clothing, or shelter;
c.Symptoms or behaviors
which present a severe
risk to the beneficiary’s
physical health;
d.Symptoms or behaviors
which represent a
recent, significant
deterioration in ability to
function;
e.Psychiatric evaluation or
treatment which can only
be performed in an acute
psychiatric inpatient
setting or through urgent
10 SMHS provided by MHP
11 Current policy is based on DSM IV and will be updated to DSM 5 in the future
12 As specified in regulations Title 9, Section 1830.205 for adults and Section 1830.210 for those under age 21
Exhibit D
APL 17-018
Page 10
DIMENSION MCP MHP10 OUTPATIENT MHP INPATIENT
ELIGIBILITY
(continued)
for SMHS to the MHP.
When a beneficiary’s
condition improves under
SMHS and the mental
health providers in the
MCP and MHP coordinate
care, the beneficiary may
return to the MCP’s
network mental health
provider.
Note: Conditions that the
current DSM identifies as
relational problems are not
covered (e.g., couples
counseling or family
counseling.)
to correct or ameliorate a
mental health condition or
impairment.13
or emergency
intervention provided in
the community or clinic;
and;
f.Serious adverse
reactions to medications,
procedures or therapies
requiring continued
hospitalization.
SERVICES Mental health services
provided by licensed mental
health care professionals
(as defined in the Medi-Cal
provider bulletin) acting
within the scope of their
license:
Individual and group
mental health evaluation
and treatment
(psychotherapy)
Psychological testing
when clinically indicated
to evaluate a mental
health condition
Outpatient services for
the purposes of
monitoring medication
therapy
Outpatient laboratory,
medications, supplies,
and supplements
Psychiatric consultation
Mental Health Services
o Assessment
o Plan development
o Therapy
o Rehabilitation
o Collateral
Medication Support
Services
Day Treatment Intensive
Day Rehabilitation
Crisis Residential
Treatment
Adult Residential
Treatment
Crisis Intervention
Crisis Stabilization
Targeted Case
Management
Intensive Care
Coordination
Intensive Home Based
Services
Therapeutic Foster Care
Therapeutic Behavioral
Services
Acute psychiatric inpatient
hospital services
Psychiatric Health Facility
Services
Psychiatric Inpatient
Hospital Professional
Services if the beneficiary
is in fee-for-service
hospital
13 Title 9, CCR, §1830.210
Exhibit D
APL 17-018
Page 11
Attachment 2
Drugs Excluded from MCP Coverage
The following psychiatric drugs are noncapitated except for HCP 170 (KP Cal, LLC):
Amantadine HCl Olanzapine Fluoxetine HCl
Aripiprazole Olanzapine Pamoate
Monohydrate
(Zyprexa Relprevv)
Asenapine (Saphris)
Benztropine Mesylate Paliperidone (oral and
injectable)
Brexpiprazole (Rexulti) Perphenazine
Cariprazine Phenelzine Sulfate
Chlorpromazine HCl Pimavanserin
Clozapine Pimozide
Fluphenazine Decanoate Quetiapine
Fluphenazine HCl Risperidone
Haloperidol Risperidone Microspheres
Haloperidol Decanoate Selegiline (transdermal only)
Haloperidol Lactate Thioridazine HCl
Iloperidone (Fanapt) Thiothixene
Isocarboxazid Thiothixene HCl
Lithium Carbonate Tranylcypromine Sulfate
Lithium Citrate Trifluoperazine HCl
Loxapine Succinate Trihexyphenidyl
Lurasidone Hydrochloride Ziprasidone
Molindone HCl Ziprasidone Mesylate
Olanzapine
These drugs are listed in the Medi-Cal Provider Manual in the following link:
http://files.medi-cal.ca.gov/pubsdoco/publications/masters-mtp/part1/mcpgmc_z01.doc
Exhibit D
State of California—Health and Human Services Agency Department of Health Care Services
JENNIFER KENT EDMUND G. BROWN JR.
DIRECTOR GOVERNOR
DATE:July 17, 2017
ALL PLAN LETTER 17-010 (REVISED)
TO:ALL MEDI-CAL MANAGED CARE HEALTH PLANS
SUBJECT: NON-EMERGENCY MEDICAL AND NON-MEDICAL TRANSPORTATION
SERVICES
PURPOSE:
This All Plan Letter (APL) provides Medi-Cal managed care health plans (MCPs) with
guidance regarding Non-Emergency Medical Transportation (NEMT) and Non-Medical
Transportation (NMT) services. With the passage of Assembly Bill (AB) 2394 (Chapter
615, Statutes of 2016), which amended Section 14132 of the Welfare and Institutions
Code (WIC), the Department of Health Care Services (DHCS) is clarifying MCPs’
obligations to provide and coordinate NEMT and NMT services. In addition, this APL
provides guidance on the application of NEMT and NMT services due to the Medicaid
Mental Health Parity Final Rule (CMS-2333-F)1. Revised text is found in italics.
BACKGROUND:
DHCS administers the Medi-Cal Program, which provides comprehensive health care
services to millions of low-income families and individuals through contracts with MCPs.
Pursuant to Social Security Act (SSA) Section 1905(a)(29) and Title 42 of the Code of
Federal Regulations (CFR) Sections 440.170, 441.62, and 431.53, MCPs are required
to establish procedures for the provision of Early and Periodic Screening, Diagnostic,
and Treatment (EPSDT) services for qualifying members to receive medically
necessary transportation services. NEMT services are authorized under SSA Section
1902 (a)(70), 42 CFR Section 440.170, and Title 22 of the California Code of
Regulations (CCR) Sections 51323, 51231.1, and 51231.2.
AB 2394 amended WIC Section 14132(ad)(1) to provide that, effective July 1, 2017,
NMT is covered, subject to utilization controls and permissible time and distance
standards, for MCP members to obtain covered Medi-Cal medical, dental, mental
health, and substance use disorder services. Beginning on July 1, 2017, MCPs must
provide NMT for MCP members to obtain medically necessary MCP-covered services
and must make their best effort to refer for and coordinate NMT for all Medi-Cal services
CMS-2333-F
Managed Care Quality and Monitoring Division
1501 Capitol Avenue, P.O. Box 997413, MS 4400
Sacramento, CA 95899-7413
Phone (916) 449-5000 Fax (916) 449-5005
www.dhcs.ca.gov
1
Exhibit E
ALL PLAN LETTER 17-010 (REVISED)
Page 2
not covered under the MCP contract. Effective October 1, 2017, in part to comply with
CMS-2333-F and to have a uniform delivery system, MCPs must also provide NMT for
Medi-Cal services that are not covered under the MCP contract. Services that are not
covered under the MCP contract include, but are not limited to, specialty mental health,
substance use disorder, dental, and any other services delivered through the Medi-Cal
fee-for-service (FFS) delivery system.
REQUIREMENTS:
Non-Emergency Medical Transportation
NEMT services are a covered Medi-Cal benefit when a member needs to obtain
medically necessary covered services and when prescribed in writing by a physician,
dentist, podiatrist, or mental health or substance use disorder provider. NEMT services
are subject to a prior authorization, except when a member is transferred from an acute
care hospital, immediately following an inpatient stay at the acute level of care, to a
skilled nursing facility or an intermediate care facility licensed pursuant to Health and
Safety Code (HSC) Section 12502.
MCPs must ensure that the medical professional’s decisions regarding NEMT are
unhindered by fiscal and administrative management, in accordance with their contract
with DHCS 3. MCPs are also required to authorize, at a minimum, the lowest cost type
of NEMT transportation (see modalities below) that is adequate for the member’s
medical needs. For Medi-Cal services that are not covered by the MCP’s contract, the
MCP must make its best effort to refer for and coordinate NEMT. MCPs must ensure
that there are no limits to receiving NEMT as long as the member’s medical services are
medically necessary and the NEMT has prior authorization.
MCPs are required to provide medically appropriate NEMT services when the member’s
medical and physical condition is such that transport by ordinary means of public or
private conveyance is medically contraindicated and transportation is required for
obtaining medically necessary services 4. MCPs are required to provide NEMT for
members who cannot reasonably ambulate or are unable to stand or walk without
assistance, including those using a walker or crutches5. MCPs shall also ensure door-
to-door assistance for all members receiving NEMT services.
Unless otherwise provided by law, MCPs must provide transportation for a parent or a
guardian when the member is a minor. With the written consent of a parent or guardian,
MCPs may arrange NEMT for a minor who is unaccompanied by a parent or a guardian.
2 22 CCR Section 51323 (b)(2)(C)
3 Exhibit A, Attachment 1 (Organization and Administration of the Plan)
4 22 CCR Section 51323 (a)
5 Manual of Criteria for Medi-Cal Authorization, Chapter 12.1 Criteria for Medical Transportation and Related Services
Exhibit E
ALL PLAN LETTER 17-010 (REVISED)
Page 3
MCPs must provide transportation services for unaccompanied minors when applicable
State or federal law does not require parental consent for the minor’s service. The MCP
is responsible to ensure all necessary written consent forms are received prior to
arranging transportation for an unaccompanied minor.
MCPs must provide the following four available modalities of NEMT transportation in
accordance with the Medi-Cal Provider Manual6 and the CCR 7 when the member’s
medical and physical condition is such that transport by ordinary means of public or
private conveyance is medically contraindicated and transportation is required for the
purpose of obtaining needed medical care:
1.MCPs must provide NEMT ambulance services for8:
•Transfers between facilities for members who require continuous
intravenous medication, medical monitoring or observation.
•Transfers from an acute care facility to another acute care facility.
•Transport for members who have recently been placed on oxygen (does
not apply to members with chronic emphysema who carry their own
oxygen for continuous use).
•Transport for members with chronic conditions who require oxygen if
monitoring is required.
2.MCPs must provide litter van services when the member’s medical and
physical condition does not meet the need for NEMT ambulance services, but
meets both of the following:
•Requires that the member be transported in a prone or supine position,
because the member is incapable of sitting for the period of time needed
to transport9.
•Requires specialized safety equipment over and above that normally
available in passenger cars, taxicabs or other forms of public conveyance 10.
3.MCPs must provide wheelchair van services when the member’s medical and
physical condition does not meet the need for litter van services, but meets any
of the following:
•Renders the member incapable of sitting in a private vehicle, taxi or other
form of public transportation for the period of time needed to transport11.
6 Medi-Cal Provider Manual: Medical Transportation – Ground
7 22 CCR Section 51323(a) and (c)
8 Medi-Cal Provider Manual: Medical Transportation – Ground, page 9, Ambulance: Qualified Recipients
9 22 CCR Section 51323 (2)(A)(1)
10 22 CCR Section 51323 (2)(B)
11 22 CCR Section 51323 (3)(A)
Exhibit E
ALL PLAN LETTER 17-010 (REVISED)
Page 4
•Requires that the member be transported in a wheelchair or assisted to
and from a residence, vehicle and place of treatment because of a
disabling physical or mental limitation 12.
•Requires specialized safety equipment over and above that normally
available in passenger cars, taxicabs or other forms of public conveyance13.
Members with the following conditions may qualify for wheelchair van transport
when their providers submit a signed Physician Certification Statement (PCS) form
(as described below)14:
•Members who suffer from severe mental confusion.
•Members with paraplegia.
•Dialysis recipients.
•Members with chronic conditions who require oxygen but do not require
monitoring.
4.MCPs must provide NEMT by air only under the following conditions15:
•When transportation by air is necessary because of the member’s medical
condition or because practical considerations render ground transportation
not feasible. The necessity for transportation by air shall be substantiated
in a written order of a physician, dentist, podiatrist, or mental health or
substance use disorder provider.
NEMT Physician Certification Statement Forms
MCPs and transportation brokers must use a DHCS approved PCS form to determine
the appropriate level of service for Medi-Cal members. Once the member’s treating
physician prescribes the form of transportation, the MCP cannot modify the
authorization. In order to ensure consistency amongst all MCPs, all NEMT PCS forms
must include, at a minimum, the components listed below:
•Function Limitations Justification: For NEMT, the physician is required to
document the member’s limitations and provide specific physical and medical
limitations that preclude the member’s ability to reasonably ambulate without
assistance or be transported by public or private vehicles.
•Dates of Service Needed: Provide start and end dates for NEMT services;
authorizations may be for a maximum of 12 months.
•Mode of Transportation Needed: List the mode of transportation that is to be
used when receiving these services (ambulance/gurney van, litter van,
wheelchair van or air transport).
12 22 CCR Section 51323 (3)(B)
13 22 CCR Section 51323 (3)(C)
14 Medi-Cal Provider Manual: Medical Transportation – Ground, page 11, Wheelchair Van
15 22 CCR Section 51323 (c)(2)
Exhibit E
ALL PLAN LETTER 17-010 (REVISED)
Page 5
•Certification Statement: Prescribing physician’s statement certifying that medical
necessity was used to determine the type of transportation being requested.
Each MCP must have a mechanism to capture and submit data from the PCS form to
DHCS. Members can request a PCS form from their physician by telephone,
electronically, in person, or by another method established by the MCP.
Non-Medical Transportation
NMT has been a covered benefit when provided as an EPSDT service 16. Beginning on
July 1, 2017, MCPs must provide NMT for MCP members to obtain medically necessary
MCP-covered services. For all Medi-Cal services not covered under the MCP contract,
MCPs must make their best effort to refer for and coordinate NMT.
Effective October 1, 2017, MCPs must provide NMT for all Medi-Cal services, including
those not covered by the MCP contract. Services that are not covered under the MCP
contract include, but are not limited to, specialty mental health, substance use disorder,
dental, and any other benefits delivered through the Medi-Cal FFS delivery system.
NMT does not include transportation of the sick, injured, invalid, convalescent, infirm, or
otherwise incapacitated members who need to be transported by ambulances, litter
vans, or wheelchair vans licensed, operated, and equipped in accordance with state
and local statutes, ordinances, or regulations. Physicians may authorize NMT for
members if they are currently using a wheelchair but the limitation is such that the
member is able to ambulate without assistance from the driver. The NMT requested
must be the least costly method of transportation that meets the member’s needs.
MCPs are contractually required to provide members with a Member Services Guide
that includes information on the procedures for obtaining NMT transportation services 17.
The Member Services Guide must include a description of NMT services and the
conditions under which NMT is available.
At a minimum, MCPs must provide the following NMT services 18:
•Round trip transportation for a member by passenger car, taxicab, or any other
form of public or private conveyance (private vehicle)19, as well as mileage
reimbursement for medical purposes20 when conveyance is in a private vehicle
arranged by the member and not through a transportation broker, bus passes,
taxi vouchers or train tickets.
16 WIC 14132 (ad)(7)
17 Exhibit A, Attachment 13 (Member Services), Written Member Information
18 WIC Section 14132(ad)
19 Vehicle Code (VEH) Section 465
20 IRS Standard Mileage Rate for Business and Medical Purposes
Exhibit E
ALL PLAN LETTER 17-010 (REVISED)
Page 6
•Round trip NMT is available for the following:
o Medically necessary covered services.
o Members picking up drug prescriptions that cannot be mailed directly to
the member.
o Members picking up medical supplies, prosthetics, orthotics and other
equipment.
•MCPs must provide NMT in a form and manner that is accessible, in terms of
physical and geographic accessibility, for the member and consistent with
applicable state and federal disability rights laws.
Conditions for Non-Medical Transportation Services:
•MCP may use prior authorization processes for approving NMT services and re
authorize services every 12 months when necessary.
•NMT coverage includes transportation costs for the member and one attendant,
such as a parent, guardian, or spouse, to accompany the member in a vehicle or
on public transportation, subject to prior authorization at time of initial NMT
authorization request.
•With the written consent of a parent or guardian, MCPs may arrange for NMT for
a minor who is unaccompanied by a parent or a guardian. MCPs must provide
transportation services for unaccompanied minors when state or federal law does
not require parental consent for the minor’s service. The MCP is responsible to
ensure all necessary written consent forms are received prior to arranging
transportation for an unaccompanied minor.
•NMT does not cover trips to a non-medical location or for appointments that are
not medically necessary.
•For private conveyance, the member must attest to the MCP in person,
electronically, or over the phone that other transportation resources have been
reasonably exhausted. The attestation may include confirmation that the member:
o Has no valid driver’s license.
o Has no working vehicle available in the household.
o Is unable to travel or wait for medical or dental services alone.
o Has a physical, cognitive, mental, or developmental limitation.
Non-Medical Transportation Private Vehicle Authorization Requirements
The MCPs must authorize the use of private conveyance (private vehicle)21 when no
other methods of transportation are reasonably available to the member or provided by
the MCP. Prior to receiving approval for use of a private vehicle, the member must
exhaust all other reasonable options and provide an attestation to the MCP stating other
methods of transportation are not available. The attestation can be made over the
21 VEH Section 465
Exhibit E
ALL PLAN LETTER 17-010 (REVISED)
Page 7
phone, electronically, or in person. In order to receive gas mileage reimbursement for
use of a private vehicle, the driver must be compliant with all California driving
requirements, which include22:
•Valid driver’s license.
•Valid vehicle registration.
•Valid vehicle insurance.
MCPs are only required to reimburse the driver for gas mileage consistent with the
Internal Revenue Service standard mileage rate for medical transportation23.
Non-Medical Transportation Authorization
MCPs may authorize NMT for each member prior to the member using NMT services.
If the MCP requires prior authorization for NMT services, the MCP is responsible for
developing a process to ensure that members can request authorization and be
approved for NMT in a timely matter. The MCP’s prior authorization process must be
consistently applied to medical/surgical, mental health and substance use disorder
services as required by CMS-2333-F.
Non-Medical Transportation and Non-Emergency Medical Transportation Access
Standards
MCPs are contractually required to meet timely access standards24. MCPs that have a
Knox-Keene license are also required to meet the timely access standards contained in
Title 28 CCR Section 1300.67.2.2. The member’s need for NMT and NEMT services do
not relieve the MCPs from complying with their timely access standard obligations.
MCPs are responsible for ensuring that their delegated entities and subcontractors
comply with all applicable state and federal laws and regulations, contractual
requirements, and other requirements set forth in DHCS guidance, including APLs and
Dual Plan Letters. MCPs must timely communicate these requirements to all delegated
entities and subcontractors in order to ensure compliance.
22 VEH Section 12500, 4000, and 16020
23 IRS Standard Mileage Rate for Business and Medical Purposes
24 28 CCR Section1300.51(d)(H); Exhibit A, Attachment 9 (Access and Availability)
Exhibit E
ALL PLAN LETTER 17-010 (REVISED)
Page 8
If you have any questions regarding this APL, contact your Managed Care Operations
Division Contract Manager.
Sincerely,
Original Signed by Nathan Nau
Nathan Nau, Chief
Managed Care Quality and Monitoring Division
Exhibit E