HomeMy WebLinkAboutAgreement A-13-034-1 with Blue Cross of California Partnership Plan Inc..pdf Agreement No. 13-034-1
1 AMENDMENT I TO MENTAL HEALTH MEMORANDUM OF UNDERSTANDING
2 BETWEEN
3 COUNTY OF FRESNO
4 AND
5 BLUE CROSS OF CALIFORNIA PARTNERSHIP PLAN,INC.
6
7 THIS AMENDMENT, (hereinafter referred to as"Amendment I"), is entered into this
8 V01D day of 2015,by and between the COUNTY OF FRESNO, a
9 political subdivision of the State of California, (hereinafter referred to as"COUNTY") and Blue
10 Cross of California Partnership Plan, Inc., (formerly BLUE CROSS) (hereinafter referred to as
11 "ANTHEM").
12 WHEREAS, the parties entered into that certain Memorandum of Understanding
13 (hereinafter referred to as"MOU"),identified as COUNTY Agreement No. 13-034, effective
14 January 15,2013,which remains in full force and effect; and
15 WHEREAS,on January 1, 2014,the State Department of Health Care Services("DHCS")
16 expanded the array of Medi-Cal mental health services available to Medi-Cal Members.The
17 following outpatient mental health benefits will be available through ANTHEM for Medi-Cal
18 Members with mild to moderate impairment of mental, emotional, or behavioral functioning
19 resulting from any mental health condition defined by the Diagnostic and Statistical Manual of
20 Mental Disorders, Fourth Edition,Text Revision(DSM IV); to include the following services:
21 • Individual and group mental health evaluation and treatment(psychotherapy);
22 • Psychological testing,when clinically indicated to evaluate a mental health condition;
23 • Outpatient services for the purposes of monitoring drug therapy;
24 • Psychiatric consultation; and,
25 • Outpatient services that include laboratory,drugs, supplies and supplements excluding
26 medications as described in the list of Drugs Excluded from ANTHEM Coverage
27 included in APL 13-021.
28 WHEREAS, ANTHEM is required to provide through its network of mental health
1 COUNTY OF FRESNO
Fresno,CA
1 providers the above additional mental health services to the extent they are not provided by the
2 COUNTY Mental Health Plan("MHP")under the Specialty Mental Health Services Waiver to its
3 Medi-Cal Members; and
4 WHEREAS, the parties wish to amend the MOU to delineate the specific roles and
5 responsibilities of the MHP and ANTHEM for these additional services; and
6 NOW,THEREFORE, in consideration of their mutual promises,covenants and conditions,
7 hereinafter set forth, the sufficiency of which is acknowledged, the parties agree to amend the MOU
8 as follows:
9 1. That in the existing COUNTY Agreement No. 13-034, the following is inserted on
10 page six (6), right after Section 12 (Entire Agreement), as Sections 13 through 16:
11 13. COVERED SERVICES AND POPULATIONS
12 The Mental Health Services Description Chart for Medi-Cal Managed Care
13 Members included with APL 13-021 as developed by DHCS and identified as
14 Exhibit D, is attached hereto and incorporated herein.
15 14. OVERSIGHT RESPONSIBILITIES OF ANTHEM AND THE MHP
16 A. ANTHEM will oversee a subcontracted mental health provider network,
17 which will provide the above additional mental health services to the
18 extent they are not provided by the MHP under the Specialty Mental
19 Health Services Waiver to its Medi-Cal Members.
20 B. ANTHEM and MHP will configure a mental health Medi-Cal oversight
21 team comprised of representatives from ANTHEM and MHP that are
22 responsible for program oversight, quality improvement,problem and
23 dispute resolution, and ongoing management of this Amendment I to the
24 MOU.
25 C. ANTHEM and MHP will formulate a multidisciplinary clinical team
26 oversight process for clinical operations: screening, assessment,referrals,
27 care management, care coordination, and exchange of medical
28 information. ANTHEM and MHP will determine the final composition
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Fresno,CA
1 of the multidisciplinary teams to conduct this oversight function.
2 D. ANTHEM and the MHP will designate as appropriate and when possible
3 the same staff to conduct tasks associated within the oversight and
4 multidisciplinary clinical teams.
5 15. SPECIFIC ROLES AND RESPONSIBLITIES
6 A. Screening,Assessment and Referral
7 1. Determination of Medical Necessity
8 a. The MHP will follow the medical necessity criteria for Medi-
9 Cal specialty mental health 1915(b) waiver services described
10 in Title 9, California Code of Regulations (CCR), Sections
11 1820.205, 1830.205,and 1830.210.
12 2. Assessment Process
13 a. ANTHEM and MHP shall develop and agree to written
14 policies and procedures regarding screening, assessment and
15 referral processes, including screening and assessment tools
16 for use in determining if ANTHEM or MHP will provide
17 mental health services within a reasonable period that allows
18 for timely access to services for Members.
19 b. ANTHEM will conduct a mental health assessment for
20 Members with a potential mental health condition using an
21 assessment tool mutually agreed upon with the MHP to
22 determine the appropriate care needed.
23 3. Referrals
24 a. ANTHEM and MHP shall develop and agree to written
25 policies and procedures regarding referral processes, including
26 the following:
27 i. The MHP agrees to accept referrals from ANTHEM
28 staff, providers, and Members' self-referral for
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Fresno,( k
1 determination of medical necessity for specialty mental
2 health services.
3 ii. ANTHEM Primary Care Provider agrees to refer the
4 Member to the ANTHEM's mental health network
5 provider for initial assessment and treatment (except in
6 emergency situations or in cases when the Member
7 clearly has a significant impairment that the Member can
8 be referred directly to the MHP). If it is determined by
9 ANTHEM mental health provider that the Member may
10 meet specialty mental health services medical necessity
11 criteria, the ANTHEM mental health network provider
12 agrees to refer the Member to the MHP for further
13 assessment and treatment.
14 iii. ANTHEM agrees to accept referrals from MHP staff,
15 providers, and Members' self-referral for assessment;
16 make a determination of medical necessity for outpatient
17 services; and provide referrals within ANTHEM mental
18 health provider network. The MHP agrees to refer to
19 ANTHEM when the service needed is one provided by
20 ANTHEM and not the MHP, and when it has been
21 determined by the MHP that the Member does not meet
22 the specialty mental health medical necessity criteria.
23 B. Care Coordination
24 ANTHEM and MHP agree to develop policies and procedures for
25 coordinating inpatient and outpatient medical and mental health care for
26 Members enrolled with ANTHEM and receiving Medi-Cal specialty mental
27 health services through the MHP. These policies and procedures shall
28 include:
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Fresno,CA
1 1. An identified point of contact from each party who will
2 initiate, provide, and maintain ongoing care coordination as
3 mutually agreed upon in ANTHEM and MHP protocols.
4 2. Coordination of care for inpatient mental health treatment
5 provided by the MHP, including a notification process
6 between the MHP and ANTHEM within 24 hours of
7 admission and discharge to arrange for appropriate follow-up
8 services. A process for reviewing and updating the care plan
9 of Members, as clinically indicated (i.e., following crisis
10 intervention or hospitalization). The process must include
11 triggers for updating care plans and coordinating with
12 outpatient mental health providers.
13 3. Transition of care for Members transitioning to or from
14 ANTHEM or MHP services.
15 4. Regular meetings to review referral, care coordination, and
16 information exchange protocols and processes.
17 C. Information Exchange
18 The MHP and ANTHEM will develop and agree to Information sharing
19 policies and procedures and agreed upon roles and responsibilities for sharing
20 protected health information ("PHI") for the purposes of medical and
21 behavioral health care coordination pursuant to Title 9, CCR, Section
22 1810.370(a)(3) and other pertinent state and federal laws and regulations,
23 including the Health Insurance Portability and Accountability Act and 42
24 CFR part 2, governing the confidentiality of mental health , alcohol and drug
25 treatment information. See Section 16 of this Amendment I to the MOU
26 regarding HIPAA.
27 D. Reporting and Quality Improvement Requirements
28
- 5 - COUNTY OF FRESNO
Fresno,CA
1 The MHP and ANTHEM will have policies and procedures to address quality
2 improvement requirements and reports.
3 1. Hold regular meetings, as agreed upon by the MHP and
4 ANTHEM, to review the referral and care coordination
5 process and monitor Member engagement and utilization.
6 2. Hold a no less than a semi-annual calendar year review of
7 referral and care coordination processes to improve quality of
8 care; and provide no less than semi-annual reports
9 summarizing quality findings, as determined in collaboration
10 with DHCS. The reports summarizing findings of the review
11 must address the systemic strengths and barriers to effective
12 collaboration between ANTHEM and MHP.
13 3. Reports that track cross-system referrals, beneficiary
14 engagement, and service utilization will be determined in
15 collaboration with DHCS, including, but not limited to: 1) the
16 number of disputes between ANTHEM and MHP, 2) the
17 dispositions/outcomes of those disputes, 3) the number of
18 grievances related to referrals and network access, and 4) the
19 dispositions/outcomes of those grievances. The reports shall
20 address utilization of mental health services by Members
21 receiving such services from ANTHEM and the MHP, as well
22 as quality strategies to address duplication of services.
23 4. The performance measures and quality improvement
24 initiatives will be determined by DHCS.
25 E. Dispute Resolution Process
26 ANTHEM and MHP agree to follow the resolution of dispute process in
27 accordance to Title 9, Section 1850.505, and the contract between ANTHEM
28 and DHCS and Centers for Medicare & Medicaid Services ("CMS"). The
- 6 - COUNTY OF FRESNO
Fresno,CA
1 process referenced above is outlined in Resolution of Disputes section of the
2 signed MOU.
3 F. Telephone Access
4 ANTHEM shall ensure that Members will be able to assess urgent or
5 emergency mental health services 24 hours per day, 7 days a week.
6 The approach will be the "no wrong door" to service access. There will be
7 multiple entry paths for Members to access mental health services. Referrals
8 may come from primary care physicians, providers, ANTHEM staff, MHP
9 Departments, and self-referral by calling the MHP's toll-free number that will
10 be available 24 hours per day, 7 days a week for service access, service
11 authorization,and referral.
12 G. Provider and Member Education
13 ANTHEM and MHP shall determine the requirements for coordination of
14 Member and provider information about access to ANTHEM and MHP
15 covered services. ANTHEM and MHP may develop a "Quick Guide" that
16 will assist for referrals and access to services.
17 H. Point of Contact for the MOU Amendment
18 The Point of Contact for the MOU Amendment will be a designated liaison
19 from both the MHP and ANTHEM.
20 16. HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY
21 ACT
22 MHP and ANTHEM each consider and represent themselves as covered
23 entities as defined by the U.S. Health Insurance Portability and
24 Accountability Act of 1996, Public Law 104-191("HIPAA") and agree to use
25 and disclose PHI as required by law.
26 MHP and ANTHEM acknowledge that the exchange of PHI between them is
27 only for treatment, payment, and health care operations. MHP and
28 ANTHEM intend to protect the privacy and provide for the security of PHI
- 7 - COUNTY OF FRESNO
Fresno,CA
1 pursuant to the Agreement in compliance with HIPAA, the Health
2 Information Technology for Economic and Clinical Health Act, Public Law
3 111-005 ("HITECH"), and regulations promulgated thereunder by the U.S.
4 Department of Health and Human Services (HIPAA Regulations) and other
5 applicable laws.
6 3. COUNTY and ANTHEM agree that this Amendment I is sufficient to amend the
7 MOU and shall be considered the Amendment I. The original MOU Agreement No. 13-034, as
8 hereby amended, is ratified and continued. All provisions, terms,covenants, conditions and
9 promises contained in the original MOU Agreement, and not amended herein, shall remain in full
10 force and effect. The Amendment I shall become effective January 1, 2014.
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8 — COUNTY OF FRESNO
Fresno,CA
1 IN WITNESS WHEREOF, the parties hereto have caused this Amendment I to the Agreement 13-
2 034 to be executed by their duly authorized representatives, effective January 1,2014.
3
4 BLUE CROSS OF CALIFORNIA COUNTY OF FRESNO
PARTNERSHIP PLAN,INC.
5
6 By / By:
7 Chairman, Board of Supervisors
8 Print Name:
9 Title: Date:
President
10
11
12 By: BERNICE E. SEIDEL,Clerk
13 Board of Supervisors
Print Name:
14
15 Title: By: , 4 �
Chief Financial Officer
16 Date: to
17 Mailing Address:
18 3330 W. Mineral King Avenue
Visalia,CA 93291
19 Contact: Chief Executive Officer
20
21
22
PLEASE SEE ADDITIONAL
23 SIGNATURE PAGE ATTACHED
24
25
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— 9 — COUNTY OF FRESNO
Fresno,CA
1
2 APPROVED AS TO ACCOUNTING FORM:
3
VICKI CROW, C.P.A.,
4 AUDITOR-CONTROLLER/TREASURER-TAX COLLECTOR
5
6 c�7 By.
8
9
APPROVED AS TO LEGAL FORM:
10
11 DANIEL C. CEDERBORG, COUNTY COUNSEL
12
13 By:
14
15
16 REVIEWED AND RECOMMENDED FOR
17
APPROVAL:
18
19
20 By. � 1 � '�-- Itk-t
21 Dawan Utecht, Director
22 Department of Behavioral Health
23
24
25
26
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— 10 — COUNTY OF FUSNO
Fresno,CA
Exhibit D
Page 1
DHSS State of California—Health and Human Services Agency
IPDepartment of Health Care Services
OW
TOBY DOUGLAS EDMUND G.BROWN JR.
DIRECTOR GOVERNOR
DATE: December 13, 2013
ALL PLAN LETTER 13-021
TO: ALL MEDI-CAL MANAGED CARE HEALTH PLANS
SUBJECT: MEDI-CAL MANAGED CARE 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 plans (MCPs) for the provision of medically necessary
outpatient mental health services. MCPs must provide specified services to adults and
children diagnosed with a mental health disorder, as defined by the Diagnostic and
Statistical Manual of Mental Disorders(DSM) that results in mild to moderate distress or
impairment' of mental, emotional, or behavioral functioning. 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.
This letter provides updates to the responsibilities of the MCPs for providing mental
health services that were described in Policy Letter(PL)00-001 REV2. Specialty mental
health services (SMHS) provided by county MHPs as described in PL 00-001 REV have
not changed, and therefore remain the same. The Department of Health Care Services
(DHCS) also issued APL 13-018 on November 27, 2013 to address the required
memorandum of understanding (MOU) between each MCP and its county MHP.3
BACKGROUND:
The Section 1915(b) Freedom of Choice waiver entitled Medi-Cal Specialty Mental
Health Services requires Medi-Cal beneficiaries needing specialty mental health
services to access these services through MHPs. To qualify for these services,
beneficiaries must meet specialty mental health services medical necessity criteria
including having received a covered diagnosis, demonstrating specified impairments,
DHCS recognizes that the medical necessity criteria for impairment and intervention for Medi-Cal specialty mental
health services differ for children and adults. Therefore, many children with impairments that may be considered
moderate meet,and will continue to meet,medical necessity criteria(Title 9,CCR,Section 1830.210)to access
Medi-Cal specialty mental health services provided by MHPs.
'-Policy Letters are available at http://www.dhcs.ca.-gov/formsandpub.s/PaLes/PoIicyLetters.asox.
APLs are available at http://www.dhcs.ca.gov/formsandpubs/Pages/AlIPlanLetters.a.m.
Medi-Cal Managed Care Division
1501 Capitol Avenue,P.O.Box 997413,MS 4400
Sacramento,CA 95899-7413
Phone(916)449-5000 Fax(918)449.5005
www.dhcs.r-a.gov
Exhibit D
All Plan Letter 13-021 Page 2
Page 2
and meeting specific intervention criteria. Medical necessity criteria differ depending on
whether the determination is for:
1. Inpatient services;
2. Outpatient services; or
3. Outpatient services for beneficiaries under the age of 21.
Regulations governing medical necessity criteria may be found at Title 9, California
Code of Regulations (CCR), Sections (§§) 1820.205 (inpatient),4 1830.205 (outpatient),
and 1830.210 (outpatient for beneficiaries under the age of 21).
1. Pursuant to Title 9, CCR §1830.205, a beneficiary must meet the following
criteria to receive outpatient Medi-Cal specialty mental health services:
a. Diagnosis: The beneficiary has one or more diagnoses covered by Title 9,
CCR §1 830.205(b)(1), whether or not additional diagnoses that are not
included in Title 9, CCR §1830.210(b)(1)are also present.
b. Impairment: The beneficiary must have at least one of the following
impairments as a result of the covered mental health diagnosis (see#1.a.
above):
i. A significant impairment in an important area of life functioning;
ii. A reasonable probability of significant deterioration in an important
area of life functioning; or,
iii. Except as described in #2 below, a reasonable probability a child
(e.g. a beneficiary under the age of 21)will not progress
developmentally as individually appropriate.
c. Intervention: The proposed intervention is focused on addressing 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, or,
except as described in #2 below, allow the child to progress
developmentally as individually appropriate. In addition, the beneficiary's
condition would not be responsive to physical health care based
treatment.
2. Pursuant to Title 9, CCR, §1830.210, for beneficiaries under the age of 21
receiving services under the Early and Periodic Screening, Diagnosis, and
Treatment(EPSDT) benefit who do not meet the medical necessity requirements
described in #1.b and #1.c above, medical necessity criteria for specialty mental
health services other than psychiatric inpatient hospital services are met when all
of the following exist:
a. Diagnosis: The beneficiary has one or more diagnoses covered by Title 9,
CCR §1830.205(b)(1), whether or not additional diagnoses that are not
included in Title 9, CCR §1830.210(b)(1)are also present;
4 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.
Exhibit D
Page 3
All Plan Letter 13-021
Page 3
b. Impairment: The beneficiary has a condition that would not be responsive
to physical health care-based treatment and meets the requirements of
Title 22, CCR §51340(e)(3)(A)with respect to the mental illness which
provides a list of criteria that apply to the provision of EPSDT
supplemental services including, but not limited to, the requirement that
the service provided must correct or ameliorate the mental health
condition; and,
c. Intervention: The services are necessary to correct or ameliorate defects
and physical and mental illnesses and conditions discovered by the
screening services.
Through December 31, 2013, MCP beneficiaries with mental health conditions that do
not meet medical necessity criteria for specialty mental health services have only had
access to limited outpatient mental health services delivered by primary care providers
(PCPs) or were referred to Medi-Cal Fee-for-Service mental health providers. DHCS
pays MCPs a capitated rate to provide mental health services that are within the PCP's
scope of practice(unless otherwise excluded by contract). Effective January 1, 2014,
DHCS will adjust MCP capitation payments to include the expanded outpatient mental
health services described in this APL.
This letter describes the new policy regarding outpatient mental health services 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.
POLICY:
Beginning January 1, 2014, MCPs are responsible for the delivery of certain mental
health services through the MCP provider network to beneficiaries with mild to moderate
impairment of mental, emotional, or behavioral functioning resulting from a mental
health disorder as defined by the current DSM, that are outside of the PCP's scope of
practice. The eligibility and medical necessity criteria for Medi-Cal specialty mental
health services provided by MHPs have not changed pursuant to this policy. Specialty
mental health services provided by MHPs continue to be available.
MCPs continue to be responsible for the provision of mental health services within the
scope of PCP practice. MCPs will also continue to be responsible for the arrangement
and payment of all medically necessary Medi-Cal physical health care services, not
otherwise excluded by contract, to MCP beneficiaries who require specialty mental
health services.
MCP Responsibility for Outpatient Mental Health Services
Effective January 1, 2014, each MCP is obligated to cover and pay for mental health
assessments of MCP beneficiaries with potential mental health disorders conducted by
licensed mental health professionals as specified in the Medi-Cal Provider Manual. This
new requirement is in addition to the existing requirement that PCPs offer mental health
Exhibit D
Page 4
All Plan Letter 13-021
Page 4
services within their scope of practice. MCPs are also obligated to cover outpatient
mental health services to beneficiaries with mild to moderate impairment of mental,
emotional, or behavioral functioning (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. Conditions that the DSM identifies as relational problems (e.g. couples
counseling, family counseling for relational problems) are not covered as part of the new
benefit by an MCP nor by an MHP. All services must be provided in a culturally and
linguistically appropriate manner.
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 licensed mental health professionals in the MCP provider network within the
scope of their 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 codes that are covered can be found in the Medi-Cal
Provider Manual.
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 MCP-covered services, 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 specialty mental health services when a
mental health diagnosis covered by the MHP results in significant impairment; or
Exhibit D
Page 5
All Plan Letter 13-021
Page 5
refer children under age 21 to the MHP for specialty mental health services when
they meet the criteria for those services.
The number of visits for mental health services is not limited as long as the MCP
beneficiary meets medical necessity criteria.
Each MCP is obligated to continue to ensure mental health screening of all beneficiaries
by network PCPs. Beneficiaries with positive screening results may be treated by a
network PCP within the PCP's scope of practice. When the condition is beyond the
PCP's scope of practice, the MCP must refer the beneficiary to a mental health provider
within the MCP network for a mental health assessment. The mental health provider
must use a Medi-Cal-approved clinical tool or the set of tools mutually agreed upon with
the MHP to assess the beneficiary's disorder, level of impairment, and appropriate care
needed. This tool must be identified in the MOU between the MCP and MHP, as
discussed in APL 13-018.
If an MCP beneficiary with a mental health diagnosis is not eligible for MHP services
because the adult beneficiary's level of impairment is mild to moderate, or, for adults
and children, the recommended treatment does not meet criteria for Medi-Cal specialty
mental health services, then the MCP is required to ensure the provision of the
outpatient mental health services listed or other appropriate services within the scope of
the MCP's covered services.
Each MCP must ensure its network providers refer beneficiaries with significant
impairment resulting from a covered mental health diagnosis to the county MHP. Also,
when the 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.
MCPs must also cover outpatient laboratory tests, medications (excluding those listed in
Attachment 2), 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 covered services be provided through the MCP's provider
network and be subject to a medical necessity determination.
The MCP may negotiate with the MHP to provide the outpatient 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 specialty mental health services. The MCP must coordinate 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.
Exhibit D
Page 6
All Plan Letter 13-021
Page 6
DHCS will monitor the implementation of this new policy and make adjustments as
needed. Reporting requirements and performance metrics are being established with
input from MCPs and will be communicated in a separate APL.
If you have any questions regarding this APL, please contact Sarah Royce, MD, MPH at
sarah.royice(cdhcs.ca.gov or Liana Lianov, MD, MPH, at liana.lianov ,)dhcs.ca.gov,
Medi-Cal Managed Care Division.
Sincerely,
0#,4Cnal/S 4+iz&by Margcwet Tatar
Margaret Tatar
Assistant Deputy Director
Health Care Delivery Systems
Attachments
Exhibit D
Page 7,
Attachment'i
Menta[HealthsSenrices Description Chart for Medi-Cal Managed Gare Members h:
DIMENSION=- 'Medi-Cai_ " : MHP aUTPATIENT",`T MHP INPATIENT
ELIGIBILITY Mild to Moderate Significant Impairment in Emergency and Inpatient
Impairment in Functioning
Functioning
A member is covered by A member is eligible for A member is eligible for services
the MCP for services if he services if he or she meets if he or she meets the following
or she is diagnosed with a all of the following medical medical necessity criteria:
mental health disorder as necessity criteria:
defined by the current 1. An included diagnosis;
DSM3 resulting in mild to 1. Has an included mental 2. Cannot be safely treated at a
moderate distress or health diagnosis;4 lower level of care;
impairment of mental, 2. Has a significant 3. Requires inpatient hospital
emotional,or behavioral impairment in an services due to one of the
functioning: important area of life following which is the result
function,or a reasonable of an included mental
• Primary care providers probability of significant disorder:
identify the need for a deterioration in an a. Symptoms or behaviors
mental health screening important area of life which represent a current
and refer to a specialist function, or a reasonable danger to self or others, or
within their network. probability of not significant property
Upon assessment,the progressing destruction;
mental health specialists developmentally as b. Symptoms or behaviors
can assess the mental individually appropriate; which prevent the
health disorder and the 3. The focus of the beneficiary from providing
level of impairment and proposed treatment is to for,or utilizing,food,
refer members that meet address the clothing, or shelter;
medical necessity impairment(s)described c. Symptoms or behaviors
criteria to the MHP for a in#2; which present a severe risk
Specialty Mental Health 4. The expectation that the to the beneficiary's physical
Services(SMHS) proposed treatment will health;
assessment. significantly diminish the d. Symptoms or behaviors
• When a member's impairment, prevent which represent a recent,
condition improves significant deterioration in significant deterioration in
under SMHS and the an important area of life ability to function;
mental health providers function, and e. Psychiatric evaluation or
in the MCP and MHP 5. The condition would not treatment which can only be
coordinate care,the be responsive to physical performed in an acute
member may return to health care-based psychiatric inpatient setting
the MH provider in the treatment. or through urgent or
MCP network. emergency intervention
Note:For members under provided in the community
Note:Conditions that the age 21 who meet criteria or clinic;and
current DSM identifies for EPSTD specialty f. Serious adverse reactions
as relational problems mental health services, to medications, procedures
are not covered, i.e. the criteria allow for a or therapies requiring
couples counseling or range of impairment continued hospitalization.
family counseling. levels'and include
treatment that allows the
child to progress
developmentally as
individually appropriate.
1 Medi-Cal Managed Care Plan
Z County Mental Health Plan Medi-Cal Specialty Mental Health Services
3 Current policy is based on DSM IV and will be updated to DSM 5 in the future
4 As specified in regulations Title IX,Sections 1820.205 and 1830.205 for adults and 1830.210 for those under age 21
Exhibit D
Page 8
DIMENSION Mod -Cal, MHP6.OUTPATIENT ' MHP INPATIENT
SERVICES Mental health services Medi-Cal Specialty Mental • Acute psychiatric inpatient
when provided by licensed Health Services: hospital services
mental health care • Psychiatric Health Facility
professionals(as defined Mental Health Services Services
in the Medi-Cal provider o Assessment • Psychiatric Inpatient Hospital
bulletin)acting within the o Plan development Professional Services if the
scope of their license: o Therapy beneficiary is in fee-for-
o Rehabilitation service hospital
• Individual and group o Collateral
mental health Medication Support
evaluation and Services
treatment • Day Treatment Intensive
(psychotherapy) Day Rehabilitation
• Psychological testing Crisis Residential
when clinically Adult Crisis Residential
indicated to evaluate a . Crisis Intervention
mental health condition . Crisis Stabilization
• Outpatient services for . Targeted Case
the purposes of Management
monitoring medication
therapy
• Outpatient laboratory,
medications,supplies,
and supplements
• Psychiatric
consultation
5 Medi-Cal Managed Care Plan
6 County Mental Health Plan Medi-Cal Specialty Mental Health Services
Exhibit D
Page 9
Attachment 2
Drugs Excluded from MCP Coverage
The following psychiatric drugs are noncapitated except for HCP 170(KP These drugs are listed in the Medi-Cal
Cal,LLC) Provider Manual in the following link:
Amantadine HCI Olanzapine Fluoxetine HCI http://files.medi-
Aripiprazole Olanzapine Pamoate cal.ca.pov/pubsdoco/publications/masters-
Asenapine(Saphris) Monohydrate(Zyprexa Relprew) mtp/partl/mcpgmc zOl.doc
Benztropine Mesylate Paliperidone(Invega)
Biperiden HCI Paliperidone Palmitate
Biperiden Lactate (Invega Sustenna)
Chlorpromazine HCl Perphenazine
Chlorprothixene Phenelzine Sulfate
Clozapine Pimozide
Fluphenazine Decanoate Proclyclidine HCI
Fluphenazine Enanthate Promazine HCI
Fluphenazine HCI Quetlapine
Haloperidol Risperidone
Haloperidol Decanoate Risperidone Microspheres
Haloperidol Lactate Selegiline(transdermal only)
Iloperidone(Fanapt) Thioridazine HCI
Isocarboxazid Thiothixene
Lithium Carbonate Thiothixene HCI
Lithium Citrate Tranylcypromine Sulfate
Loxapine HCI Trifluoperazine HCl
Loxapine Succinate Triflupromazine HCI
Lurasidone Hydrochloride Trihexyphenidyl
Mesoridazine Mesylate Ziprasidone
Molindone HCI Ziprasidone Mesylate
Olanzapine