HomeMy WebLinkAboutAgreement A-13-034-1 with Blue Cross of California Partnership Plan, Inc..pdfAgreement 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 PARTNERSIDP PLAN, INC.
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7 THIS AMENDMENT, (hereinafter referred to as "Amendment I"), is entered into this
8 \1 ptb day of :I lJ..-y"UL , 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 defmed by the Diagnostic and Statistical Manual of
2 0 Mental Disorders, Fourth Edition, Text Revision (DSM N); to include the following services:
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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 drug therapy;
Psychiatric consultation; and,
Outpatient services that include laboratory, drugs, supplies and supplements excluding
2 6 medications as described in the list of Drugs Excluded from ANTHEM Coverage
2 7 included in APL 13-021.
2 8 WHEREAS, ANTHEM is required to provide through its network of mental health
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providers theaboveadditionalmentalhealthservicesto theextenttheyare notprovidedby the
COUNTY Mental Health Plan ("MHP")under the Specialty Mental Health Services Waiver to its
Medi-Cal Members;and
WHEREAS, the parties wish to amend the MOU to delineate the specific roles and
responsibilities ofthe MHPand ANTHEM for theseadditional services;and
NOW,THEREFORE,in consideration of their mutual promises,covenants and conditions,
hereinafter set forth, the sufficiency of which is acknowledged,the parties agree to amend the MOU
as follows:
1.That in the existing COUNTY Agreement No. 13-034, the following is inserted on
pagesix(6),rightafter Section12(Entire Agreement),as Sections 13 through16:
13.COVERED SERVICES AND POPULATIONS
The Mental Health Services Description Chart for Medi-Cal Managed Care
Members included with APL 13-021 as developed by DHCS and identified as
Exhibit D, is attached hereto and incorporated herein.
14.OVERSIGHT RESPONSIBILITIES OF ANTHEM AND THE MHP
A.ANTHEM will oversee a subcontracted mental health provider network,
which will provide the above additional mental health services to the
extent they are not provided by the MHP under the Specialty Mental
Health Services Waiver to its Medi-Cal Members.
B.ANTHEM and MHP will configure a mental health Medi-Cal oversight
team comprised of representatives from ANTHEM and MHP that are
responsible forprogram oversight, quality improvement,problemand
dispute resolution, and ongoing management of this Amendment I to the
MOU.
C.ANTHEM and MHP will formulate a multidisciplinary clinical team
oversightprocess forclinical operations: screening,assessment,referrals,
care management, care coordination,and exchange of medical
information.ANTHEM and MHP will determine the final composition
COUNTY OF FRF.SNO
Fresno,CA
1 of the multidisciplinaryteams 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
a. The MHP will follow the medical necessity criteria for Medi-
9 Cal specialtymentalhealth 1915(b)waiverservicesdescribed
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.
2 3 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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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 emolled with ANTHEM and receiving Medi-Cal specialty mental
27 health services through the MHP. These policies and procedures shall
2 8 include:
COUNTY OF'FRESNO
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
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1 The MHP and ANTHEM will have policies and procedures to addressquality
2 improvement requirements and reports.
3 1.Hold regular meetings,as agreedupon by the MHP and
4 ANTHEM,to review the referral and care coordination
5 processandmonitorMemberengagementand 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 servicesfromANTHEMand the MHP,as well
22 as quality strategies toaddressduplicationof 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
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1 process referenced aboveis outlinedin 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 multipleentry paths for Membersto access mentalhealth services.Referrals
8 may come from primary care physicians,providers,ANTHEM staff, MHP
9 Departments,and self-referral bycallingthe MHP's toll-free number thatwill
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
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Fresno,CA
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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.
Departmentof Health and Human Services (HIPAA Regulations)and other
applicable laws.
3. COUNTY and ANTHEM agree that this Amendment I is sufficient to amend the
MOU and shall be considered the Amendment I.The original MOU Agreement No. 13-034, as
hereby amended,is ratifiedand continued.All provisions,terms,covenants,conditions and
promises contained in the original MOU Agreement,and not amended herein,shall remain in full
force and effect.The Amendment I shall become effective January 1,2014.
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.
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BLUE CROSS OF CALIFORNIA
PARTNERSHIP PLAN, INC.
9 Title:------------
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President
Print Name: CA$1 e t<Atvf
Title:------------
Chief Financial Officer
Mailing Address:
3330 W. Mineral King Avenue
Visalia, CA 93291
Contact: Chief Executive Officer
COUNTY OF FRESNO
By:~~~~~~-~~~~
Chairman, Board of Supervisors
BERNICE E. SEIDEL, Clerk
Board of Supervisors
By: C\~~ C~, kip~
Date: \_p \ \lD \ l $""
PLEASE SEE ADDITIONAL
SIGNATURE PAGE ATTACHED
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APPROVED AS TO ACCOUNTING FORM:
VICKI CROW,C.P.A.,
AUDITOR-CONTROLLER/TREASURER-TAX COLLECTOR
Bv:(J2£c Hl^ej2^:
APPROVED AS TO LEGAL FORM:
DANIEL C.CEDERBORG,COUNTY COUNSEL
REVIEWED AND RECOMMENDED FOR
APPROVAL:
By:&*Mrl^y IjJc^dr
Dawan Utecht,Director
Departmentof Behavioral Health
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Fresno,CA
DHCS
TOBY DOUGLAS
DIRECTOR
State of California—Health and Human Services Agency
Department of Health Care Services
Exhibit D
Page 1
EDMUNDG.BROWN JR.
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
impairment1 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)betweeneach MCP and its county MHP.
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 mustmeet 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.
2Policy Letters are available at http://www.dhcs.ca.gov/formsandpubs/Pages/PolicyLetters.aspx.
i API.s areavailableat http://www.dhcs.ca.gov/formsandpubs/Pages/AliPlanLetters.aspx.
Medi-Cal Managed Care Division
1501 Capitol Avenue,P.O.Box997413,MS4400
Sacramento,CA 95899-7413
Phone (916)449-5000 Fax (916)449-5005
www.dhcs.ca.gov
All Plan Letter 13-021
Page 2
Exhibit D
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. Outpatientservices forbeneficiariesunder 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 (outpatientforbeneficiaries under the age of 21).
1.Pursuant to Title9, CCR §1830.205,a beneficiarymust meet the following
criteria to receive outpatient Medi-Cal specialty mental health services:
a.Diagnosis:The beneficiary has one ormorediagnoses 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.
b.Impairment:The beneficiary must have at least one ofthe following
impairments as a resultofthe covered mental healthdiagnosis (see #1 .a.
above):
i. A significant impairment inan important area of life functioning;
ii.A reasonable probabilityof significant deterioration inan important
area of life functioning;or,
iii.Exceptas described in#2 below,a reasonable probability a child
(e.g. a beneficiary under the age of 21)will not progress
developmental^as individually appropriate.
c.Intervention:The proposed intervention isfocused 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, allowthe childto progress
developmentally as individually appropriate.In addition,the beneficiary's
condition would not be responsive to physical health care based
treatment.
2.Pursuant toTitle9, CCR,§1830.210,forbeneficiariesunder the age of21
receiving servicesunderthe Early and Periodic Screening,Diagnosis,and
Treatment (EPSDT)benefit whodo notmeet the medical necessity requirements
described in #1 .b and #1 .c above,medical necessity criteria for specialty mental
health services other than psychiatricinpatienthospitalservices 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),whetheror 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 indetail inthis APL,as this APL is primarily focused on outpatient mental health services.
All Plan Letter 13-021
Page 3
Exhibit D
Page 3
b.Impairment:The beneficiary has a condition that would notbe responsive
to physical health care-based treatment and meets the requirements of
Title 22,CCR §51340(e)(3)(A)with respect tothe mental illness which
provides a list of criteria that apply tothe provision of EPSDT
supplemental services including,but not limited to,the requirement that
the service provided mustcorrector 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 serviceshave 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 ofthe First Extraordinary
Session (Hernandez &Steinberg,Chapter 4,Statutes of 2013),which added
§§14132.03 and 14189 tothe 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 bythe current DSM,thatare outside ofthe PCP'sscopeof
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 tobe 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 forOutpatient 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
All Plan Letter 13-021
Page 4
Exhibit D
Page 4
services within their scope ofpractice. MCPsare also obligated to cover outpatient
mental health services to beneficiaries with mild to moderate impairment of mental,
emotional,or behavioral functioning (assessed bya licensed mental health professional
through theuseofa Medi-Cal-approved clinical tool orset of tools agreed upon by both
the MCPand MHP),resultingfroma mental health disorder,as defined inthe current
DSM.Conditions that the DSM identifies as relational problems (e.g.couples
counseling,family counseling for relational problems)are not covered as partofthe new
benefit byan MCP norbyan MHP.All services mustbe 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 toevaluatea mental health
condition;
3. Outpatient services forthe purposes of monitoring drug therapy;
4.Outpatient laboratory,drugs,supplies,and supplements (excluding medications
listed in Attachment 2);and,
5.Psychiatric consultation.
CurrentProcedural Terminology codes that are covered can be found inthe Medi-Cal
Provider Manual.
Laboratory testing may include tests todeterminea baseline assessment before
prescribing psychiatric medications orto monitor side effects from psychiatric
medications.Supplies may include laboratory supplies. Supplements may include
vitaminsthat are not specifically excluded inthe Medi-Cal formulary and that are
scientifically proven effective in the treatmentof mental healthdisorders (although none
are currently indicated for this purpose).
For MCP-covered services,medically necessary services are defined as reasonable
and necessary servicesto protect life,prevent significant illness or significant disability,
or to alleviate severe painthroughthe 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
couplesand family counseling for relational problems)that result in mild or
moderate impairment;and,
3. Refer adults to the county MHP forspecialty mental health services when a
mental healthdiagnosis covered bythe MHP results in significant impairment;or
All Plan Letter 13-021
Page 5
Exhibit D
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 toensure mental healthscreeningof all beneficiaries
by network PCPs.Beneficiaries with positive screening results maybe treatedbya
network PCP within the PCP's scope of practice. When the condition is beyond the
PCP's scope of practice,the MCP must referthe beneficiary toa 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 oftools 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 healthdiagnosis is not eligible for MHP services
because the adult beneficiary's levelof impairment is mild to moderate,or, foradults
and children, the recommended treatment does not meet criteriafor Medi-Cal specialty
mental health services,then the MCP is required to ensure the provision of the
outpatient mental health services listed orother appropriate services within the scope of
the MCP's covered services.
Each MCP must ensure its network providers refer beneficiaries withsignificant
impairment resulting from a covered mental health diagnosis tothe county MHP.Also,
when the MCP beneficiary has a significant impairment,butthe diagnosis is uncertain,
the MCP must ensure that the beneficiary is referred to the MHPfor further assessment.
MCPs must also cover outpatient laboratory tests,medications (excluding those listed in
Attachment 2),supplies,and supplements prescribedbythe mental health providers in
the MCP network,as well as by PCPs,to assess and treat mental health conditions.
The MCP may require thatcoveredservices be provided through the MCP's provider
network and be subject to a medical necessity determination.
The MCP maynegotiate 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 healthcare servicesforan MCP
beneficiary receiving specialty mental health services. The MCP must coordinate with
the MHP.The MCP is responsible forthe appropriate management ofa beneficiary's
mental and physical health care,which includes,butisnot 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.
All Plan Letter 13-021
Page 6
Exhibit D
Page 6
DHCS will monitorthe implementation of this new policy and make adjustments as
needed.Reporting requirements and performance metrics are beingestablished with
input from MCPsand will be communicated ina separate APL.
If you have any questions regarding this APL,please contact Sarah Royce,MD,MPH at
sarah.rovce(S)dhcs.ca.qov or Liana Lianov, MD, MPH,at liana.lianov@dhcs.ca.qov,
Medi-Cal Managed Care Division.
Sincerely,
OrLg^ncd/SCgyied/by Margaret Tatar
Margaret Tatar
Assistant Deputy Director
Health Care Delivery Systems
Attachments
Exhibit D
Attachment 1 a9e
Mental Health Services Description Chart for Medi-Cat Managed Care Members
DIMENSION
ELIGIBILITY
Medi-Cal
Mild to Moderate
Impairment in
Functioning
A member is covered by
the MCP for services if he
or she is diagnosed with a
mental health disorder as
defined by the current
DSM3 resulting in mild to
moderate distress or
impairment of mental,
emotional,or behavioral
functioning:
•Primary care providers
identify the need for a
mental health screening
and refer to a specialist
within their network.
Upon assessment,the
mental health specialists
can assess the mental
health disorder and the
level of impairment and
refer members that meet
medical necessity
criteria to the MHP for a
Specialty Mental Health
Services (SMHS)
assessment.
•When a member's
condition improves
under SMHS and the
mental health providers
in the MCP and MHP
coordinate care,the
member may return to
the MH provider in the
MCP network.
Note:Conditions that the
current DSM identifies
as relational problems
are not covered,i.e.
couples counseling or
family counseling.
MHP2 OUTPATIENT
Significant Impairment in
Functioning
A member is eligible for
services if he or she meets
all of the following medical
necessity criteria:
1.Has an included mental
health diagnosis;4
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,or a reasonable
probability of not
progressing
developmentally as
individually appropriate;
3.The focus of the
proposed treatment is to
address the
impairment(s)described
in #2;
4.The expectation 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 members under
age 21 who meet criteria
for EPSTD specialty
mental health services,
the criteria allow for a
range of impairment
levels4 and include
treatment that allows the
child to progress
developmentally as
individually appropriate.
MHP INPATIENT
Emergency and Inpatient
A member 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 or
emergency intervention
provided in the community
or clinic;and
f.Serious adverse reactions
to medications,procedures
or therapies requiring
continued hospitalization.
Medi-Cal Managed Care Plan
2 County Mental Health Plan Medi-Cal Specialty Mental Health Services
3 Current policy isbased on DSM IV and will be updatedto DSM 5 inthe future
4As specified in regulations Title IX,Sections 1820.205 and 1830.205 for adultsand 1830.210forthose underage 21
DIMENSION
SERVICES
Medi-Cal5
Mental health services
when 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
MHP6 OUTPATIENT
Medi-Cal Specialty Mental
Health Services:
•Mental Health Services
o Assessment
o Plan development
o Therapy
o Rehabilitation
o Collateral
•Medication Support
Services
•Day Treatment Intensive
•Day Rehabilitation
•Crisis Residential
•Adult Crisis Residential
•Crisis Intervention
•Crisis Stabilization
•Targeted Case
Management
1Medi-Cal Managed Care Plan
County Mental Health Plan Medi-Cal Specialty Mental Health Services
Exhibit D
Page 8
MHP INPATIENT
Acute psychiatric inpatient
hospital services
Psychiatric Health Facility
Services
Psychiatric Inpatient Hospital
Professional Services if the
beneficiary is in fee-for-
service hospital
Attachment 2
Exhibit D
Page 9
Drugs Excluded from MCP Coverage
The following psychiatric drugs are noncapitated except for HCP 170 (KP
Cal,LLC)
Amantadine HCI Olanzapine Fluoxetine HCI
Aripiprazole Olanzapine Pamoate
Monohydrate (Zyprexa Relprew)Asenapine(Saphris)
Benztropine Mesylate Paliperidone (Invega)
Biperiden HCI Paliperidone Palmitate
(Invega Sustenna)Biperiden Lactate
Chlorpromazine HCI Perphenazine
Chlorprothixene Phenelzine Sulfate
Clozapine Pimozide
Fluphenazine Decanoate Proclyclidine HCI
Fluphenazine Enanthate Promazine HCI
Fluphenazine HCI Quetiapine
Haloperidol Risperidone
Haloperidol Decanoate Risperidone Microspheres
Haloperidol Lactate Selegiline (transdermal only)
lloperidone (Fanapt)Thioridazine HCI
Isocarboxazid Thiothixene
Lithium Carbonate Thiothixene HCI
Lithium Citrate Tranylcypromine Sulfate
Loxapine HCI Trifluoperazine HCI
Loxapine Succinate Triflupromazine HCI
Lurasidone Hydrochloride Trihexyphenidyl
Mesoridazine Mesylate Ziprasidone
Molindone HCI 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/partl/mcpgmc zOl.doc