HomeMy WebLinkAboutAgreement A-18-362 with Blue Cross of California.pdfAgreement No. 18-362
1 AGREEMENT
2
3 This MEMORANDUM OF UNDERSTANDING (MOU) is made and entered into as of this
4 10th day of July , 2018 by and between the COUNTY OF FRESNO, a Political Subdivision
5 of the State of California, hereinafter referred to as "COUNTY" and Blue Cross of California Partnership
6 Plan, Inc., a Medi-Cal Managed Care Health Plan whose address is 3330 W. Mineral King Avenue,
7 Visalia, CA 93291, hereinafter referred to as "ANTHEM", (collectively the "parties").
8 W I T N E S S E T H:
9 WHEREAS, COUNTY through its Department of Behavioral Health, is a Mental Health Plan,
10 hereinafter referred to as "MHP", as defined in Title 9 of the California Code of Regulations (CCR),
11 section 1810.226; and
12 WHEREAS, ANTHEM, is a prepaid full-service health care service plan licensed under the Knox-
13 Keene Health Care Service Plan Act of 1975, as amended (the "Knox-Keene Act"), which has entered
14 into an agreement with the California Department of Health Care Services under the Medi-Cal Managed
15 Care Program for the provision of specialty mental health and/or alcohol and other drug services to
16 persons who enroll in the Medi-Cal Plan for Fresno County; and
17 WHEREAS, COUNTY contracts with the Califomia Department of Health Care Services (DHCS)
18 to provide medically necessary specialty mental health services to the Medi-Cal beneficiaries of Fresno
19 County. The COUNTY and DHCS work collaboratively to ensure timely and effective access to specialty
20 mental health and/or alcohol and other drug services; and
21 WHEREAS, ANTHEM and COUNTY desire to identify responsibilities and protocols in the delivery
22 of specialty mental health and/or alcohol and other drug services to Medi-Cal Members served by both.
23 NOW, THEREFORE, in consideration of their mutual covenants and conditions, the parties hereto
24 agree as follows:
25 1. DEFINITIONS
26 Many words and terms are capitalized throughout this Agreement to indicate that
27 they are defined as set forth in this Section.
28 A. ANTHEM Medi-Cal Plan -is the ANTHEM benefit plan covering the provision of
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Health Care and Behavioral Health Services to ANTHEM Members pursuant to the Medi-Cal Agreement.
The benefits of the ANTHEM 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 ANTHEM Medi-Cal Plan.
C. Medi-Cal Fee-for Service (“FFS”) Rate – is the applicable fee-for-service rate
determined by the State Department of Health Services for the service under the Medi-Cal Program. All
services to be provided by COUNTY and compensated by ANTHEM pursuant to this Agreement shall
be billed by COUNTY, and compensated by ANTHEM, at the then current, applicable Medi-Cal FFS
Rate.
D. Member – is a Medi-Cal beneficiary who is eligible and enrolled in the ANTHEM
Medi-Cal Plan for Fresno County.
E. Primary Care Physician (PCP) – is either an internist, pediatrician, general
practitioner, OB/GYN, or family practitioner contracting with ANTHEM, or one of ANTHEM’s contracting
medical groups, who has been selected by or assigned to a Member for the purpose of providing and
coordinating Health Care Services under the ANTHEM Medi-Cal Plan.
2. RESPONSIBILITIES
A. JOINT RESPONSIBILITIES
1. The parties understand that ANTHEM 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 ANTHEM 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 ANTHEM’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
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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 ANTHEM
1. ANTHEM shall arrange for the provision of health care for its Members
through contracts with Contracting Providers. ANTHEM covers Health Care Services, but it does not
provide Health Care Services.
2. ANTHEM shall require that its Contracting Providers comply with all laws
requiring the reporting of certain diseases. ANTHEM will disseminate to its Contracting Providers the
information provided by the COUNTY regarding local community resources.
3. ANTHEM shall require that its PCP provide behavioral health services
limited PCP training and scope of practice.
4. ANTHEM shall promote organized managed care systems that reduce
fragmentation in case management and which improve quality of care.
5. ANTHEM 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 ANTHEM and its Contracting Providers.
6. ANTHEM shall assist COUNTY to determine the membership status of its
Members and to which PCP they have been assigned.
7. ANTHEM shall make every reasonable effort to provide linguistic services
for non-English speaking and limited English speaking Members and those who speak Spanish, Hmong,
Cambodian, and Lao as their primary language. In the event that a Member seeks services from
COUNTY and COUNTY has exhausted all reasonable resources for providing linguistic services to the
Member, ANTHEM agrees to provide linguistic services to that Member.
8. In accordance with Exhibit A, all responsibilities of ANTHEM are outlined.
C. RESPONSIBILITIES OF COUNTY
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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 ANTHEM 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.
3. COUNTY shall require all its specialty mental health and/or alcohol and
other drug service providers to assist COUNTY and ANTHEM 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
other drug services providers shall in any event, including, without limitation, non-payment by ANTHEM,
insolvency of ANTHEM, 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 other drug services provided pursuant to this Agreement. Neither COUNTY nor any COUNTY
specialty mental health and/or alcohol and other drug services provider shall maintain any action at law
or equity against a Member to collect sums owed by ANTHEM 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
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notice of any violation of this section, ANTHEM 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 other drug services providers to return all sums improperly collected from
Members or their representatives. COUNTY and ANTHEM’s obligations under this paragraph shall
survive the termination of this Agreement with respect to specialty mental health and/or alcohol and
other drug 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.
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 ANTHEM or COUNTY or COUNTY’s 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 MOU, 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 ANTHEM thirty (30) days advance written notice.
B. Breach of Contract - COUNTY may immediately suspend or terminate this
Agreement in whole or in part, where in the determination of COUNTY 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;
4. Improperly performed service: and/or
5. Failure by ANTHEM to obtain and maintain a license under the Knox-
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Keene Act.
In no event shall any payment by COUNTY constitute a waiver by COUNTY of any breach of
this Agreement or any default which may then exist on the part of ANTHEM. Neither shall such payment
impair or prejudice any remedy available to COUNTY with respect to the breach or default. COUNTY
shall have the right to demand of ANTHEM the repayment to COUNTY of any funds disbursed to
ANTHEM under this Agreement, which in the judgment of COUNTY were not expended in accordance
with the terms of this Agreement. ANTHEM shall promptly refund any such funds upon demand or, at
COUNTY’s option; such repayment shall be deducted from future payments owing to ANTHEM under
this Agreement.
C. Without Cause - Under circumstances other than those set forth above, this
Agreement may be terminated by ANTHEM 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 this Agreement shall be performed
without the payment of any monetary consideration by ANTHEM or COUNTY, one to the other.
6. INDEPENDENT CONTRACTOR
In performance of the work, duties, and obligations assumed by ANTHEM under this
Agreement, it is mutually understood and agreed that ANTHEM, including any and all of ANTHEM’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 COUNTY. Furthermore, COUNTY shall have no right to control
or supervise or direct the manner or method by which ANTHEM shall perform its work and function.
However, COUNTY shall retain the right to administer this MOU so as to verify that ANTHEM is
performing its obligations in accordance with the terms and conditions thereof. ANTHEM 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 MOU.
Because of its status as an independent contractor, ANTHEM shall have absolutely no
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right to employment rights and benefits available to COUNTY employees. ANTHEM shall be solely
liable and responsible for providing to, or on behalf of, its employees all legally-required employee
benefits. In addition, ANTHEM shall be solely responsible and save COUNTY harmless from all
matters relating to payment of ANTHEM’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, ANTHEM may be providing services to others unrelated to the COUNTY 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
ANTHEM 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 ANTHEM, 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 ANTHEM, its officers, agents or
employees under this Agreement.
10. CONFIDENTIALITY
All responsibilities performed by the ANTHEM 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, ANTHEM shall not unlawfully discriminate
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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 ANTHEM
Director, Fresno County Manager, CRC
Department of Behavioral Health 3330 W. Mineral King Ave., Suite A
4441 E. Kings Canyon Rd. Visalia, CA 93219
Fresno, CA 93702
Any and all notices between COUNTY and ANTHEM 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.
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 ANTHEM AND THE COUNTY
A. ANTHEM 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
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Drug Medi-Cal Organized Delivery System Waiver (herein after referred to as “DMC-ODS Waiver”) to
its Drug Medi-Cal Members.
B. ANTHEM 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. ANTHEM and COUNTY will configure a behavioral health Medi-Cal oversight team
comprised of representatives from ANTHEM and COUNTY that are responsible for program oversight,
quality improvement, problem and dispute resolution, and ongoing management of this MOU.
D. ANTHEM 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. ANTHEM and COUNTY will determine the final composition of
the multidisciplinary teams to conduct this oversight function.
E. ANTHEM and the COUNTY will designate as appropriate and when 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. ANTHEM 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
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a. ANTHEM 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 ANTHEM or COUNTY will provide behavioral health services
within a reasonable period that allows for timely access to services for Members.
b. ANTHEM 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 ANTHEM 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.
d. ANTHEM 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. ANTHEM 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 ANTHEM
staff, providers, and Members’ self-referral for determination of medical necessity for specialty mental
health services and/or alcohol and other drug services.
ii. ANTHEM Primary Care Provider agrees to refer the
Member to the ANTHEM’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 ANTHEM behavioral health
provider that the Member may meet specialty mental health services and/or alcohol and other drug
services medical necessity criteria, the ANTHEM behavioral health network provider agrees to refer the
Member to the COUNTY for further assessment and treatment.
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iii. ANTHEM 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 ANTHEM behavioral health provider network. The
COUNTY agrees to refer to ANTHEM when the service needed is one provided by ANTHEM 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 or higher levels of care not supported by Fresno County contracted
providers.
B. Care Coordination
ANTHEM and COUNTY agree to develop policies and procedures for coordinating
inpatient and outpatient medical and behavioral health care for Members enrolled with ANTHEM and
receiving Medi-Cal specialty mental health and/or alcohol and other drug 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 ANTHEM and
COUNTY protocols.
2. Coordination of care for inpatient behavioral health treatment provided by
the COUNTY, including a notification process between the COUNTY and ANTHEM 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 other drug 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.
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4. ANTHEM 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. ANTHEM 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.
6. Transition of care for Members transitioning to or from ANTHEM or
COUNTY services.
7. Regular meetings to review referral, care coordination, and information
exchange protocols and processes will occur with COUNTY and ANTHEM representatives.
8. The delineation of case management responsibilities will be outlined.
C. Information Exchange
The COUNTY and ANTHEM 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 drug treatment information.
D. Reporting and Quality Improvement Requirements
The COUNTY and ANTHEM will have policies and procedures to address quality
improvement requirements and reports.
1. Hold regular meetings, as agreed upon by the COUNTY and ANTHEM, to
review the referral and care coordination process and monitor Member engagement and utilization.
2. Hold a no less than a semi-annual calendar year review of referral and care
coordination processes to improve quality of care; and provide no less than semi-annual reports
summarizing quality findings, as determined in collaboration with DHCS. The reports summarizing
findings of the review must address the systemic strengths and barriers to effective collaboration
between ANTHEM and COUNTY.
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3. Reports that track cross-system referrals, beneficiary engagement, and
service utilization will be determined in collaboration with DHCS, including, but not limited to: 1) the
number of disputes between ANTHEM 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 reports shall address utilization of behavioral health services by Members
receiving such services from ANTHEM 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
ANTHEM 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
ANTHEM 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, ANTHEM 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
ANTHEM and COUNTY shall determine the requirements for coordination of
Member and provider information about access to ANTHEM and COUNTY covered services to increase
navigation support for beneficiaries and caregivers. ANTHEM and COUNTY may develop a “Quick
Guide” that will assist for referrals and access to services.
H. Point of Contact for the MOU Amendment
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The Point of Contact for the MOU will be a designated liaison from both the
COUNTY and ANTHEM.
17. HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT
COUNTY and ANTHEM each consider and represent themselves as covered entities as
defined by the U.S. Health Insurance Portability and Accountability Act of 1996, Public Law 104-191
(“HIPAA”) and agree to use and disclose PHI as required by law. COUNTY and ANTHEM acknowledge
that the exchange of PHI between them is only for treatment, payment, and health care operations.
COUNTY and ANTHEM 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 MOU including all Exhibits constitutes the entire agreement between ANTHEM and
COUNTY with respect to the subject matter hereof and supersedes all previous agreement
negotiations, proposals, commitments, writings, advertisements, publications, and understandings of
any nature whatsoever unless expressly included in this MOU.
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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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FOR ACCOUNTING USE ONLY:
Fund /Subclass: 0001/10000
18 Account No.: 7295 ($0)
Org No.: 56302666 ($0)
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COUNTY OF FRESNO
i n
e·~~ the Board of Supervisors
of the County of Fresno
ATTEST:
Bernice E. Seidel
Clerk of the Board of Supervisors
County of Fresno, State of Californi a
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MEMORANDUM OF UNDERSTANDING (MOU)
DEPARTMENT OF BEHAVIORAL HEALTH (COUNTY)
AND
ANTHEM
CATEGORY COUNTY ANTHEM BLUE CROSS
A. Liaison 1. COUNTY’s Administrative Staff is the
liaison to coordinate activities with
ANTHEM and to notify COUNTY
providers and relevant staff of their
roles and responsibilities
2. COUNTY Liaison will provide
ANTHEM with an updated list of
approved COUNTY providers,
specialists and behavioral health care
centers in the county.
3. Information for Mental Health (MH)
services 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 (SUD) treatment and
recovery services is also available on
the COUNTY’s Substance Use
Disorders Services Webpage and is
updated at a minimum on a 30 day
basis.
1. ANTHEM has a liaison that coordinates
activities with the COUNTY and COUNTY
Liaison.
2. The Liaison will notify ANTHEM staff and
ANTHEM providers of their responsibilities to
coordinate services with the COUNTY.
3. The ANTHEM Provider Directory is available
on line and updated at a minimum on a
quarterly basis.
4. The ANTHEM 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 MH services MH service 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 SUD services, 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.
1. ANTHEM will utilize the COUNTY to identify
COUNTY providers who are willing to accept
Medi-Cal fee for service reimbursement to
provide services for MH 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. ANTHEM 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 SUD services, ANTHEM 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 will be required.
4. ANTHEM 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
ANTHEM liaison quarterly and upon request.
Exhibit A
Page 1 of 19
4. COUNTY will continually monitor the
COUNTY provider network to ensure
Member access to quality behavioral
health care. COUNTY will assist
ANTHEM in arranging for a specific
COUNTY provider or community
service.
5. COUNTY will assist ANTHEM to
develop and update a list of providers
or provider organizations to be made
available to Members. For MH
services this list is available on the
COUNTY’s managed care website.
Any updates to the list will be
forwarded to the ANTHEM liaison
quarterly and upon request. For SUD
services, this list is available on the
COUNTY’s SUD Services Webpage.
Any updates to the list will be
forwarded to the ANTHEM 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-
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)
1. ANTHEM and contracted providers are
allowed to release medical information under
HIPAA regulations specific to the HIPPA Privacy
Rule (45 C.F.R. Part 164.)
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 MH and SUD
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
MH and SUD services
covered by the COUNTY
when the Member’s
behavioral health condition
meets COUNTY medical
1. ANTHEM 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 ANTHEM
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:
Exhibit A
Page 2 of 19
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 MH and
SUD 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
MH 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
SUD 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.
a. Basic education, assessment (MH
services only), counseling (MH
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
“Excluded Diagnosis” as identified in
Specialty MH 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. ANTHEM 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 MH
medical necessity, ANTHEM and PCP will be
responsible for coordinating a referral in
accordance with Category B2 “Mental Health
Services” or an ANTHEM contracted
provider.
7. When the member meets SUD medical
necessity for COUNTY contracted services,
ANTHEM 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 MH 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
1. ANTHEM must cover and pay for medically
necessary laboratory, radiological, and
radioisotope services described in Title 22,
CCR, Section 51311. ANTHEM will cover
and pay for related services for
Electroconvulsive Therapy (ECT),
anesthesiologist services provided on an
outpatient basis, per Exhibit B, attached
hereto.
2. ANTHEM will cover and pay for all medically
necessary professional services to meet the
physical health care needs of the Members
Exhibit A
Page 3 of 19
hereto.
2. When SUD 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 ANTHEM.
3. COUNTY will make training available
for community based physicians
interested in providing MAT services,
including an eight hour
Buprenorphine Waiver Training
required to become a community
based MAT service provider.
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. ANTHEM 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. ANTHEM will provide SUD 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. ANTHEM will provide SUD 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. ANTHEM will provide SUD treatment for
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. ANTHEM will provide SUD 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
ANTHEM will refer to a lower level of care to
increase the likelihood of successful
recovery.
8. ANTHEM Providers will have the ability to
prescribe, dose and/or refer Members with
an Opioid Use Disorder to Medication
Exhibit A
Page 4 of 19
Assisted Treatment (MAT) when appropriate.
ANTHEM 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. ANTHEM shall coordinate with COUNTY
NTP 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 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 SUD 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 SUD
inpatient hospital services at that
facility or any other facility, per Exhibit
B, attached hereto.
1. ANTHEM will maintain a 24 hour member
service and Nurse Advice Line.
2. ANTHEM 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. ANTHEM 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 and/or SUD inpatient hospital
services or when such services result in an
admission of the member for psychiatric
and/or SUD inpatient hospital services at a
different facility.
4. ANTHEM 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 SUD 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 ANTHEM.
E2. Home Health
Agency Services
1. COUNTY shall cover and pay for
medication support services, case
management, crisis intervention
services, or any other specialty MH
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
ANTHEM on any specialty MH
services being provided to a Member.
1. ANTHEM will cover and pay for prior
authorized home health agency services as
described in Title 22, CCR, Section 51337
prescribed by an ANTHEM provider when
medically necessary to meet the needs of
homebound Members. ANTHEM is not
obligated to provide home health agency
services that would not otherwise be
authorized by the Medi-Cal program.
2. ANTHEM will refer Members who may be at
risk of institutional placement to the Home
and Community Based services (HCBS)
Exhibit A
Page 5 of 19
Waiver Program (ANTHEM/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 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 MH services,
typically visits by psychiatrists and
psychologists.
1. ANTHEM 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. ANTHEM will arrange for disenrollment from
managed care if Member needs nursing
services for a longer period of time.
3. ANTHEM will pay for all medically necessary
DHCS contractually required Medi-Cal
covered services until the disenrollment is
effective.
E4. Emergency
and Non-
Emergency
Medical
Transportation
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. ANTHEM 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. ANTHEM 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. ANTHEM will cover all nonemergency
medical transportation, necessary to obtain
program covered services
a. When the service needed is of such
an urgent nature that written
Exhibit A
Page 6 of 19
authorization could not have been
reasonably submitted beforehand,
the medical transportation provider
may request prior authorization by
telephone. Such telephone
authorization shall be valid only if
confirmed by a written request for
authorization.
b. Transportation shall be authorized
only to the nearest facility capable of
meeting the member’s medical
needs.
6. ANTHEM 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
authorization is obtained. ANTHEM will
maintain a policy of non-discrimination
regarding Members with behavioral health
disorders who require access to any other
transportation services provided by
ANTHEM.
7. ANTHEM will assure that SUD clients
receive 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 the
Non-Emergency medical transportation has
prior authorization.
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. ANTHEM 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. ANTHEM will maintain a current MOU with
Central Valley Regional Center
E6. History and
Physical for
Psychiatric
Hospital
Admission
1. COUNTY will utilize ANTHEM
network providers to perform medical
histories and physical examinations
required for behavioral health
examinations required for behavioral
health and psychiatric hospital
1. ANTHEM 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
Exhibit A
Page 7 of 19
admissions for ANTHEM members.
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. ANTHEM is responsible for separately
billable outpatient services related to
electroconvulsive therapy, such as
anesthesiologist services, per Exhibit B,
attached hereto.
2. ANTHEM will cover and pay for professional
services and associated room charges for
hospital outpatient department services
consistent with medical necessity and
ANTHEM‘s contract with its contractors and
DHCS, per Exhibit B, attached hereto.
F. Diagnostic
Assessment and
Triage
1. 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 ANTHEM.
2. 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.
3. 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.
4. COUNTY provider assessments will:
a. Determine if Member meets
medical necessity criteria
(See Attachment B, attached
hereto and incorporated
herein by reference.)
b. Provide a resolution of
diagnostic dilemmas not
resolved by consultations
(e.g., multiple interacting
syndromes, patient’s
symptoms interfere with the
diagnostic conclusion and
1. ANTHEM will provide Members with SUD
screenings, brief intervention (SBIRT),
referral and assessment. If it is found that a
Member preliminarily meets medical
necessity for COUNTY provided services
ANTHEM 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. ANTHEM will arrange and pay for
assessments of ANTHEM members by
PCPs to:
a. Rule out general medical conditions
causing psychiatric and SUD
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 SUD 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 ANTHEM will
cover and pay for physician services
provided by specialists such as neurologists,
per Exhibit B, attached hereto.
Exhibit A
Page 8 of 19
has a bearing on the primary
care physician’s treatment
plan or if the diagnostic
conclusion is needed to
determine appropriateness
for specialized MH care.
c. Identify stability level, if the
result is needed to determine
appropriateness for specialty
MH services.
G. Referrals 1. COUNTY will accept referrals from
ANTHEM staff and providers.
ANTHEM providers and Members will
be referred to determine medical
necessity for specialty MH services.
For SUD 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
ANTHEM 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 MH and/or SUD 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 ANTHEM will
coordinate services as necessary in
such 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 ANTHEM
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
1. Following the PCP assessment, ANTHEM
staff and/or PCP will refer those Members
whose psychiatric condition or SUD would
not be responsive to physical health care to
the COUNTY to determine if specialty MH
and/or SUD services medical necessity
criteria are met.
2. ANTHEM 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. ANTHEM 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
ANTHEM to appropriate community
resources for assistance in identifying
programs available for low income Medi-Cal
beneficiaries.
Exhibit A
Page 9 of 19
deferrals from ANTHEM , 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 MH services, COUNTY will
authorize assessment and/or
treatment services by COUNTY
providers who are credentialed and
contracted with COUNTY for services
that meet specialty MH services
medical necessity criteria.
2. For SUD 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 SUD services that meet
medical necessity criteria.
1. ANTHEM will authorize medical assessment
and/or treatment services by ANTHEM
network providers who are credentialed and
contracted with ANTHEM for covered
medically necessary services.
2. ANTHEM will inform PCPs that they may
refer Members to the COUNTY for initial
diagnosis and assessment of the Member.
I. Consultation
1. COUNTY encourages consultations
between COUNTY providers,
specialty providers and ANTHEM
PCP providers as it relates to
specialty MH and/or SUD 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 ANTHEM PCPs, other
behavioral health providers and/or
ANTHEM 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
patterns)
c. Treatment of stabilized but
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 SUD will be
treated by a COUNTY provider, ANTHEM
and/or PCP will provide consultation to
COUNTY providers and/or COUNTY staff on
the following topics:
a. Acquiring access to covered
ANTHEM 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
SUD specialty practice.
Exhibit A
Page 10 of 19
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 ANTHEM
PCP’s scope of practice.
3. For those Members who are excluded
from COUNTY services, COUNTY
will provide clinical consultation and
training to the ANTHEM PCPs, and/or
ANTHEM 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
Services.
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 criteria.
2. When EPSDT supplemental criteria
are met, COUNTY is responsible for
arranging and paying for EPSDT
supplemental services provided by
COUNTY specialty MH and SUD
providers.
3. When EPSDT supplemental criteria
are not met, COUNTY will refer
Member children as follows:
a. For MH 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 SUD services, ASAM
criteria will be applied, level
1. When ANTHEM determines that EPSDT
supplemental services criteria are not met
and the Member child’s condition is not CCS
eligible, ANTHEM will refer the Member child
to the PCP for treatment of conditions within
the PCP’s 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. ANTHEM will assist the COUNTY
and Members by providing links to known
community providers of supplemental
services.
3. ANTHEM 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.
Exhibit A
Page 11 of 19
of care will be determined
and a referral to treatment will
be made.
c. When a referral is made, the
COUNTY will notify ANTHEM
of the referral.
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
ANTHEM representatives to ensure
that psychotropic drugs prescribed by
COUNTY providers are included in
the ANTHEM formulary and/or
available for dispensing by ANTHEM
network pharmacies unless otherwise
stipulated by state regulation.
3. COUNTY will inform COUNTY
providers regarding process and
procedure for obtaining prescribed
medications for Members.
4. COUNTY providers will utilize
ANTHEM contracted laboratories for
laboratory tests required for
medication administration and
management of psychotropic
medications.
5. COUNTY will assist ANTHEM in the
utilization review of psychotropic
drugs prescribed by out-of-network
psychiatrists.
6. COUNTY will share with ANTHEM 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.
1. ANTHEM 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 laboratory services.
e. Provide the process for obtaining
timely authorization and delivery of
prescribed drugs and laboratory
services to the COUNTY.
2. ANTHEM 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 ANTHEM
network pharmacies unless otherwise
stipulated by state regulation. (See
Enclosure2, “Drugs Excluded from Plan
Coverage” of Exhibit B)
3. ANTHEM 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 ANTHEM network
pharmacies.
b. ANTHEM will provide Members with
the same drug accessibility written
by out-of-network psychiatrists as in-
network providers.
c. ANTHEM 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. ANTHEM PCPs will monitor the effects and
Exhibit A
Page 12 of 19
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 ANTHEM 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 ANTHEM contract
providers.
1. ANTHEM 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. ANTHEM 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 ANTHEM 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 ANTHEM 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 ANTHEM will work
collaboratively to resolve any formal
grievance or complaint brought to the
attention of either plan.
1. ANTHEM 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. ANTHEM 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 reconsideration and
appeal for denied, modified or
delayed services.
2. COUNTY will ensure that the
Members receive specialty MH and/or
SUD services and prescription drugs
1. ANTHEM will ensure that Members and
providers are given an opportunity for
reconsideration and an appeal for denied,
modified or delayed services
2. ANTHEM will ensure that medically
necessary services continue to be provided
to Members while the dispute is being
resolved. ANTHEM’s appeal process will be
Exhibit A
Page 13 of 19
while the dispute is being resolved.
shared with the COUNTY.
O.
Conflict
Resolution/MOU
Monitoring
1. COUNTY Liaison will meet with the
ANTHEM Liaison to monitor this MOU
quarterly and/or upon request.
a. Within two weeks of a formal
request, COUNTY Liaison will
meet with ANTHEM Liaison
when COUNTY or ANTHEM
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 ANTHEM.
c. COUNTY Liaison will
communicate and coordinate
MOU changes to the State
Department of Health Care
Services (DHCS), COUNTY
service providers and to
ANTHEM and its providers.
2. COUNTY Liaison will participate in an
annual review, update and/or
renegotiations with ANTHEM, as
mutually agreed.
3. COUNTY management will provide
60 days advance written notice to
ANTHEM should the COUNTY decide
to modify this MOU. [Unless
mandated by the Department of
Health Care Services directives, state
mandated requirements and/or
Federal guidelines.]
1. Local ANTHEM liaison will meet with the
COUNTY Liaison to monitor this MOU
quarterly and/or upon request.
a. Within two weeks of a formal
request, ANTHEM Liaison will meet
with the COUNTY Liaison when the
COUNTY or ANTHEM management
identifies problems requiring
resolution through the MOU.
b. ANTHEM Liaison will be responsible
for coordinating, assisting and
communicating suggestions for MOU
changes for to ANTHEM and the
COUNTY leadership.
c. ANTHEM will coordinate and
communicate MOU changes to the
California Department of Health
Care Services (DHCS), COUNTY
providers and ANTHEM network
services providers.
d. ANTHEM 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. ANTHEM Liaison will conduct an annual
review, update and/or renegotiations of this
MOU, as mutually agreed.
3. ANTHEM management will provide 60 day
advance written notice to COUNTY should
ANTHEM decide to modify this MOU.
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
1. ANTHEM 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. ANTHEM 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. ANTHEM 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 ANTHEM or anyone else
including state agencies.
4. ANTHEM will notify COUNTY within 24 hours
Exhibit A
Page 14 of 19
transmitted via email.
4. COUNTY will notify ANTHEM 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.
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.
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 15 of 19
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 16 of 19
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 17 of 19
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 18 of 19
ATTACHMENT A
Medical Necessity For Specialty MH Services That Are The Responsibility Of MH 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 19 of 19
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.
Anthem 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
Anthem 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