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California Advancing and Innovating Medi-Cal (CalAIM) Reforms

Medical Necessity

Pursuant to Welfare and Institutions Code (WIC) sections 14184.402(d) and (f)(1)(A), a mental health diagnosis is no longer a prerequisite for foster youth to access Specialty Mental Health Services (SMHS), as trauma due to involvement in child welfare or juvenile justice makes children and youth under age 21 eligible for SMHS. These changes are reflected in the California Department of Health Care Services (DHCS) issued Behavioral Health Information Notice (BHIN) 21-073.

Due to these changes to medical necessity, the California Department of Social Services (CDSS) issued the All County Letter No. 24-35. The purpose of ACL 24-35 is to inform county child welfare agencies (CWA), juvenile probation departments (JPD), Tribes with a Title IV-E Agreement with the State, and county mental health plans (MHPs) that there is no longer a requirement for CWAs and JPDs to conduct a mental health screening for the purpose of determining whether to refer a child or youth to MHPs. This change is effective as of July 12, 2024. Further, in lieu of the required mental health screening, CWAs and JPDs must submit referrals to the appropriate MHPs for all children and youth within three business days of opening a child welfare case or juvenile probation placement case, and on an ongoing basis, as determined necessary by the child and family team (CFT) and as informed by the Child Adolescent Needs and Strengths (CANS) tool.

Policy pertaining to Medical Necessity:

  • Welfare and Institutions Code 14059.5
  • ACL 15-11: Recording Developmental and Mental Health Screening, Referral, and Plan Intervention Information in the Child Welfare Services/Case Management System
  • ACL 18-09: Requirements for Implementing the Child and Adolescent Needs and Strengths Assessment Tool Within a Child and Family Team
  • ACL 24-35: Elimination of Required Mental Health Screening and Replacement with Required Referral to County Mental Health Plans for All Children with an Open Child Welfare or Juvenile Probation Placement Case
  • BHIN 20-012: 2020 Federal Network Certification Requirements for County Mental Health Plans (MHPs)
  • BHIN 23-068: Updates to Documentation Requirements for all Specialty Mental Health (SMH), Drug Medi-Cal (DMC), and Drug Medi-Cal Organized Delivery System (DMC-ODS) Services
  • BHIN 21-073: Criteria for Beneficiary Access to Specialty Mental Health Services (SMHS), Medical Necessity and Other Coverage Requirements

Medi-Cal for Kids & Teens

Department of Health Care Services (DHCS) is responsible for providing full-scope early and periodic screenings, diagnostics, and treatment services to Medi-Cal beneficiaries under the age of 21. This Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit is now referred to as Medi-Cal for Kids & Teens.

Medi-Cal managed care plans (MCPs) are responsible for providing Medi-Cal for Kids and Teens, to ensure that children receive early detection, prevention, and treatments for health issues as early as possible.

What Services are Included?

  • Screening services: Health and development history, physical exam, immunizations, laboratory tests, and health education
  • Vision services: Diagnosing and treating any issues with vision
  • Dental services: Relief of pain and infections, restoring teeth, and maintaining dental health. A dental screening/oral health assessment must be performed as part of every periodic assessment
  • Hearing services: Diagnosing and treating hearing issues. This may include the provision of hearing aids

Other EPSDT Services Included

  • Behavioral health treatment that is considered medically necessary and consistent with APL 23-005
  • Case management and care coordination for medically necessary EPSDT services
  • Offering help with scheduling doctor appointments and securing transportation to and from medical appointments for medically necessary EPSDT services

Policy Guidance:

APL 23-005: Requirements for Coverage of Early and Periodic Screening, Diagnostic, and Treatment Services for Medi-Cal Members Under the Age of 21

APL 19-014: Responsibilities for Behavioral Health Treatment Coverage for Members Under the Age of 21

EPSDT Manual: Benefit, Coverage, and Medical Necessity Policy Information

Screening and Transition Tools

DHCS developed standardized Cal-AIM Screening and Transition Tools for both adults and individuals under 21 years old for use by MHPs and MCPs to determine the appropriate delivery system(s) for members who are not currently receiving mental health services when they contact the MCP or MHP seeking mental health services. In addition, DHCS developed a standardized Transition of Care Tool to ensure that Medi-Cal members receive timely and coordinated care when completing a transition of services to the other delivery system or when adding a service from the other delivery system to their existing mental health treatment. These tools went live on January 1, 2023.

Policy Guidance:

APL 22-028: Adult and Youth Screening and Transition of Care Tools for Medi-Cal Mental Health Services

BHIN 22-065: Adult and Youth Screening and Transition of Care Tools for Medi-Cal Mental Health Services

No Wrong Door

DHCS released Behavioral Health Information Notice No: 22-011, that introduced the No Wrong Door policy to ensure that Medi-Cal beneficiaries receive timely mental health services without delay regardless of the delivery system where they seek care, and that beneficiaries are able to maintain treatment relationships with trusted providers without interruption.

Policy Guidance:

APL 22-005: No Wrong Door for Mental Health Services Policy

CalAIM: No Wrong Door for Mental Health Services Practical Guide to Key Implementation Scenarios (August 2022)

References:

BHIN 22-011. (2022, March 31). Department of Health Care Services. Retrieved June 14, 2024, from https://www.dhcs.ca.gov/Documents/BHIN-22-011-No-Wrong-Door-for-Mental-Health-Services-Policy.pdf

California Advancing and Innovating Medi-Cal (CalAIM) OVERVIEW: Behavioral Health Payment Reform. (2022). Department of Health Care Services. Retrieved June 14, 2024, from

CalAIM Behavioral Health Initiative Frequently Asked Questions. (2024). DHCS. Retrieved June 14, 2024, from https://www.dhcs.ca.gov/Pages/CalAIM-BH-Initiative-FAQ-No-Wrong-Door-And-Co-Occurring-Treatment.aspx

Difficult Bi Design. (n.d.). The Promises and Possibilities of California’s Bifurcated Mental Health System. https://cachildrenstrust.org/wp-content/uploads/2024/05/CCT-Bifurcated-Promises-Possibilities.pdf

Frequently asked questions. (2024). DHCS. Retrieved June 14, 2024, from https://www.dhcs.ca.gov/Pages/Screening-and-Transition-of-Care-Tools-FAQ.aspx

Medi-Cal for Kids and Teens. (2024). DHCS. Retrieved June 5, 2024, from https://www.dhcs.ca.gov/services/Medi-Cal-For-Kids-and-Teens/Pages/home.aspx

Medi-cal's foster care strategies. (2022, November). DHCS. Retrieved July 17, 2024, from https://www.dhcs.ca.gov/Documents/DHCS-Medi-Cal-Foster-Care-Strategies-11-22-2022.pdf

Medi-Cal Manual. (2018). For Intensive Care Coordination (ICC), Intensive Home Based Services (IHBS), and Therapeutic Foster Care (TFC) Services for Medi-Cal Beneficiaries. https://www.dhcs.ca.gov/Documents/ChildrensMHContentFlaggedForRemoval/Manuals/Medi-Cal_Manual_Third_Edition.pdf

Mental health and foster care. (2019, November 1). National Conference of State Legislatures. Retrieved July 15, 2024, from https://www.ncsl.org/human-services/mental-health-and-foster-care

MHSUDS Information Notice 18-059. (2018, December 17). Department of Health Care Services. Retrieved from https://www.dhcs.ca.gov/services/MH/Documents/Information%20Notices/IN_18-059_Continuity_of_Care/MHSUDS_Information_Notice_18-059_Continuity_of_Care.pdf

Myers, C., Lam, N. (n.d). Foster youth access to Medi-Cal specialty mental health services: A review of policies, procedures, and beneficiary-facing materials in the California counties with the largest foster care populations. National Health Law Program. https://healthlaw.org/wp-content/uploads/2023/09/CA-Foster-Youth-SMHS-Document-Review-Report.pdf

Provider Information. (2024). DHCS. Retrieved June 5, 2024, from https://www.dhcs.ca.gov/services/Medi-Cal-For-Kids-and-Teens/Pages/Provider-Information.aspx

Screening and Transition of Care Tools for Medi-Cal Mental Health Services. (2024). DHCS. Retrieved June 14, 2024, from https://www.dhcs.ca.gov/Pages/Screening-and-Transition-of-Care-Tools-for-Medi-Cal-Mental-Health-Services.aspx