Services Overview:Mental Health/Substance Use Disorders Programs and Managed Care Plans

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Medi-Cal Managed Care Plans Medi-Cal Managed Care Plans (MCP)(MCP)

Medi-Cal Managed Care Plans Medi-Cal Managed Care Plans (MCP)(MCP)

County Mental Health Plan County Mental Health Plan (MHP)(MHP)

County Mental Health Plan County Mental Health Plan (MHP)(MHP)

Outpatient Services Mental Health Services (assessments plan

development, therapy, rehabilitation and collateral)

Medication Support Day Treatment Services and Day

Rehabilitation Crises Intervention and Crises Stabilization Targeted Case Management Therapeutic Behavior Services

Residential Services Adult Residential Treatment Services Crises Residential Treatment Services

Inpatient Services Acute Psychiatric Inpatient Hospital

Services Psychiatric Inpatient Hospital Professional

Services Psychiatric Health Facility services

Target Population for mental health services: Children and adults in Managed Care Plans who meet medical necessity or EPSDT for Mental Health ServicesFor SBIRT: all members 18 years and older

Target Population: Children and adults who meet medical necessity or EPSDT criteria for Medi-Cal Specialty Mental health Services

County Alcohol and Other County Alcohol and Other Drug Programs (AOD)Drug Programs (AOD)

County Alcohol and Other County Alcohol and Other Drug Programs (AOD)Drug Programs (AOD)

Outpatient ServicesOutpatient Drug FreeIntensive Outpatient (newly expanded to additional populations) Residential Services (newly expanded to additional populations) Narcotic Treatment ProgramNaltrexone

New Services

Inpatient Detoxification Services(Administrative linkage to County AOD still being discussed)

Target Population: Children and adults who meet medical necessity or EPSDT criteria for Drug Medi-Cal Substance Use Disorder Services

MCP services to be carved-in effective 1/1/14

Individual/group mental health evaluation and treatment (psychotherapy)

Psychological testing when clinically indicated to evaluate a mental health conditioncondition

Outpatient services for the purposes of Outpatient services for the purposes of monitoring medication treatmentmonitoring medication treatment

Psychiatric consultation

Outpatient laboratory, medications, supplies and supplements

Screening, Brief Intervention and Referral to Treatment (SBIRT)

Screening Assessments Referrals Care Coordination Case Management

Services Overview: Expanded Mental Health Benefits Managed Care Plans (APL 13-021)Effective January 1, 2014, eligible Medi-Cal beneficiaries may receive mental health benefits through Medi-Cal Managed Care Plans (MCPs). •MCP/FFS* Mental Health Services:

• Individual and group mental health evaluation and treatment (psychotherapy)

• Psychological testing when clinically indicated to evaluate a mental health condition

• Outpatient services for the purposes of monitoring drug therapy • Outpatient laboratory, drugs, supplies and supplements• Psychiatric consultation

*Fee for Service benefits if not enrolled in an MCP.

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Eligibility for MCP Coverage:Mild to Moderate Impairment in Functioning

 

A member is covered by the MCP for services if the he or she is diagnosed with a mental health condition as defined by the current DSM resulting in mild to moderate distress or impairment of mental, emotional, or behavioral functioning (those who do not qualify for Specialty Mental Health Services --SMHS):

•Primary care providers identify the need for a mental health screening and refer to a specialist within their network.

•Upon assessment the mental health specialists can determine the level of impairment and refer members with significant impairment to the MHP for a SMHS assessment. Members may also contact the MCP for a referral to a mental health provider within the MCP network. When a member’s condition improves under SMHS and the mental health providers in the MCP and MHP coordinate care, the member may return to the MH provider in the MCP network. Note: Conditions that the current DSM identifies as relational problems are not covered, i.e. couples counseling or family counseling.

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Eligibility for SMHS:Significant Impairment in Functioning

• Has an included mental health diagnosis; • Has a significant impairment in an important area of life function, or a

reasonable probability of significant deterioration in an important area of life function, or a reasonable probability of not progressing developmentally as individually appropriate;

• The focus of the proposed treatment is to address the impairment(s) described in #2;

• The expectation that the proposed treatment will significantly diminish the impairment, prevent significant deterioration in an important area of life function, and

• The condition would not be responsive to physical health care based treatment.

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Note: For members under age 21 who meet criteria for EPSTD specialty mental health services, the criteria allow for a range of impairment levels and include treatment that allows the child to progress developmentally as individually appropriate.

MCP-MHP Relationship• The MCP and MHP must make a good faith effort to develop an

Memorandum of Understanding (MOU), including the elements defined in APL 13-018.

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Covered Services and Populations

Oversight Responsibilities of the MCP and the MHPScreening, Assessment, and Referral (including an agreed -upon assessment tool)Care Coordination

Information Exchange

Reporting and Quality Improvement Requirements

Dispute Resolution

After-Hours Policies and ProceduresMember and Provider Education