Section 14184.402 - Medically necessary determinations for covered specialty mental health services and substance use disorder services; nonspecialty mental health services coverage(a) Notwithstanding any other law, including, but not limited to, the applicable provisions of Chapter 11 (commencing with Section 1810.100) of Division 1 of Title 9, and Chapter 3 (commencing with Section 51000) of Subdivision 1 of Division 3 of Title 22, of the California Code of Regulations, commencing no sooner than January 1, 2022, all medically necessary determinations for covered specialty mental health services and substance use disorder services provided by a Medi-Cal behavioral health delivery system shall be made in accordance with Section 14059.5, except as provided in this section and any written instructions issued by the department pursuant to subdivision (j) until such time that regulations are promulgated or amended.(b)(1) Subject to subdivision (f) of Section 14184.102, the following nonspecialty mental health services shall be covered by a Medi-Cal managed care plan, or available through the Medi-Cal fee-for-service delivery system for beneficiaries not enrolled in a Medi-Cal managed care plan or for services that are carved out from a Medi-Cal managed care plan's comprehensive risk contract:(A) Individual and group mental health evaluation and treatment, including psychotherapy, family therapy, and dyadic services.(B) Psychological testing, when clinically indicated to evaluate a mental health condition.(C) Outpatient services for the purposes of monitoring drug therapy.(D) Psychiatric consultation.(E) Outpatient laboratory, drugs, supplies, and supplements.(2) Covered nonspecialty mental health services for adult beneficiaries with mild-to-moderate distress or mild-to-moderate impairment of mental, emotional, or behavioral functioning resulting from mental health disorders, as defined by the current edition of the Diagnostic and Statistical Manual of Mental Disorders, shall be provided by a Medi-Cal managed care plan or through the Medi-Cal fee-for-service delivery system. A Medi-Cal managed care plan shall provide medically necessary nonspecialty mental health services to enrolled beneficiaries under 21 years of age as required pursuant to Section 1396d(r) of Title 42 of the United States Code. A Medi-Cal managed care plan shall also be responsible for providing covered nonspecialty mental health services to enrolled beneficiaries with potential mental health disorders not yet diagnosed.(c) For enrolled beneficiaries 21 years of age or older, a county mental health plan shall provide covered specialty mental health services for beneficiaries who meet both of the following criteria:(1) The beneficiary has one or both of the following: (A) Significant impairment, where impairment is defined as distress, disability, or dysfunction in social, occupational, or other important activities.(B) A reasonable probability of significant deterioration in an important area of life functioning.(2) The beneficiary's condition as described in paragraph (1) is due to either of the following: (A) A diagnosed mental health disorder, according to the criteria of the current editions of the Diagnostic and Statistical Manual of Mental Disorders and the International Statistical Classification of Diseases and Related Health Problems.(B) A suspected mental disorder that has not yet been diagnosed.(d) For enrolled beneficiaries under 21 years of age, a county mental health plan shall provide all medically necessary specialty mental health services required pursuant to Section 1396d(r) of Title 42 of the United States Code. Covered specialty mental health services shall be provided to enrolled beneficiaries who meet either of the following criteria: (1) The beneficiary has a condition placing them at high risk for a mental health disorder due to experiencing trauma evidenced by scoring in the high-risk range under a trauma screening tool approved by the department, involvement in the child welfare system, juvenile justice involvement, or experiencing homelessness.(2) The beneficiary meets both of the following requirements:(A) The beneficiary has at least one of the following:(i) A significant impairment.(ii) A reasonable probability of significant deterioration in an important area of life functioning.(iii) A reasonable probability of not progressing developmentally as appropriate.(iv) A need for specialty mental health services, regardless of presence of impairment, that are not included within the mental health benefits that a Medi-Cal managed care plan is required to provide.(B) The beneficiary's condition as described in subparagraph (A) is due to one of the following: (i) A diagnosed mental health disorder, according to the criteria of the current editions of the Diagnostic and Statistical Manual of Mental Disorders and the International Statistical Classification of Diseases and Related Health Problems.(ii) A suspected mental health disorder that has not yet been diagnosed.(iii) Significant trauma placing the beneficiary at risk of a future mental health condition, based on the assessment of a licensed mental health professional.(e)(1) Covered services provided under a county Drug Medi-Cal Treatment Program or a Drug Medi-Cal organized delivery system shall use criteria adopted by the American Society of Addiction Medicine to determine the appropriate level of care for substance use disorder treatment services.(2) Covered services provided under a county Drug Medi-Cal Treatment Program or a Drug Medi-Cal organized delivery system shall include all medically necessary substance use disorder services for an individual under 21 years of age as required pursuant to Section 1396d(r) of Title 42 of the United States Code.(3) A full assessment utilizing the criteria adopted by the American Society of Addiction Medicine shall not be required for a beneficiary to begin receiving services through a Drug Medi-Cal Treatment Program or a Drug Medi-Cal organized delivery system.(f)(1) This section and Section 14059.5 shall not be construed to exclude coverage for, or reimbursement of, a clinically appropriate and covered mental health or substance use disorder prevention, screening, assessment, treatment, or recovery service under any of the following circumstances: (A) Services were provided prior to determining a diagnosis.(B) The prevention, screening, assessment, treatment, or recovery service was not included in an individual treatment plan.(C) The treated Medi-Cal beneficiary has a co-occurring mental health condition and substance use disorder.(D) For a provider who provides specialty mental health services to a Medi-Cal beneficiary under a contract between the department and a county mental health plan when that beneficiary concurrently receives nonspecialty mental health services from a Medi-Cal managed care plan or under the Medi-Cal fee-for-service delivery system, if those services are coordinated between the specialty and nonspecialty delivery systems and those services are not duplicative.(E) For a provider who provides nonspecialty mental health services to a Medi-Cal beneficiary pursuant to a comprehensive risk contract with a Medi-Cal managed care plan or under the Medi-Cal fee-for-service delivery system when that beneficiary concurrently receives specialty mental health services from a county mental health plan, if those services are coordinated between the nonspecialty and specialty delivery systems and those services are not duplicative.(2) This section and Section 14059.5 shall not be construed to exclude clinically appropriate and covered mental health or substance use disorder services during the assessment process.(g) A dispute between a county mental health plan and a Medi-Cal managed care plan shall not delay the provision of medically necessary services by the county mental health plan or the Medi-Cal managed care plan.(h)(1) The department shall develop, in consultation with county behavioral health directors, consumer advocates, labor organizations representing county behavioral health workers, mental health and substance use disorder treatment providers, and Medi-Cal managed care plans, standardized screening tools to guide a referral to a Medi-Cal behavioral health delivery system. The department shall develop a standardized screening tool for Medi-Cal beneficiaries who are under 21 years of age and a separate standardized screening tool for those who are 21 years of age or older. The department may require the use of these standardized screening tools by Medi-Cal behavioral health delivery systems and Medi-Cal managed care plans.(2) The department shall develop, in consultation with county behavioral health directors, consumer advocates, labor organizations representing county behavioral health workers, mental health and substance use disorder treatment providers, and Medi-Cal managed care plans, standardized statewide transition tools to ensure that Medi-Cal beneficiaries requiring transition between delivery systems receive timely coordinated care. The department shall develop a standardized statewide transition tool for Medi-Cal beneficiaries who are under 21 years of age and a separate standardized statewide transition tool for those who are 21 years of age or older. The department may require the use of these standardized statewide transition tools.(3) The department shall develop, in consultation with county behavioral health directors, consumer advocates, labor organizations representing county behavioral health workers, and mental health and substance use disorders treatment providers, documentation standards and changes to the department's clinical auditing standards. The department may require the use of these documentation standards by Medi-Cal behavioral health delivery systems, including, but not limited to, restrictions developed in consultation with representatives of Medi-Cal behavioral health delivery systems on what Medi-Cal behavioral health delivery systems impose on their contract providers, consistent with Medi-Cal managed care plans and taking into account the need to ensure quality and program integrity and to address equity and disparities.(i)(1) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department, without taking any further regulatory action, shall implement, interpret, and make specific this section and the associated CalAIM terms and conditions by means of all-county letters, plan letters, information notices, or similar instructions, until regulations are promulgated or amended in accordance with paragraph (2).(2) Notwithstanding subdivision (d) of Section 14184.102, the department shall promulgate or amend regulations, as necessary, to implement, interpret, and make specific this section and the associated CalAIM terms and conditions in accordance with the requirements of Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code by July 1, 2024.Ca. Welf. and Inst. Code § 14184.402
Added by Stats 2021 ch 143 (AB 133),s 402, eff. 7/27/2021.