Code Section Group

Welfare and Institutions Code - WIC

DIVISION 9. PUBLIC SOCIAL SERVICES [10000 - 18999.8]

  ( Division 9 added by Stats. 1965, Ch. 1784. )

PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15771]

  ( Part 3 added by Stats. 1965, Ch. 1784. )

CHAPTER 8.8. Medi-Cal Management: Alternative Methods [14600 - 14685.1]

  ( Chapter 8.8 added by Stats. 1981, Ch. 102, Sec. 133. )

ARTICLE 5. Mental Health Managed Care [14680 - 14685.1]
  ( Article 5 heading added by Stats. 1995, Ch. 91, Sec. 187. )

14680.
  

(a) The Legislature finds and declares that there is a need to establish a standard set of guidelines that governs the provision of managed Medi-Cal specialty mental health services at the local level, consistent with federal law.

(b) Therefore, in order to ensure quality and continuity, and to efficiently utilize mental health services under the Medi-Cal program, there shall be developed mental health plans for the provision of those services that are consistent with guidelines established by the department. The guidelines shall be consistent with federal Medicaid requirements and the approved Medicaid state plan and waivers to ensure full and timely federal reimbursement to mental health plans for services that are rendered and reimbursed consistent with federal Medicaid requirements.

(c) It is the intent of the Legislature that mental health plans be developed and implemented regardless of whether other systems of Medi-Cal managed care are implemented.

(d) It is further the intent of the Legislature that Sections 14681 to 14685, inclusive, shall not be construed to mandate the participation of counties in Medi-Cal managed mental health care plans.

(e) This section shall become operative on July 1, 2012.

(Amended (as added by Stats. 2011, Ch. 651, Sec. 10) by Stats. 2012, Ch. 34, Sec. 236. (SB 1009) Effective June 27, 2012. Section operative July 1, 2012, by its own provisions.)

14681.
  

The department shall ensure that all contracts for Medi-Cal managed care include a process for screening, referral, and coordination with any mental health plan established, of medically necessary specialty mental health care services.

(Amended by Stats. 2012, Ch. 34, Sec. 237. (SB 1009) Effective June 27, 2012. Operative July 1, 2012, by Sec. 254 of Ch. 34.)

14682.1.
  

(a) The State Department of Health Care Services shall be designated as the state agency responsible for development, consistent with the requirements of Section 4060, and implementation of, mental health plans for Medi-Cal beneficiaries.

(b) The department shall convene a steering committee for the purpose of providing advice and recommendations on the transition and continuing development of the Medi-Cal mental health managed care systems pursuant to subdivision (a). The committee shall include work groups to advise the department of major issues to be addressed in the managed mental health care plan, as well as system transition and transformation issues pertaining to the delivery of mental health care services to Medi-Cal beneficiaries, including services to children provided through the Early and Periodic Screening, Diagnosis, and Treatment Program.

(c) The committee shall consist of diverse representatives of concerned and involved communities, including, but not limited to, beneficiaries, their families, providers, mental health professionals, substance use disorder treatment professionals, statewide representatives of health care service plans, representatives of the California Behavioral Health Planning Council, public and private organizations, county behavioral health directors, and others as determined by the department. The department has the authority to structure this steering committee process in a manner that is conducive for addressing issues effectively, and for providing a transparent, collaborative, meaningful process to ensure a more diverse and representative approach to problem-solving and dissemination of information.

(Amended by Stats. 2017, Ch. 511, Sec. 32. (AB 1688) Effective January 1, 2018.)

14683.
  

The department shall ensure all of the following:

(a) That mental health plans include a process for screening, referral, and coordination with other necessary services, including, but not limited to, health, housing, and vocational rehabilitation services. For Medi-Cal eligible children, the mental health plans shall also provide coordination with education programs and any necessary medical or rehabilitative services, including, but not limited to, those provided under the California Children’s Services Program (Article 5 (commencing with Section 123800) of Chapter 3 of Part 2 of Division 106 of the Health and Safety Code) and the Child Health and Disability Prevention Program (Article 6 (commencing with Section 124025) of Chapter 3 of Part 2 of Division 106 of the Health and Safety Code), and those provided by a fee-for-service provider or a Medi-Cal managed care plan. This subdivision shall not be construed to establish any higher level of service from a county than is required under existing law. The mental health plan shall not be liable for the failure of other agencies responsible for the provision of nonmental health services to provide those services or to participate in coordination efforts.

(b) That mental health plans include a system of outreach to enable Medi-Cal beneficiaries and providers to participate in and access Medi-Cal specialty mental health services under the plans, consistent with existing law.

(c) That standards for quality and access developed by the department in consultation with the steering committee established pursuant to Section 14682.1 are included in mental health plans serving Medi-Cal beneficiaries.

(Amended by Stats. 2012, Ch. 34, Sec. 240. (SB 1009) Effective June 27, 2012. Operative July 1, 2012, by Sec. 254 of Ch. 34.)

14684.
  

(a) Notwithstanding any other provision of state law, and to the extent permitted by federal law, mental health plans, whether administered by public or private entities, shall be governed by the following guidelines:

(1) State and federal Medi-Cal funds identified for the diagnosis and treatment of mental illness shall be used solely for those purposes. Administrative costs incurred by counties for activities necessary for the administration of the mental health plan shall be clearly identified and shall be reimbursed in a manner consistent with federal Medicaid requirements and the approved Medicaid state plan and waivers. Administrative requirements shall be based on and limited to federal Medicaid requirements and the approved Medicaid state plan and waivers, and shall not impose costs exceeding funds available for that purpose.

(2) The development of the mental health plan shall include a public planning process that includes a significant role for Medi-Cal beneficiaries, family members, mental health advocates, providers, and public and private contract agencies.

(3) The mental health plan shall include appropriate standards relating to quality, access, and coordination of services within a managed system of care, and costs established under the plan, and shall provide opportunities for existing Medi-Cal providers to continue to provide services under the mental health plan, as long as the providers meet those standards.

(4) Continuity of care for current recipients of services shall be ensured in the transition to managed mental health care.

(5) Medi-Cal covered specialty mental health services shall be provided in the beneficiary’s home community, or as close as possible to the beneficiary’s home community. Pursuant to the objectives of the rehabilitation option described in subdivision (a) of Section 14021.4, mental health services may be provided in a facility, a home, or other community-based site.

(6) Medi-Cal beneficiaries whose mental or emotional condition results or has resulted in functional impairment, as defined by the department, shall be eligible for covered specialty mental health services. Emphasis shall be placed on adults with serious and persistent mental illness and children with serious emotional disturbances, as defined by the department.

(7) Mental health plans shall provide specialty mental health services to eligible Medi-Cal beneficiaries, including both adults and children. Specialty mental health services include Early and Periodic Screening, Diagnosis, and Treatment Services to eligible Medi-Cal beneficiaries under the age of 21 pursuant to 42 U.S.C. Section 1396d(a)(4)(B) of Title 42 of the United States Code.

(8) Each mental health plan shall include a mechanism for monitoring the effectiveness of, and evaluating accessibility and quality of, services available. The plan shall utilize and be based upon state-adopted performance outcome measures and shall include review of individual service plan procedures and practices, a beneficiary satisfaction component, and a grievance system for beneficiaries and providers.

(9) Each mental health plan shall provide for culturally competent and age-appropriate services, to the extent feasible. The mental health plan shall assess the cultural competency needs of the program. The mental health plan shall include, as part of the quality assurance program required by Section 14725, a process to accommodate the significant needs with reasonable timeliness. The department shall provide demographic data and technical assistance. Performance outcome measures shall include a reliable method of measuring and reporting the extent to which services are culturally competent and age-appropriate.

(b) This section shall become operative on July 1, 2012.

(Amended (as added by Stats. 2011, Ch. 651, Sec. 12) by Stats. 2012, Ch. 34, Sec. 241. (SB 1009) Effective June 27, 2012. Section operative July 1, 2012.)

14684.1.
  

(a) The department shall establish a process for second level treatment authorization request appeals to review and resolve disputes between mental health plans and hospitals.

(b) When the department establishes an appeals process, the department shall comply with all of the following:

(1) The department shall review appeals initiated by hospitals and render decisions on appeals based on findings that are the result of a review of supporting documents submitted by mental health plans and hospitals.

(2) If the department upholds a mental health plan denial of payment of a hospital claim, a review fee shall be assessed on the provider.

(3) If the department reverses a mental health plan denial of payment of a hospital claim, a review fee shall be assessed on the mental health plan.

(4) If the department decision regarding a mental health plan denial of payment upholds the claim in part and reverses the claim in part, the department shall prorate the review fee between the parties accordingly.

(c) The amount of the review fees shall be calculated and adjusted annually. The methodology and calculation used to determine the fee amounts shall result in an aggregate fee amount that, in conjunction with any other outside source of funding for this function, may not exceed the aggregate annual costs of providing second level treatment authorization request reviews.

(d) Fees collected by the department shall be retained by the department and used to offset administrative and personnel services costs associated with the appeals process.

(e) The department may use the fees collected, in conjunction with other available appropriate funding for this function, to contract for the performance of the appeals process function.

(Amended by Stats. 2012, Ch. 34, Sec. 242. (SB 1009) Effective June 27, 2012. Operative July 1, 2012, by Sec. 254 of Ch. 34.)

14685.1.
  

Section 14685 is hereby repealed on November 7, 2012, if Section 36 has been added to Article XIII of the California Constitution as of that date.

(Added by Stats. 2012, Ch. 34, Sec. 244. (SB 1009) Effective June 27, 2012.)

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