California Children’s Services Whole-Child Model Program

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#7132.01
This pub tells you about the Whole Child Model Program. This program is for children getting CCS (California Children’s Services) and Medi-Cal. Not all counties will have this program. The pub tells you if your child will keep the same services and doctors if they are in the program. If the program denies your child a service, the pub tells you what to do.

The California Legislature authorized the Department of Health Care Services (DHCS) to establish the Whole-Child Model program. This program will incorporate California Children’s Services (CCS) program covered services into Medi-Cal managed care plans. It means that all CCS and non-CCS services will be authorized or provided by the Medi-Cal managed care plan. Whole-Child Model program will be implemented in 21 counties, no sooner than July 1, 2018.1

This publication discusses the Whole-Child Model program. Note: this publication is for CCS eligible children and youth who have full-scope Medi-Cal2 through a Medi-Cal managed care plan and county that are participating in the Whole-Child Model.

1. What is CCS?

CCS is a state program for children and young adults under 21 years old with certain eligible health conditions such as infectious diseases, diseases of the nervous system and eye.  Through this program, they get the healthcare they need for their CCS eligible condition.3

There is a large percentage of CCS eligible children and young adults who have Medi-Cal.4  Of those who have Medi-Cal, many are enrolled in a Medi-Cal managed care plan.  Some children only have CCS.

Currently, children who have CCS and are in a Medi-Cal managed care plan get specialty care for their CCS condition in a fee-for-service (FFS) system.5  They get primary and some behavioral care through their Medi-Cal managed care plan.  This means that children receive care through multiple separate systems.

The primary goals of the Whole-Child Model program is to “[provide] comprehensive treatment and [focus] on the whole-child, including the child’s full range of needs rather than only on the CCS health condition.6

2. What counties and Medi-Cal managed care plans are participating in the Whole-Child Model program7?

Starting July 1, 2018 (three plan and six counties):

CenCal Health in San Luis Obispo and Santa Barbara counties.

Health Plan of San Mateo in San Mateo County.

​Central California Alliance for Health in Merced, Monterey and Santa Cruz counties.

Starting January 1, 2019 (two plans and fifteen counties):

Partnership HealthPlan of California in Del Norte, Humboldt, Lake, Lassen, Marin, Mendocino, Modoc, Napa, Siskiyou, Shasta, Solano, Sonoma, Trinity and Yolo counties.

CalOptima in Orange County.

3. How will I know if my child will be transitioned into the Whole-Child Model program?

Your child will receive notices 90, 60 and 30 days before the change.8  The Medi-Cal managed care plan will also contact you.9

4. I live in Modoc County. My child has CCS but does not have full-scope Medi-Cal. Will my child be enrolled the Whole-Child Model program?

No.  In order to participate in the Whole-Child Model program, your child must have full scope Medi-Cal.1o  Your child will continue to receive CCS services as she or he has in the past.

5. My child has CCS but not Medi-Cal Managed care. Will her CCS be affected?

No. CCS State-Only children and children with Medi-Cal and other health coverage will continue to receive services the way they do today11.  CCS services for children who do not have Medi-Cal will continue to be on a FFS basis.12

6. Once on the Whole Child Model program, will my child’s CCS benefits change?

No. Your child will continue to have the same benefits provided by CCS paneled providers, specialty care centers, pediatric acute care hospitals, pharmacy and other services, as long as they are medically necessary.13

7. Can my child continue to see his CCS doctor and specialists?

Your child can keep the same CCS doctor and specialists if this they are in the Medi-Cal managed care’s network of providers.  If not, then your child can see these doctors for up to 12 months after moving into the Whole-Child Model program.14  The 12-month period can be extended under certain circumstances.

8. Will there be any changes to the CCS program in counties and Medi-Cal managed care plans that are not participating in the Whole-Child Model program?

No.

9. With respect to my child’s CCS services, what will be the Medi-Cal managed care’s responsibilities?

Your child’s Medi-Cal managed care plan will approve services, provide case management and coordinate CCS services.15  Some CCS administrative functions, that are currently the responsibility of county CCS programs, will move to the Medi-Cal managed care plans.  These functions include clerical and claims support and reimbursing providers for CCS-related services.16

The county CCS program will continue to be responsible for Medical Therapy Unit services.17

10. Will local county CCS offices be responsible for anything under the Whole-Child Model program?

Yes, counties will continue to do CCS eligibility determinations and eligibility appeals18, administer the Medical Therapy Unit program and medical therapy conference services.19

11. What happens if I the Medi-Cal managed care plan denies my child a CCS service?

You can appeal.  Rather than using the CCS appeal process, you will follow the appeals and grievances processes in place that all Medi-Cal managed care plans must follow.  Generally speaking, you can appeal within 60 days from the date of the Notice of Adverse Benefit Determination.  The Medi-Cal managed care plan has 5 calendar days after it gets the appeal that it received it, and has 30 days from the date it got the appeal to let you know of its decision.20  You have 120 from the date of the decision to ask for a state fair hearing. 21   

12. What about the CCS numbered letters22 – will they still apply?

Yes in the sense that they are guidelines.  Service authorization requests that are consistent with a numbered letter guideline should be approved.  However, managed care plans are required to follow the broader and sometimes more expansive scope of benefits for children and youth under federal law.23

 

For legal assistance call 800-776-5746 or complete a request for assistance form. For all other purposes call 916-504-5800 (Northern CA); 213-213-8000 (Southern CA).

Disability Rights California is funded by a variety of sources, for a complete list of funders, go to here.

 

1 Letter from Patricia McClelland, Chief Systems of Care Department of Health Care Division, to County California Children’s Services (CCS) (January 2017) available at County Guidance for CCS Whole-Child Model (WCM) Implementation; See also California Department of Health Care Services, California Children’s Services (CCS) Whole-Child Model (WCM), (Last visited May 29, 2018) California Children's Services (CCS) Whole-Child Model (WCM). – (Return to Main Document)

2 Full scope Medi-Cal means that you are entitled to receive all benefits available under the Medi-Cal program.  Effective May 2016, children under 19 years of age without satisfactory immigration status became eligible for full-scope Medi-Cal benefits.- (Return to Main Document)

3 For more information on CCS see California Children's Services. - (Return to Main Document)

4 For more information see Program Overview.  - (Return to Main Document)

5 FFS means that you can go to any provider who accepts a particular health insurance such as CCS or Medi-Cal. Providers are reimbursed for every visit or service.  Under managed care, the state contracts with health plans to provide services to beneficiaries in exchange for a monthly premium per person enrolled.- (Return to Main Document)

6 California Department of Health Care Services, California Children’s Services Program (CCS) Advisory Group, (Last visited June 11, 2018) California Children's Services (CCS) Advisory Group. – (Return to Main Document)

7 California Department of Health Care Services, California Children’s Services Whole-Child Model Overview, pp. 16-17, (May 18, 2018) California Children's Services Whole Child Model Overview. – (Return to Main Document)

8 Id. at 27.  – (Return to Main Document)

9 California Department of Health Care Services, California Children’s Services Program (CCS) Whole-Child Model Frequently Asked Questions, p. 3, (last updated August 2017) California Children's Services Program (CCS) Whole-Child Model FAQs.  – (Return to Main Document)

10 Id. at 2. The excluded group includes children and youth who do not qualify for Medi-Cal at all or who are 19 or 20 years old and no longer eligible for full-scope Medi-Cal under Welf. & Inst. Code § 14007.8 covering children and youth through age 18 who have not established a satisfactory immigration status.- (Return to Main Document)

11 In County Operated Health Systems like Orange County’s CalOptima, the Partnership Counties and the Health Plan of San Mateo enrollment in Medi-Cal managed care is mandatory for all Medi-Cal beneficiaries with other health care coverage; enrollment in Medi-Cal managed care is voluntary for persons with other health care coverage in the other listed Whole-Child program counties. - (Return to Main Document)

12 Id. at 4.- (Return to Main Document)

13 Id. at 3.- (Return to Main Document)

14 Id. - (Return to Main Document)

15 Id. at 2-3. - (Return to Main Document)

16 Letter from Patricia McClelland, Chief Systems of Care Department of Health Care Division, to County California Children’s Services (CCS) (January 2017) available at County Guidance for CCS Whole-Child Model (WCM) Implementation. - (Return to Main Document)

17 California Department of Health Care Services, California Children’s Services Program (CCS) Whole-Child Model Frequently Asked Questions, p. 9, (last updated August 2017) California Children's Services Program (CCS) Whole-Child Model FAQs. - (Return to Main Document)

18 Letter from Patricia McClelland, Chief Systems of Care Department of Health Care Division, to County California Children’s Services (CCS) (January 2017) available at  County Guidance for CCS Whole-Child Model (WCM) Implementation; California Department of Health Care Services, California Children’s Services Program (CCS) Whole-Child Model Frequently Asked Questions, p. 3, (last updated August 2017) California Children's Services Program (CCS) Whole-Child Model FAQs. - (Return to Main Document)

19 Id. at 5-6.- (Return to Main Document)

20 You can ask for an expedited appeal if your child’s health is at risk. The Medi-Cal managed care plan has 72 hours from the date it got the appeal to let you know of its decision. - (Return to Main Document)

21 California Health and Human Services Agency, Department of Health Care Services, California Children’s Services Whole-child Model Grievance, Appeal and Fair Hearing Process, p. 4-5, (November 2016) California Children's Services (CCS) Whole-Child Model (WCM) Grievance, Appeal, and Fair Hearing Processes; also see our publication on appeals and grievances, available at Medi-Cal Managed Care: Appeals and Grievances. - (Return to Main Document)

22 For more information see California Children's Services - Letters.  - (Return to Main Document)

23 Explanation of Managed Care obligations under EPSDT – Early and Periodic Screening, Diagnostic and Treatment Services for Medi-Cal Beneficiaries under Age 21.  Requirements for Coverage of Early and Periodic Screening, Diagnostic, and Treatment Services for Medi-Cal Beneficiaries Under the Age of Twenty One. - (Return to Main Document)

 

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