Medi-Cal Managed Care Plans And Mental Health Services

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You can get some mental health services from fee-for-service Medi-Cal or Medi-Cal managed care plans. You can only get certain services from county Mental Health Plans. This publication tells you what services you have to get from the county and about mental health services available from Medi-Cal managed care plans. Managed care is a way to provide and pay for health care. You receive most of your health care from a managed care plan. A managed care plan is an organized network of health care providers that focuses on primary and preventive care. Hospitals, physicians and other health care providers are members of the network. This publication tells you what services you can get. It tells you what to do if you do not agree with the health plan.

Some mental health services are available through fee-for-service Medi-Cal1 providers or Medi-Cal managed care plans, while others are available only through county Mental Health Plans under the Specialty Mental Health Services Waiver.2   Examples of specialty mental health services include intensive day treatment, day care rehabilitation and adult residential treatment services.3 For more information on specialty mental health services see “Getting Medi-Cal Outpatient Specialty Mental Health Services” Publication 5084.01.4

This publication focuses on mental health services available through Medi-Cal managed care plans.

What is a Managed Care Plan?

A managed care plan is a network of health care providers including hospital, doctors, etc… that provide services to its members. You must use the health care providers and facilities within the network in order to receive services, unless it's an emergency. You choose a primary care physician (PCP) who will coordinate your care and refer you to a specialist if needed. This is different from Fee-For Service where you can go to any provider who accepts Medi-Cal.

A managed care plan can be private or public. Public managed care plans include Medi-Cal and Medicare. This publication will focus on Medi-Cal managed care plans.

For more information on Medi-Cal managed care plans see “Medi-Cal Managed Care Health Plans What are they? What do I need to know about them?” What mental health services are Medi-Cal managed care plan required to provide?

Prior to 2014, Medi-Cal recipients in managed care plans received mental health services within the scope of their PCP’s practice, and were referred to Medi-Cal fee-for service providers or to county Mental Health Plans for specialty mental health services. Starting on January 1, 2014, managed care plans became responsible for providing certain outpatient mental health services to persons with mild to moderate impairment of mental, emotional, or behavioral functioning resulting from a mental health disorder as defined in the Diagnostic and Statistical Manual of mental Disorders (DSM), even when those services are outside the PCP’s scope of practice. 

The California Department of Health Care Services (DHCS) issued All Plan Letter (APL) 17-018. This APL discusses the services available to Medi-Cal recipients in managed care plans, and the managed care plans’ responsibility for coordinating mental health services with county Mental Health Plans.

Outpatient mental health services managed care plans must provide are:   

  • Individual and group mental health evaluation and treatment (psychotherapy):
  • Outpatient services to monitor  drug therapy;
  • Outpatient laboratory, drug (there are excluded drugs), supplies and supplements;
  • Psychiatric consultation;
  • Psychological testing to evaluate a mental health condition.5

Conditions identified as relational problems such as couples or family counseling are not covered.

Is there a limit on the amount of treatment I can receive from the managed care plan?

No, so long as it is medically necessary.

What is the medical necessity standard?

There are different medical necessity standards. For children and young adults under the age of 21, managed care plans must provide services necessary to correct or ameliorate a child’s illness or condition.6

For persons 21 years old and older, managed care plans must cover services that are reasonable and necessary to protect life, prevent significant illness or significant disability, or to alleviate severe pain through the diagnosis and treatment of disease, illness or injury.7

Who provides the services?

Psychologist, psychiatrist, Licensed Clinical Social Workers and Marriage and Family Therapists.   Clinical social workers, psychology assistants and MFP interns may also provide services if performed under a supervising clinician.8

What other things can I get from my managed care plan?

You can get:

  • Mental health screenings;
  • Referral to and coordination of care with Mental Health Plans;
  • Case management.

What if my managed care plan denies, reduces, or terminates services?

Beginning July 1, 2017, new federal regulations came into effect that dictate how you appeal a managed care plan’s decision and/or bring other matters to the managed care plan’s attention through a grievance. 

DHCS issued an All Plan Letter (APL) 17-006 on these new procedures. 

Also, see DRC’s “Medi-Cal Managed Care: Appeals and Grievances at”

Other resources:

“National Health Law Program”

 

 

1 If you are on fee-for-service Medi-Cal you can go to any provider who takes Medi-Cal. It also means that you are not enrolled in a Medi-Cal managed care plan. – (Return to main document)

2 Welfare & Institutions Code § 14189 – (Return to main document)

3 9 C.C.R  1810.247 – (Return to main document)

4 Also see: Clarification on Mental Health Plan Responsibility for Providing Medi-Cal Specialty Mental Health Services to Beneficiaries Enrolled in  Medi-Cal Managed Care Plans(Return to main document)

5 APL 17-018 p. 6; Welf. & Inst. Code 14132.03 – (Return to main document)

6 42 USC § 1396d(r)(5); 22 CCR §§ 51340 and 51340.1 – (Return to main document)

7 APL 17-018 p. 7 – (Return to main document)

8 See: Medi-Cal Provider Manual  and scroll down to Psychological Services (psychol). Best to open the zip file. – (Return to main document)

 

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