If you are under 21 and have Medi-Cal, you have a right to mental health services if you meet certain requirements. These mental health services may include therapy, medication support, case management, day programs, in-home support, crisis support, hospital stays, and other services.

For information on Medi-Cal Specialty Mental Health Services for adults ages 21 and older — Medi-Cal Specialty Mental Health Services Covered by County Mental Health Plans – Adults Ages 21 and Older.

If you get Medi-Cal services through a Managed Care Plan or a fee-for-service provider instead of the county, you still have a right to mental health services. However, Managed Care Plan services are usually not as intensive as county Specialty Mental Health Services (SMHS).

For information on mental health services available through Medi-Cal Managed Care Plans — Medi-Cal Managed Care Plans and Mental Health Services.

What are Medi-Cal Specialty Mental Health Services (SMHS)?

Medi-Cal covers Specialty Mental Health Services (SMHS) through your county’s Mental Health Plan (MHP).1 These services include a wide range of mental health services, which may be provided in the community where you live or in a hospital or other institution. Many of these services are designed to keep you out of the hospital. Some examples of SMHS are: individual and group therapy, medication support, case management, day programs, in-home support, crisis support, and other services. A full list of SMHS is included below.

The county Mental Health Plan (MHP) is part of your county’s mental health or behavioral health department. County employees may provide Specialty Mental Health Services (SMHS) to you directly. Sometimes, the County chooses to contract with another organization to provide the services.2

How do I request Specialty Mental Health Services?

You must request SMHS from your county’s Mental Health Plan (MHP), which your county’s behavioral health department usually runs. You can call the MHP’s access line and ask for an assessment. Visit the California Department of Health Care Services website for a list of MHP access line toll-free telephone numbers by county: https://www.dhcs.ca.gov/individuals/Pages/MHPContactList.aspx.

Another person or organization, including a healthcare provider, a family member, guardian, or school, may also refer you to the county’s MHP for SMHS.3 The MHP may not deny you an initial assessment to determine whether you meet criteria to receive SMHS.

If you are approved for SMHS, you have a right to help create a client plan that you agree to.4 A client plan includes goals, treatment objectives, and proposed interventions related to your mental health needs.

What Specialty Mental Health Services does Medi-Cal cover?

This section provides a full list of Medi-Cal Specialty Mental Health Services (SMHS). If you are approved for SMHS, you may request specific services that you need as part of your treatment plan.5 However, you are not automatically entitled to get all these services. Depending on your situation, you may be approved for one or more of these services:

• Rehabilitative Mental Health Services help people improve, maintain, or restore their daily living skills or social skills.6 These services may include:
  • Mental health services are individual or group therapies meant to reduce a person’s mental health symptoms and improve their ability to function.7
  • Medication support services includes psychiatric medications needed to reduce a person’s mental health symptoms.8
  • Day rehabilitation and day treatment intensive services are therapeutic programs provided in the community as alternatives to hospitals or other restrictive placements. These programs are available for at least 3 hours, but less than 24 hours per day.9
  • Crisis intervention and crisis stabilization are services that require a faster response than if a person requested an appointment. The services may include assessments or therapy, and they can be provided in the community or at facilities like hospitals or clinics.10
  • Crisis residential treatment services are 24/7 services provided in community settings that have 16 beds or less. These services are for people at risk of psychiatric hospitalization or as alternatives to psychiatric hospitalization.11 People ages 18-20 may be eligible for adult residential treatment services, which are like crisis residential treatment services.12
  • Psychiatric health facility services are therapeutic and/or rehabilitative services provided in an inpatient facility (generally locked) with 16 beds or less.13
• Psychiatric inpatient hospital services are psychiatric services provided on an inpatient basis at a hospital.14
• Targeted case management assists people to obtain needed community services, such as medical, educational, or vocational (work) services.15
• Psychiatrist and psychologist services are mental health diagnosis and treatment services that licensed psychiatrists and psychologists provide.16
• Psychiatric nursing facility services are provided to people in certain skilled nursing facilities.17
• EPSDT Services are additional Medi-Cal services for children and youth. These services are not available to people ages 21 and older. EPSDT stands for “Early and Periodic Screening, Diagnosis, and Treatment,” and services may include:18
  • Intensive Care Coordination (ICC) is an intensive form of targeted case management that makes it easier for children and youth to receive assessments, care planning, and coordination of services.
  • Intensive Home-Based Services (IHBS) are services provided in a person’s home that address their mental health symptoms and help them build skills to be successful in the community.
  • Therapeutic Foster Care (TFC) is a short-term service provided that a TFC parent to a child or youth with complex emotional and behavioral needs. This service includes client plan development and rehabilitation services and is provided in a family environment instead of a group environment.
  • Therapeutic Behavioral Services (TBS) is a short-term service focused on one or two behaviors for children and youth with complex behavioral health needs. It can help people learn ways to reduce challenging behaviors, or to develop new skills that will promote their success.

What are the criteria for getting Specialty Mental Health Services?

You have a right to SMHS if they are: (1) medically necessary and (2) you meet certain requirements relating trauma or a mental health disability, called “access criteria.”19

What is medically necessary?

For people on Medi-Cal who are under 21 years of age, SMHS are medically necessary when needed to “correct or ameliorate” a mental health condition.20

SMHS do not need to cure a mental health condition. Mental health services are medically necessary if they support, improve, or make more tolerable a mental health condition.21

What are the access criteria?

People on Medi-Cal who are under 21 can access SMHS if they meet requirements (1) or (2), below.22 Take note that a specific mental health diagnosis is not necessary to qualify for SMHS.23

(1) You have a condition that places you at high risk for a mental health disorder due to trauma. A person can show that they experienced trauma by (1) scoring high on a trauma screening tool,24 (2) involvement in the child welfare system, (3) juvenile justice involvement, or (4) experiencing homelessness.25

OR

(2) You meet both requirements in (a) and (b), below:

a) You have at least one of the following:

1. A significant impairment.
2. A reasonable likelihood of getting worse in an important area of life.
3. A reasonable likelihood of not making appropriate developmental progress.
4. A need for SMHS that a Medi-Cal managed care plan is not required to provide. A Medi-Cal managed care plan is a health plan for people who have low income.

AND

b) Your condition as described in (2)(a), above, is caused by one of the following:

1. A diagnosed mental health disorder, based on the Diagnostic and Statistical Manual of Mental Disorders (DSM) and the International Statistical Classification of Diseases and Related Health Problems (ICD).
2. A suspected mental health disorder that has not yet been diagnosed.
3. Significant trauma placing you at risk of a future mental health condition, based on the assessment of a licensed mental health professional.

If you meet the criteria in (1), above, you meet criteria for SMHS. You do not have to prove that you also meet the criteria in (2), above.

How long will I have to wait for a Specialty Mental Health Services appointment?

MHPs must provide SMHS to you when you need them.26 This means that you cannot be placed on a waitlist for services. This is called “Timely Access.” It also means that you cannot be told to call back later because all the appointment slots are filled. You should at least be assessed for services.

The Timely Access rules for different kinds of appointments are listed here:

Urgent Appointment27	Within 48 hours of requesting an appointment if prior authorization from the MHP is not required. Within 96 hours if prior authorization is required. An appointment is urgent if, without immediate help, your condition is highly likely to result in a psychiatric emergency.28
Non-Urgent Non-Physician Mental Health Care Provider Appointment29	Within 10 business days of requesting appointment.
Non-Urgent Psychiatrist Appointment30	Within 15 business days of requesting appointment.

Sometimes, the wait times for appointments may be longer. For example, this can happen when your doctor thinks that waiting longer will not negatively affect your health.31 Your wait time may also be longer if you are getting preventive care or regular follow-up care.32

How far will I have to travel to get my Specialty Mental Health Services?

MHPs must make sure that you are able to get services close to where you live. This is called the “Time and Distance Standard.” Time and Distance Standards vary depending on the county where you live. For outpatient SMHS, such as Mental Health Services, Targeted Case Management, Crisis Intervention, and Psychiatrist Services,33 the Time and Distance Standards are listed here:34

• No more than 15 miles and 30 minutes from your home if you live in one of these counties: Alameda, Contra Costa, Los Angeles, Orange, Sacramento, San Diego, San Francisco, San Mateo, and Santa Clara.
• No more than 30 miles and 60 minutes from your home if you live in one of these the counties: Marin, Placer, Riverside, San Joaquin, Santa Cruz, Solano, Sonoma, Stanislaus, and Ventura.
• No more than 45 miles and 75 minutes from your home if you live in one of these counties: Amador, Butte, El Dorado, Fresno, Kern, Kings, Lake, Madera, Merced, Monterey, Napa, Nevada, San Bernardino, San Luis Obispo, Santa Barbara, Sutter, Tulare, Yolo, and Yuba.
• No more than 60 miles and 90 minutes from your home if you live in one of these counties: Alpine, Calaveras, Colusa, Del Norte, Glenn, Humboldt, Imperial, Inyo, Lassen, Mariposa, Mendocino, Modoc, Mono, Plumas, San Benito, Shasta, Sierra, Siskiyou, Tehama, Trinity, and Tuolumne.

MHPs can also choose to provide some services by telehealth. Telehealth includes services over the phone or through video.35 However, you have the right to have an in-person appointment if you want one, and telehealth can only be used when it is medically appropriate.36

What if I am unhappy with my Specialty Mental Health Services? What if my MHP denies, reduces, or stops my services?

If you are unhappy with your services or your provider, you can file a grievance.

If your MHP denies, reduces or stops services that you believe you should get, you can file an appeal.

For more information about how to file an MHP Grievance or Appeal, see DRC’s Publication, County Mental Health Plan (MHP) Grievances, and Fair Hearings.

You can also ask your provider or the MHP for information about how to file a grievance or an appeal. They should provide you with the information you need.

• 1. Cal. Welf. & Inst. Code §§ 14680(b), 14684(a)(6)-(7); 9 Cal. Code Regs. § 1810.345(a).
• 2. See 9 Cal. Code Regs. §§ 1810.435, 1810.436(a).
• 3. 9 Cal. Code Regs. § 1810.405.
• 4. 9 Cal. Code Regs. §§ 1810.205.2, 1810.440(c).
• 5. 9 Cal. Code Regs. §§ 1810.205.2, 1810.440(c).
• 6. 9 Cal. Code Regs. §§ 1810.243, 1810.243.1.
• 7. 9 Cal. Code Regs. § 1810.227.
• 8. 9 Cal. Code Regs. § 1810.225.
• 9. 9 Cal. Code Regs. §§ 1810.212, 1810.213.
• 10. 9 Cal. Code Regs. §§ 1810.209, 1810.210.
• 11. 9 Cal. Code Regs. §§ 1810.203, 1810.208. Note that the Medicaid “IMD exclusion” prohibits federal funding for services provided to residents (who are not 65 years or older) of mental health and substance use disorder facilities with more than 16 beds. 42 U.S.C. §§ 1396d(a)(B), 1396d(i).
• 12. 9 Cal. Code Regs. § 1810.203.
• 13. 9 Cal. Code Regs. § 1810.237.
• 14. 9 Cal. Code Regs. § 1810.238.
• 15. 9 Cal. Code Regs. § 1810.249.
• 16. 9 Cal. Code Regs. §§ 1810.240, 1810.241.
• 17. 9 Cal. Code Regs. § 1810.239.
• 18. 9 Cal. Code Regs. § 1810.215. These additional benefits were obtained through a settlement agreement in Katie A. v. Bontá, (Case No. CV-02-056662 JAK [SHx]). See National Health Law Program, Katie A. v. Bonta, Executive Summary (September 22, 2020); National Health Law Program, Meeting the Moment: Understanding EPSDT and Improving Implementation in California to Address Growing Mental Health Needs (January 6, 2021); (September 17, 2021); DHCS Medi-Cal Manual for ICC, IHBS, and TFC (January 2018).
• 19. See Dept. of Health Care Services, Behavioral Health Information Notice Number 21-073 (December 10, 2021) (“BHIN 21-073”). This new guidance issued in December 2021 took effect on January 1, 2022. It does not apply to two types of Specialty Mental Health Services: psychiatric inpatient hospital stays and psychiatric health facility services. If you have questions about Medi-Cal coverage for either of these types of services, contact DRC.
• 20. 42 U.S.C. § 1396d(r)(5).
• 21. See Centers for Medicare & Medicaid Services, A Guide for States: Coverage in the Medicaid Benefit for Children and Adolescents (June 2014) at 10.
• 22. BHIN 21-073 at 4-5; Cal. Welf. & Inst. § 14184.402(d).
• 23. Cal. Welf. & Inst. § 14184.402(f)(1)(A).
• 24. The Pediatric ACEs and Related Life-Events Screener (PEARLS) tool is one example of a standard way of measuring trauma for those under age 19. The Adverse Childhood Experiences (ACEs) Questionnaire is one example of a standard way of measuring trauma for adults starting at age 18.
• 25. These terms are further defined in BHIN 21-073 at 8-9.
• 26. 9 Cal. Code Regs. § 1810.405.
• 27. 28 Cal. Code Regs. §§ 1300.67.2.2(c)(5)(A), (B).
• 28. 9 Cal. Code Regs. § 1810.253.
• 29. 28 Cal. Code Regs. §§ 1300.67.2.2(c)(5)(C), 1300.67.2.2(c)(5)(E).
• 30. 28 Cal. Code Regs. § 1300.67.2.2(c)(5)(D).
• 31. 28 Cal. Code Regs. § 1300.67.2.2(c)(5)(G).
• 32. 28 Cal. Code Regs. § 1300.67.2.2(c)(5)(H).
• 33. See Dept. of Health Care Services, Behavioral Health Information Notice Number 22-033(June 24, 2022) at 25 (“BHIN 22-033”).
• 34. See BHIN 22-033, Attachment B, Time and Distance Standards.
• 35. See BHIN 23-018, Updated Telehealth Guidance for Specialty Mental Health Services and Substance Use Disorder Treatment Services in Medi-Cal(April 2023).
• 36. BHIN 22-033 at 30.