Medi-Cal Specialty Mental Health Services Covered by County Mental Health Plans – Adults Ages 21 and Older

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Medi-Cal Specialty Mental Health Services Covered by County Mental Health Plans – Adults Ages 21 and Older

You can get mental health services through Medi-Cal. You can get them through fee-for-service or managed care plans. In addition, you can get Medi-Cal mental health services through county mental health plans. This pub tells you about county mental health plan services.

If you have health insurance through Medi-Cal, medically-necessary mental health services are a covered benefit for you. Some mental health services are available through your Medi-Cal Managed Care Plan or fee-for-service Medi-Cal providers. Other mental health services are available only through County Mental Health Plans (MHPs). Mental health services provided by MHPs are called Medi-Cal Specialty Mental Health Services. This publication focuses on Medi-Cal Specialty Mental Health Services (SMHS) for adults ages 21 and older.

For more information on mental health services available through Medi-Cal Managed Care Plans see Publication 5609.01 – Publication #5609.01 – Medi-Cal Managed Care Plans and Mental Health Services.

What are Medi-Cal Specialty Mental Health Services?

SMHS are a variety of services covered by Medi-Cal and provided by county MHPs and agencies that contract with them. Generally, SMHS are more intensive and provide more support than the mental health services that are covered by a Managed Care Plan. A complete list of covered SMHS is provided below.

SMHS are provided to Medi-Cal beneficiaries through county MHPs.1  MHPs are part of county mental health or behavioral health departments.  SMHS may be provided by employees of the county, or employees of agencies that the county contracts with to provide the services.2

When you are accepted to receive SMHS, you are entitled to have a client plan that you help make and that you agree to.3 A client plan includes goals and treatment objectives related to your mental health needs and the proposed intervention to be provided. 

What Specialty Mental Health Services are covered by Medi-Cal?

Under the Medi-Cal rules, the following Specialty Mental Health Services are covered if you meet the access and medical necessity criteria described below.4 If you are approved for Specialty Mental Health Services, you are not automatically entitled to get all of these services. Depending on your situation, you may be approved for one or more of these services.

  • Rehabilitative Mental Health Services are services that help Medi-Cal beneficiaries improve, maintain, or restore their skills in activities of daily living, social functioning, and other areas.5 These services include:
    • Mental health services are individual or group therapies that are designed to help reduce symptoms of mental health disabilities and improve functioning.6
    • Medication support includes services relating to the prescription of psychiatric medications to reduce the symptoms of mental health disabilities.7
    • Day rehabilitation and day treatment intensive are community-based therapy programs that may be alternatives to hospitalization or more restrictive placements. These programs are available for at least three and less than 24 hours per day.8
    • Crisis intervention and crisis stabilization are services provided for conditions that require a faster response than can be provided at a regularly scheduled appointment. These services can be provided in the community or at facilities like hospitals or clinics.9
    • Adult residential treatment services and crisis residential treatment services are 24/7 services provided in community-based settings that have 16 beds or less. These services are designed to serve Medi-Cal beneficiaries at risk of psychiatric hospitalization or as alternatives to psychiatric hospitalization.10
    • Psychiatric health facility services are therapeutic and/or rehabilitative services provided on an inpatient basis in facilities with 16 beds or less.11
  • Psychiatric inpatient hospital services are psychiatric services provided on an inpatient basis in a hospital.12
  • Targeted case management assists Medi-Cal beneficiaries with accessing needed community services.13
  • Psychiatrist and psychologist services means treatment and diagnosis services provided by licensed psychiatrists and psychologists.14
  • Psychiatric nursing facility services are provided to people in certain skilled nursing facilities.15

What are the criteria for getting Specialty Mental Health Services?

You are entitled to a specialty mental health service if it is: (1) medically necessary and (2) you meet access criteria.16 These requirements are explained below.

What is medically necessary?

For Medi-Cal beneficiaries ages 21 and older, a service is “medically necessary” or a “medical necessity” when it is reasonable and necessary to protect life, to prevent significant illness or significant disability, or to alleviate severe pain.17

How can I meet access criteria?

A specific mental health diagnosis is no longer necessary to qualify for SMHS. If you are 21 or older, you can access SMHS if you meet requirements (1) and (2), below:18

  1. You have at least one of the following:
    1. Significant impairment, where impairment is defined as distress, disability, or dysfunction in social, occupational, or other important activities.
    2. A reasonable probability of significant deterioration in an important area of life functioning.
      AND
  2. Your condition as described under requirement (1), above, is due to either of the following:
    1. 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.
    2. A suspected mental disorder that has not yet been diagnosed.

How do I request Specialty Mental Health Services?

You must request the services from your county’s MHP, which is often part of your county’s behavioral health department. If you are not getting services now, 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.

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

MHPs must provide SMHS to you when you need them.19 This means that you cannot be placed on a waiting list for services. This is called “Timely Access.” It also means that you cannot be told to call back later because all the appointment slots have been filled. You should at least get an assessment of your need for services.

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

Urgent Appointment20 Within 48 hours of requesting appointment if prior authorization 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 emergency21
Non-Urgent Outpatient Mental Health Appointment22 Within 10 business days of requesting appointment.
Non-Urgent Psychiatrist Appointment23 Within 15 business days of requesting appointment.

In some circumstances, wait times for appointments may be longer. For example, this can happen when your doctor or a provider referring you for a service thinks that waiting longer will not negatively affect your health.24 Your wait time may also be longer when you are getting preventive care or regular follow-up care.25

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

MHPs have to 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, including Mental Health Services, Targeted Case Management, Crisis Intervention, and Psychiatrist Services,26 the Time and Distance Standards are listed here:27  

  • Up to 15 miles or 30 minutes from the 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.
  • Up to 30 miles or 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.
  • Up to 45 miles or 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.
  • Up to 60 miles or 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. 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.28

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

If you do not like your services or your provider, you can file a grievance. If your services get changed or you are denied services you believe you should get, you can file an appeal.

For more information about MHP Grievances and Appeals, see DRC’s Publication, County Mental Health Plan (MHP) Grievances, and Fair Hearings: (https://www.disabilityrightsca.org/publications/county-mental-health-pl…). You can also ask your provider, your mental health clinic, or the MHP for information about how to file a grievance or an appeal and they should provide you with the information you need.  

 

Disclaimer: This publication is legal information only and is not legal advice about your individual situation. It is current as of the date posted. We try to update our materials regularly. However, laws are regularly changing. If you want to make sure the law has not changed, contact DRC or another legal office.

  • 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. §§ 1810.205.2, 1810.440(c).
  • 4. 9 Cal. Code Regs. § 1810.247(a).
  • 5. 9 Cal. Code Regs. § 1810.243.1.
  • 6. 9 Cal. Code Regs. § 1810.227.
  • 7. 9 Cal. Code Regs. § 1810.225.
  • 8. 9 Cal. Code Regs. §§ 1810.212, 1810.213.
  • 9. 9 Cal. Code Regs. §§ 1810.209, 1810.210.
  • 10. 9 Cal. Code Regs. §§ 1810.203, 1810.208.
  • 11. 9 Cal. Code Regs. § 1810.237.
  • 12. 9 Cal. Code Regs. § 1810.238.
  • 13. 9 Cal. Code Regs. § 1810.249.
  • 14. 9 Cal. Code Regs. §§ 1810.240, 1810.241.
  • 15. 9 Cal. Code Regs. § 1810.239.
  • 16. See https://www.dhcs.ca.gov/Documents/BHIN-21-073-Criteria-for-Beneficiary-… 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.
  • 17. BHIN 21-073 at 2.
  • 18. BHIN 21-073 at 3-4.
  • 19. 9 Cal. Code Regs. § 1810.405.
  • 20. 28 Cal. Code Regs. §§ 1300.67.2.2(c)(5)(A), (B).
  • 21. 9 Cal. Code Regs. § 1810.253.
  • 22. 28 Cal. Code Regs. § 1300.67.2.2(c)(5)(C).
  • 23. 28 Cal. Code Regs. § 1300.67.2.2(c)(5)(D).
  • 24. 28 Cal. Code Regs. § 1300.67.2.2(c)(5)(G).
  • 25. 28 Cal. Code Regs. § 1300.67.2.2(c)(5)(H).
  • 26. See https://www.dhcs.ca.gov/Documents/BHIN-22-033-2022-Network-Adequacy-Cer… Dept. of Health Care Services, Behavioral Health Information Notice Number 22-033 (June 24, 2022) at 25 (“BHIN 22-033”).
  • 27. See https://www.dhcs.ca.gov/Documents/Attachment-B-Time-and-Distance-Standa… BHIN 22-033, Attachment B, Time and Distance Standards.
  • 28. BHIN 22-033 at 30.

 

 

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