Medi-Cal Coverage for Consumers with Mild-to-Moderate Conditions

Memo
Date: May 5, 2014
To: All County and Contracted Alameda County Behavioral Health Care Services Providers
From: Toni Tullys, Deputy Director
RE: Medi-Cal Coverage for Consumers with Mild-to-Moderate Conditions

Under health care reform, mental health services are to be included as an essential health benefit. Beginning on January 1, 2014 Medi-Cal Managed Care Plans (MCPs) and primary care providers are expected to provide mental health services to individuals with mild to moderate impairments. Medi-Cal beneficiaries that meet medical necessity criteria with moderate-severe impairment will be referred to Behavioral Health Care Services (BHCS) for Specialty Mental Health Services.

Alameda County’s Managed Care Plans are Alameda Alliance, Anthem Blue Cross and Kaiser. Alameda Alliance has contracted with Beacon Health Strategies to manage their mental health services for consumers who do not meet the criteria for Specialty Mental Health Services.

Our shared mission is to ensure that Alameda County clients/consumers receive medically necessary behavioral health services in the most appropriate settings based on their diagnosis and level of impairment. BHCS, in collaboration with Beacon Health Strategies, developed Behavioral Health Screening Tools to determine whether a client/consumer should be served by the MCP, Primary Care Provider (PCP) or our Specialty Mental Health Service (SMHS) provider network. The tools have been shared with Kaiser and Anthem Blue Cross in an effort to align this effort across the Managed Care Plans. All callers to BHCS ACCESS are currently screened using one of the Behavioral Health Screening Tools to determine if a referral to the Managed Care Plan or Specialty Mental Health is appropriate. Those callers with mild to moderate impairments are being referred to their MCP.

Brief Guide to Expanded Medi-Cal Coverage for Consumers with Mild-to-Moderate Conditions
  1. What are the new Behavioral Health Benefits under Medi-Cal Expansion? For Medi-Cal beneficiaries with Mild-to-Moderate conditions the Medi-Cal Managed Care Plans (MCPs) expanded benefits include: individual and group therapy, psychiatric consultation, outpatient psychiatric services, psychological testing when clinically indicated to evaluate a mental health condition, and outpatient laboratory/medications/supplies and supplements.
     
  2. Who is providing these new benefits? MCPs and primary care providers. The MCPs in Alameda County are Alameda Alliance, Anthem Blue Cross and Kaiser. Alameda Alliance has contracted with Beacon Health Strategies, who is responsible for managing all of Alameda Alliance’s mental health services for consumers who do not meet the criteria for Specialty Mental Health Services.
     
  3. Are there any changes to the County Mental Health Plan (MHP) for Specialty Mental Health Services (SMHS)? Yes, the County MHP remains the carve-out for SMHS but under the Affordable Care Act we will only be serving clients with Moderate-to-Severe conditions. These are the individuals that the County has historically been responsible for and treated. The County also remains responsible for alcohol and substance use treatment.
     
  4. Who should use the screening tool? All providers should use the tool and its algorithm to “pre-screen” intake telephone calls or drop-ins. If you determine that a consumer does not meet SMHS criteria, they should be referred back to their MCP or PCP. It is recommended that if the client meets the criteria for SMHS, a copy of the screening tool be kept with their chart. Additionally, providers should use the tool to justify and support client transitions from your program(s) to MCPs. Always be sure to review/discuss with the client/consumer and family prior to making a referral. ACCESS Supervisors are available to consult with mental health providers if you are unsure if the client meets criteria for SMHS. Jane Tzudiker (Child Team) can be reached at 510-346-1042 and Jon Stenson (Adult Team) can be reached at 510-346-1077.
     
  5. I am not sure if some of the clients/consumers I am currently serving meet SMHS criteria. What should I do? In general most currently served beneficiaries are in the appropriate level of care. As SMHS treatment goals are met, the need for continued services at the current level of care should be evaluated by the provider. Providers are expected to utilize the BHCS Screening Tools to determine if beneficiaries no longer meet SMHS criteria and should be referred to their MCP. Providers should continue to serve the client during the transition to the MCP and document as needed.
     
  6. What are the contact numbers for Medi-Cal MCPs?
    • Alameda Alliance/ Beacon: (855) 856-0577
    • Kaiser: (510) 752-1075
    • Anthem Blue Cross: (888) 831-2246

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  7. What happens when a Medi-Cal Beneficiary calls their MCP to request Mental Health (MH) services? The MCP will complete a telephone screening to determine the level of the MH condition. If mild to moderate criterion are met, they will do the following:
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