Title 22 Drug Medi-Cal Frequently Asked Questions (FAQs)
Q1: Is it true that only a dependence diagnosis qualifies a client for Drug Medi-Cal (DMC) service?
A1: A substance use dependence or abuse diagnosis, as described within the Diagnostic and Statistical Manual of Mental Disorders Third Edition–Revised or Fourth Edition, may be used by physicians when establishing the medical necessity of substance use treatment services.
Q2: For reimbursement purposes, is the admission date the California Alcohol and Drug Data Systems (CADDS) date or the date of the first service?
A2: Title 22 Section 51341.1 (b) (1) specifies, “Admission to treatment date” means the date of the first face to face treatment service, as described in Subsection (d) of this regulation, rendered by the provider to the beneficiary.
As of June 30, 2006, CADDS was replaced with California Outcomes Measurement System Treatment (CALOMS Tx) as the mechanism for reporting client data. The admission date entered into CALOMS is the date that the client’s treatment services began. It is not used to determine reimbursement by DMC, although it may coincide with a DMC reimbursable service.
Q3: Can we admit to treatment under DMC a teenager who has been expelled from school for having a “pipe” but denies that he is a drug user? His mother states that he has used marijuana. The teenager is Medi-Cal qualified. Will our monitors recoup monies if they provide services to this teenager?
A3: The client must clearly have a substance use dependence or abuse diagnosis as defined by the DSM code at the time of the treatment episode.
For a provider to receive reimbursement for DMC substance abuse services, those services shall be provided by and under the direction of a physician and the admission criteria as outlined in Title 22 Section 51341.1 (h)(1)(A)(B)(C)(D) must be followed.
Specifically, the client must be DMC eligible, have a history of substance abuse and medical necessity must be established by a licensed physician.
Q4: If a treatment plan is not completed, are the services billable?
A4: No. All treatment plan requirements described in Title 22 Section 51341.1 (h) (2) must be met for a provider to receive reimbursement for Drug Medi-Cal substance abuse services.
Q5: If the treatment plan is completed late, would we still be able to bill for services?
A5: Yes; however, services billed prior to the treatment plan completion date would be disallowed.
Q6: Can we bill for the following services for Outpatient Drug Free (ODF), Narcotic Treatment Programs (NTP) and Daycare Habilitative (DCH), if they are performed by the case manager?
· Client Assessment
· Treatment Plan Development
· Collateral Services
· Crisis Sessions
A6: Title 9, Chapter 8, Subchapter 2 Sections 13010 and 13015, outlines the certification requirements for individuals providing counseling services in AOD Recovery and Treatment Programs (this includes ODF, NTP and DCH modalities). All persons providing counseling services must be a licensed professional, registered or certified counselor as defined in this chapter.
Q7: Can we bill the client for the paperwork charting for a group or is the service billable only for the time of the group?
A7: No. Title 22 only allows for reimbursement of DMC funds for counseling provided to the beneficiary, i.e. group and individual counseling sessions. The provider’s administrative costs are inclusive in the DMC rates. Therefore, the provider cannot bill the beneficiary for administrative services.
Q8: The definition of a collateral service on page 1 Exhibit 1, of Title 22, Section 51341.1, states, “Collateral services”, means face to face sessions with the therapists or counselors and significant persons in the life of a beneficiary, focusing on the treatment needs of the beneficiary in terms of supporting the achievement of the beneficiary's treatment goals. Significant persons are individuals that have a personal, not official or professional, relationship with the beneficiary.”
It does not state the client has to be present.
A8: Correct. A collateral service is the only individual treatment session for Non-Narcotic Treatment modalities (ODF, DCH and Perinatal residential) for which a face to face with the client is not required.
Q9: What is the length of time that the M.D. has to sign the six months Continuation of Treatment Authorization?
A9: Pursuant to Title 22 Section 51341.1 (h )(5) (A) (i), the continuation of treatment authorization must be signed no sooner than 5 months and no later than 6 months from the beneficiary's admission to treatment date or the date of the most recent (last) justification for continuing services.
Q10: Do substance abuse programs have to do anything other than notify Medi- Cal beneficiaries of their right to a fair hearing, as specified in Title 22 Section 51341.1 DMC substance abuse services section (p)?
A10: No. Title 22 Section 51341.1 (p) (1) (A-F) (2) outlines the entire process that the provider must follow concerning the beneficiaries fair hearing rights.
For your information, Title 22 Section 50953 outlines the State Hearing Procedure that will be followed during the actual fair hearing. To access this section, please go to www.calregs.com.
Q11: Where within Title 22 does it say how much a DMC beneficiary may be charged in fees?
A11: Language regarding specific fee amounts to be assessed on the beneficiary for health care services is not covered in Title 22. The beneficiary’s share of cost is determined through the Medi-Cal eligibility screening process. The provider should check with their local county social services office for beneficiary specific share of cost information.
Pursuant to Title 22, the provider is to accept proof of Medi-Cal as payment in full, except when a share of cost applies as outlined below.
Title 22 Section 51341.1(h) (7) states, “Except where share of cost, as defined in Section 50090, is applicable, providers shall accept proof of eligibility for Drug Medi-Cal as payment in full for treatment services rendered. Providers shall not charge fees to beneficiaries for access to Drug Medi-Cal substance abuse services or for admission to a Drug Medi-Cal Treatment slot.”
Section 50090 states, “Share of cost means a person’s or family’s net income in excess of their maintenance need that must be paid or obligated toward the cost of health care services before the person or family may be certified and receive Medi-Cal cards.”
Q12: Can you tell me if there is a limit on the number of individual counseling sessions we can bill DMC for?
A12: No. There is no limit to the number of individual counseling sessions that can be provided in an ODF modality. However, individual sessions are limited to the 5 exceptions that are listed in Title 22 Section 51341.1 (d) (2) (B). Any counseling services provided must be medically necessary and documented in accordance with Title 22.
Title 9 Section 10345, Counseling Services in Maintenance Treatment, does not specifically state a limit for individual counseling in an NTP modality; however, ADP Bulletin #12-09 found on ADP’s website limits reimbursement to NTP providers for up to 200 minutes of counseling per calendar month, per beneficiary, under methadone services only. Counseling is individual and/or group.
Q13: I understand that for group counseling the group size must be between 4 and 10 and one participant must be a Medi-Cal beneficiary. Is this correct?
A13: Pursuant to Title 22 Section 51341.1 (b)(8), group counseling sessions for outpatient drug free treatment services and narcotic treatment programs shall have no less than four (4) and no more than ten (10) clients at the same time, only one of whom needs to be a Medi-Cal beneficiary.
Q14: How many group counseling sessions can a client receive in a month? Return to Top
A14: Title 22 does not state any maximum limits for group sessions for ODF, DCH and Perinatal Residential treatment modalities. Pursuant to Title 22 Section 51341.1 (h)(4)(A), For outpatient drug free, day care habilitative, perinatal residential or Naltrexone treatment services, a beneficiary shall be provided a minimum of two (2) counseling sessions per thirty (30) day period except when the provider determines that:
(i) Fewer beneficiary contacts are clinically appropriate; and
(ii) The beneficiary is progressing toward treatment plan goals.
Title 9 Section 10345, Counseling Services in Maintenance Treatment, does not specifically state a maximum limit for group counseling in an NTP modality; however, ADP Bulletin #12-09 found on ADP’s website limits reimbursement to NTP providers for up to 200 minutes of counseling per calendar month, per beneficiary, under methadone services only. Counseling is individual and/or group.
Q15: Are we able to bill the beneficiaries for their room and board outside of treatment costs?
A15: No. Under the DMC program, Perinatal residential substance abuse treatment is reimbursable pursuant to Title 22 Section 51341.1 (d) (4) (c). Room and board shall not be reimbursed through the DMC program. Room and board can be paid through client fees, county funds or other funding sources and grants available.
Q16: I understand that each adult patient or client entering our program for substance and alcohol abuse services must have a physical examination or show documented proof of a physical examination. Does this apply to adolescents? Secondly, what should the program do if a patient or client declines or states they do not want a physical examination?
A16: Title 22 Section 51341.1 (h) (1) (A ) (iii), requires the provider to complete an assessment of the physical condition of each client within 30 days of admission. This requires either a physical examination of the client or a physician’s waiver which specifies the basis for not requiring a physical examination. This applies to all DMC clients.
The client must comply with this provision if DMC benefits are to be paid. Physicals can only be waived by a medical physician based on the criteria set forth in Title 22 Section 51341.1 (h) (1) (A) (iii) (b).
For NTPs, a physical examination must be conducted by the program physician. There is no waiver option with this modality.
Q17: Is a woman who has a still born birth considered to be post partum for 60 days? I've looked up the definition of "Postpartum" in Title 22 Sections 50260 and 50262.3a. It only mentions "pregnant women" or women with children and doesn't seem to address the postpartum period.
A17: Title 22 Section 51341.1(b) (18) outlines the definition of “postpartum” and the eligibility criteria as described in Title 22 Section 50260, 60-Day Postpartum Services, and it states, “ A pregnant woman who was eligible for and received Medi-Cal during the last month of pregnancy, shall continue to be eligible for all pregnancy related and postpartum services, for a 60-day period beginning on the last day of pregnancy, regardless of whether the other conditions of eligibility are met. Eligibility for this program ends on the last day of the month in which the 60th day occurs.”
Q18: Please explain second service same day treatment requirements.
A18: Title 22 Section 51490.1 (d) (1), Claims Submission Requirements for Counties and Providers of Drug Medi-Cal Substance Abuse Service, outlines the requirements and documentation necessary to be reimbursed for a second day service.
1. A Multiple Billing Override Certification (Form ADP 7700) must be completed and retained in the patient record to substantiate the multiple services.
2. The progress note must contain a statement that the return did not create a hardship on the client and that every effort was made to provide all necessary services during one visit, or
3. If the return visit is a crisis or collateral visit the return documentation is not necessary.
4. The additional unit of service is allowed if the return visit is to the same provider and the return visit is not a duplicate to or the same as the previously provided service on the same day.
5. For Daycare Habilitative services, the return visit shall be a crisis. Crisis services shall be documented in the progress notes.
Please review this section of the regulation for all of the requirements.
Q19: Can the primary counselor record the progress notes when group counseling was conducted by someone else?
A19: Yes. Title 22 Section 51341.1 (h)(3)(A) requires “…the counselor shall record a progress note…,” it is not specific as to which counselor that should be. Title 9, Chapter 8, Subchapter 2 Sections 13010 and 13015, outline the certification requirements for individuals providing counseling services in AOD Recovery and Treatment Programs.
All persons providing counseling services must be a licensed professional, registered or certified counselor as defined in this chapter. Additionally, progress notes must be an accurate reflection of what took place in the counseling session.
Q20: Are there other funding sources to assist or enhance DMC funding for services to be provided to clients with co-occurring disorders?
A20: Local funding maybe different in each county. Talk to your County representative about your specific funding needs.
Return to Top