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SMART - State Management Advisory and Response Team

Medi-Cal Day Treatment FAQs

(Updated 7/25)

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Q1.   Assessment window: if a child is admitted to day treatment without a recent assessment, is an assessment “window” available to establish the service necessity, as in Coordinated Care?
 
A1.  Consistent with their contract, mental health plans (MHPs) have the authority and responsibility to establish timeframes for assessments. MHPs are required to provide initial authorization for day treatment services and prior authorization for day treatment services that exceed five days per week. If providers initiate services prior to obtaining authorization from the MHP, they could be at risk for the cost of providing those services in the event the beneficiary does not meet medical necessity criteria or the MHP determines that the beneficiary does not need day treatment because another level of care is more appropriate to achieve the goals of his/her client plan. MHPs could be at risk, depending on their contractual agreements with the providers, if the MHPs authorize services, and then discover the beneficiary does not meet medical necessity or that day treatment is not the appropriate intervention. Providers should work with MHPs to agree upon time frames, notification processes, assessment requirements, and documentation that are required by the MHP for initial authorization to occur. MHPs retain the authority to require prior authorization for all day treatment services.
 

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Q2.  Staff available to the milieu: is this requirement met if staff is in the milieu room but working individually with a child? On site (in another room) but working with one child or awaiting a need for their intervention?
 
A2.  Day treatment staff must be available where and when day treatment therapeutic milieu is being provided and available to respond to the needs of the group. At least one staff person must be available to the group in the therapeutic milieu. Staff in the milieu room working with an individual beneficiary would be considered staff available to the milieu. Staffing ratios must be maintained. Staff on site, but in another room working with one client or waiting for the need for intervention would not be considered staff available to the milieu.

If a beneficiary requires such a high degree of one-to-one interaction that staffing ratios are jeopardized or that other day treatment beneficiaries do not have access to the staff, the day treatment program may not be appropriate to meet the needs of the beneficiary and other interventions should be considered. The provision of day treatment is an interactive process. Day treatment staff should not be simply awaiting a need to intervene. Staff should be actively involved the entire time the day treatment program is in operation providing therapeutic interventions to the group. It is reasonable to anticipate that one beneficiary might require additional attention at some time; however, the day treatment staff should use the milieu environment to support the intervention. For example: One beneficiary habitually interferes with other beneficiaries in a group process. The day treatment staff would use the input of the other group members to identify the behavior, to identify why the behavior is problematic and to develop interventions.
 

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Q3.  Continuous hours of operation: if staff is fully integrated into a classroom during academic instruction, may the school day hours be counted as part of the continuous hours? If so, must staff be present in the classroom to be counted as fully integrated?
 
A3.  The hours of the day treatment milieu must be continuous and are not tied to the hours of the setting in which they are provided (e.g., school). The day treatment milieu may operate for a continuous period of time during the school day, but may not be provided in discontinuous "blocks" of time, e.g., two hours in the morning, two hours in the afternoon and one hour after school. The day treatment milieu establishes the hours of operation and must exceed four hours per day for full day programs and be at least three hours per day for half-day programs.

In addition to required hours of operation, full-day programs require an average of three treatment hours and half-day program require an average of two treatment hours per day in the day treatment milieu. The community meeting time is not counted in the required treatment hours, but may be a part of the continuous hours of operation/therapeutic milieu or may be separate. (If the community meeting time is not continuous with the therapeutic milieu, the meeting time would not count toward the required hours of operation for a full-day or half day program.) If day treatment is taking place in a school setting, day treatment staff must be present during day treatment time. In cases where staff members work for both a day treatment program and another program (e.g., school), there must be a clear audit trail which documents that staff time and activities are exclusively allocated to one program at a time. The staff must only be counted in one staffing ratio at a time, i.e., while the staff is working in the day treatment program, the staff may not be counted in the school program staffing ratio and vice-versa.

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 Half Day Program

Full Day Program

Minimum hours of   Operation (continuous therapeutic milieu)

3

More than 4

Minimum average daily hours of service components (psychotherapy, process groups, skill building groups, and adjunctive therapies groups) must be made available

 2

 3

 

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Q4.  Period of stabilization: may service necessity criteria specify a period of stabilization after achieving treatment goals? If so, how long a period of stabilization is reasonable?
 
A4.  There is no set time limit for participation in a day treatment program or in any specialty mental health service. MHPs retain the authority to establish service necessity criteria, which may specify a period of stabilization the MHP establishes as reasonable. Stabilization must be based on the beneficiary’s treatment needs. During the stabilization period, day treatment staff should be actively working with the beneficiary to ensure the beneficiary is ready and prepared for the transition. Documentation should reflect these activities.
 

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Q5.  Length of stay: is there any sort of expectation about how long a client could/should remain in day treatment?
 
A5.  Clinical decisions and determinations to continue or discontinue day treatment or any other specialty mental health service must be based on the individual treatment needs of the beneficiary. MHPs and providers are responsible for monitoring beneficiaries' progress in day treatment to determine when client plan goals have been met and to determine when day treatment should be continued, reduced, or terminated. DMH is not planning to establish guidelines for how long a beneficiary should remain in day treatment.
 

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Q6.  Minimum attendance: must a child be in the milieu for over 50% of the day for billing to be allowed? Or could some of the time be spent in individual services apart from the milieu but not separately billed, or in transitioning to a mainstream classroom?
 
A6.  Beneficiaries are expected to be present in the day treatment program for all scheduled hours of operation of the day treatment program. When a beneficiary is unavoidably absent for some part of the hours of operation, day treatment for an individual beneficiary will only be reimbursed if the beneficiary is present for at least 50% of the hours of the scheduled hours of that day. Individual services may be part of the day treatment program, provided the minimum day treatment requirements are met for the beneficiary. There are no exceptions to these requirements for children being transitioned to a mainstream classroom.
 

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Q7.  Authorization: must a number of service units be authorized, or only the type of service?
 
A7.  Day treatment authorizations must address the total number of days for which the service is authorized. The number of days per week as well as the length of calendar time must be specified. Authorizations which exceed five days a week must be prior authorized by the MHP. Mental health services as defined in Title 9, California Code of Regulations (CCR), Section 1810.227, excluding services to treat emergency and urgent conditions and therapeutic behavioral services, provided to a beneficiary on the same day as day treatment must be prior authorized by the MHP. The MHP must establish that the additional services are medically necessary considering that the beneficiary is also receiving day treatment. The authorization period for the mental health services (as defined above) must identify when reauthorization, if necessary, will be required and cannot exceed the timeframes for authorization of the day treatment program. Generally, authorization of the type of service and the number of units within the authorization period would be the most effective way to achieve these goals. The MHP may use alternate methods, as long as these goals are met.
 

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Q8.  Authorization: how will authorization for day treatment work if the child is placed out of the county and the provider has clients from many counties?
 
A8.  Each MHP must meet the day treatment authorization regulatory and contractual requirements for its beneficiaries.  For beneficiaries who are placed out of county, in accordance with CCR Section 1830.220(4)(A), the MHP of the county of origin is required to make an authorization decision within three working days following the date of receipt of the request for service.  If the MHP of the county of origin needs additional time to make a authorization decision, an extension may be granted up to three working days from the date the additional information is received, or 14 calendar days  from the  receipt of the original Treatment Authorization Request, whichever is less.  Additionally, MHPs and providers are required to comply with the provisions of Senate Bill (SB) 785 regarding the standardized contract, forms, and documentation standards outlined in DMH Information Notice 09-06.
 

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Q9.  Certification: how can certification findings as to program components, corrective actions, etc. be shared with other counties that may send clients to a program?
 
A9.  DMH will work with the California Mental Health Directors Association (CMHDA) to develop a policy and strategy regarding sharing this information. More information will be provided as it becomes available.

MHPs are encouraged to contact DMH Medi-Cal Oversight staff if they have questions about certifications and decertifications. MHPs retain the authority to accept the host MHP’s certification of day treatment programs or to certify programs themselves. MHPs retain the authority to request a written description of the schedule and daily activities and to verify that program descriptions reflect program activities through site visits and chart reviews. DMH and MHPs retain the authority to decertify programs and take disallowances in the event that services provided are inconsistent with the services that are certified.
 

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Q10.  Activities outside program hours: how can required contact with caregivers, travel, documentation, etc. be distinguished from non-day treatment activities such as collateral contacts?
 
A10.  The caregiver contact requirement specific to day treatment is focused on the contact being related to the beneficiary’s progress in day treatment and to support the role of the caregiver in supporting the beneficiary’s treatment goals. Documentation of the contact should be included in the day treatment documentation.

Collateral contacts that are not part of day treatment must be documented in accordance with the documentation requirements of the specific specialty mental health service being provided to the beneficiary. If the collateral contacts are delivered as mental health services that require prior authorization, prior authorization must be obtained. If day treatment staff also deliver collateral or direct services that are not part of the day treatment program, the provider must establish fiscal tracking mechanisms that maintain a clear distinctions between staff time and related resources attributable to the day treatment program and staff time and related resources attributable to other services. For example, the staff may be required to report the actual minutes/hours in each day spent on each type of service.
 

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Q11.  Under what conditions can classroom time be counted towards day treatment time?
 
A11.  Academic educational activities cannot be counted towards day treatment time. There is no prohibition to providing day treatment intensive or day rehabilitation to address the beneficiaries' mental health needs in conjunction with classroom time, so long as the day treatment programs meet the regulatory requirements and the requirements described the MHP Contract, Exhibit A, Attachment 1, Section W.
 

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Q12.  Is it ok for some of the children in the classroom to be in day treatment although some of the other children in the same room are not in day treatment?
 
A12.   When day treatment is integrated with classroom activities, education staff and day treatment staff must work closely to determine how educational subject areas and activities will be integrated with the day treatment program. If students who were not part of the integrated program might be present during the integrated program, education staff would be responsible for assuring that the academic needs of the student who is not participating in day treatment are met. Day treatment staff would be responsible for ensuring that the rights of the participants in the day treatment, e.g., confidentiality, are protected. DMH does not believe this is a treatment configuration that would normally be beneficial to any of the children in the classroom or manageable from a day treatment or education staff point of view.
 

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Q13.  Doesn’t the authorization by the Mental Health Plan (MHP) process usurp the role of the IEP which, by federal and state statute, determines the services a special education eligible child will receive?
 
A13.  No, the authorization by the MHP described in the MHP Contract relates only to Medi-Cal payment for Medi-Cal eligible children. The Individualized Education Plan (IEP) Team process is independent of the Medi-Cal authorization process. As long as the IEP identifies the need for a mental health service and county mental health is the appropriate resource and concurs with the identified need, then county mental health is responsible for ensuring the provision of the identified service.
 

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Q14.  Is it possible to have a temporary waiver of these requirements or an extension of the new day treatment requirements for 26.5-eligible children who have this service on their IEP?
 
A14.  DMH is not planning to issue waivers or extensions.
 

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Q15.  What would be an example of a typical day of three continuous hours of group work for young kids with impulse control problems, rapid mood fluctuations, hyperactivity, and frequent need for individual attention or redirection?
 
A15.  The therapeutic milieu components can be provided while the children are engaged in various activities, as long as the components are made available the required time period during the course of the day treatment.

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Q16: Can Mental Health Plan (MHP) or MHP subcontracted organizational providers charge a fee to Medi-Cal beneficiaries for meals served at day rehabilitation or day treatment intensive program sites during the hours that the program operates?

A16:  Mental Health Plan and MHP subcontracted organizational providers may not bill Medi-Cal beneficiaries or their conservators or otherwise require Medi-Cal beneficiaries to pay a fee for meals served during day rehabilitation or day treatment intensive program hours of operation.