​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​CalAIM Behavioral Health Initiative  

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CalAIM is a multi-year initiative by DHCS to improve the quality of life and health outcomes of our population by implementing broad delivery system, program and payment reform across the Medi-Cal program. The behavioral health components of CalAIM are designed to support whole-person, integrated care; move the administration of Medi-Cal behavioral health to a more consistent and seamless system by reducing complexity and increasing flexibility; and improve quality outcomes, reduce health disparities, and drive delivery system transformation and innovation through improvements to behavioral health policies and the launch of behavioral health payment reform.

​Download the factsheet about the CalAIM initiative to advance Behavioral Health. 

For more information about the technical assistance and training for the CalAIM behavioral health initiatives, please reference the CalAIM Behavioral Health 2022 Technical Assistance and Training Overview​​​.​

Criteria for Specialty Mental Health Services 

​DHCS will update and clarify the responsibilities of specialty mental health plans, including updates to the criteria for access to specialty mental health services, both for adults and beneficiaries under age 21.  These criteria were developed and improved based on significant feedback from stakeholders. The goal of these changes is to improve beneficiaries’ access to services and reduce provider administrative burdens.

Resources​

​​Drug Medi-Cal Organized Delivery System Policy Improvemen​ts​​

​Under CalAIM, DHCS proposes to update and improve the Drug Medi-Cal Organized Delivery System (DMC-ODS), based on experience from the first several years of implementation, in order to improve beneficiary care and administrative efficiency. DHCS proposed to the Centers for Medicare and Medicaid Services (CMS) a set of updates to DMC-ODS, some of which CMS approved for the January – December 2021 extension period and others which will be effective January 2022, pending CMS approval. This includes the following proposed policy changes: 

• ​Treatment is reimbursable during the assessment period prior to diagnosis​
• The criteria for receiving SUD treatment services (medical necessity) is met by an SUD diagnosis from a licensed provider -- no authorization is required for nonresidential services 
• The full ASAM assessment must be completed within 30 days of the start of treatment in nonresidential settings (60 days for under 21 years of age, or experiencing homelessness), and the ASAM assessment is used to determine the appropriate level of care 
  
• A physician history, physical exam and determination of opioid addiction is sufficient to determine eligibility for Narcotic Treatment Program (NTP) services​
  
• All DMC-ODS providers must offer or arrange referral for medications for addiction treatment (also known as medication-assisted treatment or MAT)
• Residential treatment is no longer restricted to two episodes per year​
  
• Clarifying ASAM 0.5 services are reimbursable for beneficiaries under 21 (early intervention services)​
  
• Clarifying the availability of recovery services, including that individuals leaving incarceration with a known SUD are eligible for recovery services immediately upon release, regardless of length of incarceration and whether treatment was received during incarceration, as are individuals receiving MAT  
• ​Expanding physician consultation to other licensed clinicians (e.g. e-consult)
• Covering Contingency Management services for stimulant use disorder, offered by counties that opt into the pilot
• ​Adding Peer Support Services delivered by a certified Peer Support Specialist as a reimbursable service
• Including Traditional Healers and Natural Helpers to deliver culturally appropriate care for American Indian and Alaska Native individuals with SUD

For additional information on the DMC-ODS program, please refer to the Drug Medi-Cal Organized Delivery System​.

Timeline (Subject to Change)

Resources

Drug Medi-Cal ASAM Level of Care Determination​

To align access to SUD service delivery across the state, DHCS will issue guidance establishing that the ASAM Criteria be used to determine the appropriate level of care for covered SUD treatment services in both DMC-ODS counties and DMC State Plan counties. ​

Timeline (Subject to Change)

Updated Reasons for Recoupment

As highlighted below, DHCS is simplifying behavioral health documentation standards to remove outdated requirements and align standards across physical and behavioral health. To facilitate transition to the new documentation standards (effective July 1, 2022), DHCS will revise the audit protocols and reasons for recoupment, limiting recoupment to findings of fraud, waste and abuse.

Timeline (Subject to Change)

Behavioral Health Documentation Redesign ​

​DHCS will streamline behavioral health documentation requirements for substance use disorders and specialty mental health services (SMHS) and align with national standards. DHCS will remove the requirement to have a point-in-time treatment plan and the requirement that each chart note tie to the treatment plan. DHCS will also remove the requirement for clients to sign the treatment plan. Instead, DHCS will use problem lists to allow active and ongoing updates of a client’s evolving clinical picture, with progress notes reflecting the care given, aligning with the appropriate billing codes. 

​Informational Webinar 

​​May 26, 2022

• 3:00-4:00pm
  
• ​Agenda​ ​
• Presentation​
  
• Recording 
  

Timeline (Subject to Change)

No Wrong Door​ & Co-Occurring Treatment​

DHCS will implement a “no wrong door" policy to ensure beneficiaries receive mental health services regardless of the delivery system where they seek care (via County Behavioral Health, Medi-Cal Managed Care Plan, or the Fee for Service delivery system). This policy would allow beneficiaries who directly access a treatment provider to receive an assessment and mental health services, and to have that provider reimbursed for those services by their contracted plan, even if the beneficiary is ultimately transferred to the other delivery system due to their level of impairment and mental health needs. In certain situations, beneficiaries may receive coordinated, non-duplicative services in multiple delivery systems, such as when a beneficiary has an ongoing therapeutic relationship with a therapist or psychiatrist in one delivery system while requiring medically necessary services in the other.

DHCS seeks to clarify that patients with co-occurring mental health and substance use disorder conditions may be treated by providers in each of the behavioral health delivery systems, as long as the covered services are not duplicative and meet specified requirements for contracting and claiming. ​

Technical Assistance Webinar

June 9, 2022

• ​3:00-4:00pm
  
• Agenda ​
  
• Presentation​
  
• Recording​
  

Informational Webinar

April 28, 2022

• 3:00-4:00pm
  
• ​Agenda 
• ​Presentation ​
  
• Recording​ 
  

​Timeline (Subject to Change)

Standardized Screening & Transition Tools ​of Care Tools 

Informational Webinar

July 28, 2022

• ​3:00-4:00pm
  
• Agenda
• Presentation​ ​
  

Resources

• ​Screening & Transition Tools Stakeholder Woking Group Rosters ​
  

Behavioral Health Payment Reform​

Background

Through realignment efforts in 1991 and 2011, funding for the majority of the non-federal share of costs associated with the specialty mental health and substance use disorder (SUD) services became the responsibility of the counties. Currently, counties are reimbursed for these programs via Medicaid Certified Public Expenditure (CPE) methodologies. Under the CPE structure, reimbursements to counties are limited to costs incurred by the counties and are subject to a lengthy and labor-intensive cost reconciliation process.  The CalAIM Behavioral Health Payment Reform initiative seeks to move counties away from cost-based reimbursement to enable value-based reimbursement structures that reward better care and quality of life for Medi-Cal beneficiaries.

Payment reform will transition counties from cost-based reimbursement funded via CPEs to fee-for-service reimbursement funded via Intergovernmental Transfers (IGTs), eliminating the need for reconciliation to actual costs.  As part of payment reform, specialty mental health and SUD services will transition from existing Healthcare Common Procedure Coding System (HCPCS) Level II coding to Level I coding, known as Current Procedural Terminology (CPT) coding, when possible. ​

Timeline (Subject to Change)

​

Administrative Integration of Specialty Mental Health and Substance Use Disorder Services​

Background

Medi-Cal specialty mental health and substance use disorder (SUD) treatment services are currently administered through separate, unique structures at the county level, which creates many challenges for beneficiaries, counties and providers. DHCS is proposing administrative integration of specialty mental health and SUD services into one behavioral health managed care program. This proposal is distinct from the CalAIM Full Integration Plan proposal which would integrate physical, behavioral, and oral health care into comprehensive managed care plans. The goal is to improve outcomes for beneficiaries through coordinated treatment across the continuum of care. An additional goal and benefit would be to reduce administrative and fiscal burdens for counties, providers, and the state.

This initiative is a multi-year effort that begins with the implementation of other CalAIM behavioral health policies, starting in 2022, including Criteria for Mental Health Services, the DMC-ODS Policy Improvements and Behavioral Health Payment Reform. DHCS aims to submit for a single, integrated behavioral health plan in each county or region responsible for providing, or arranging for the provision of, specialty mental health and SUD services under the next 1915(b) waiver, effective in January 2027. Both state-level and county-level activities will be required to achieve this goal.

Timeline (Subject to Change)

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