What does each phase of Behavioral Health Administrative Integration entail?
To achieve statewide Behavioral Health Administrative Integration in 2027, DHCS will work with counties using a three-phased approach under which different components will be integrated to different degrees at different times. The phased implementation plan was developed to account for the fact that some components can be integrated under existing authorities and counties may already have taken steps to do so, while other components may require action on the part of DHCS, changes to state authorities, or federal approval.
- Phase 1 is focused on voluntary integration of county functions under existing contracts over calendar years 2023 and 2024.
- Phase 2 will focus on voluntary contract integration over calendar years 2025 and 2026 for the counties that volunteer to adopt integrated contracts early, effective January 1, 2025.
- In Phase 3, all counties will be required to adopt integrated contracts effective January 1, 2027, as specified in CalAIM statute (AB 133).
For additional information about each phase of implementation, please see the Behavioral Health Administrative Integration
Concept Paper.
Can DHCS provide more detail on the proposal to align integrated DHCS-County contracts with the Calendar Year as opposed to the Fiscal Year?
Currently, DHCS-County behavioral health contracts are aligned with the State Fiscal Year, which runs from July 1 to June 30. In AB 133, however, the Legislature directed DHCS and counties to execute integrated behavioral health contracts effective January 1, 2027. Having the integrated behavioral health contracts take effect at the beginning of the calendar year would align with the renewal of DHCS' existing 1915(b) waiver and with Managed Care Plan (MCP) contract cycles, both of which already follow the calendar year. DHCS will work closely with counties and other key stakeholders to assess the implications of shifting the behavioral health contract cycle to the calendar year, and to ensure a successful transition to calendar year contract cycles.
How will DHCS support counties to achieve compliance with Behavioral Health Administrative Integration by January 1, 2027?
DHCS acknowledges that county staff time is limited and that counties are implementing other CalAIM policy reforms. DHCS developed the phased implementation approach for Behavioral Health Administrative Integration with these capacity constraints in mind, including coordination with other CalAIM reforms. DHCS will continue to conduct extensive stakeholder engagement and technical assistance to ensure that counties have the information, resources, and technical assistance they need to successfully implement Behavioral Health Administrative Integration. Engagement will include topic-specific workgroups, informational webinars, targeted outreach, and the release of clear guidance and other resources, as appropriate.
What are the benefits for counties that volunteer for early contract integration?
In summer 2023, 21 counties expressed interest in participating in an “Early Implementers workgroup" to prepare to voluntarily enter into integrated contracts with DHCS that cover both specialty mental health and substance use disorder services, beginning January 1, 2025. This early implementation period will allow DHCS and participating counties to gain experience with integrating administrative and oversight functions. In addition to integration components that counties may implement at any time, such as integrated member access lines, these counties will use integrated member materials (member handbook, etc.) and may begin to undergo integrated External Quality Reviews (EQRs), compliance reviews, and network adequacy reporting. DHCS will continuously engage with participating counties through a workgroup to support operationalizing the integrated contracts and implement lessons learned. Early Implementer counties will be required to formally commit to implementing an integrated contract on January 1, 2025 by August 1, 2024.
What will Behavioral Health Administrative Integration look like for counties that do not volunteer for early contract integration?
During Phase 2 (1/1/25-12/31/26: Voluntary Contract Integration), counties that do not opt into early contract integration can continue integrating components that do not require additional guidance from DHCS, such as processes related to the 24/7 access line, screening, assessment, and treatment planning, quality improvement, and cultural competence plans, as well as county data storage and data sharing in preparation for full implementation by January 1, 2027. These counties will not participate in the components that require integrated contract authority, (i.e., External Quality Reviews (EQRs), compliance reviews, and network adequacy certifications) until 2027.
What will Behavioral Health Administrative Integration look like for Drug Medi-Cal (DMC) counties?
DMC counties will continue providing substance use disorder services outside the managed care structure while participating in all other applicable aspects of this initiative, including adopting an integrated Mental Health Plan (MHP) and DMC contract with DHCS that promotes integration goals. Additional information, and opportunities for stakeholder engagement specific to DMC counties, are forthcoming.
How will Behavioral Health Administrative Integration be implemented for counties who are in the Drug Medi-Cal-Organized Delivery System (DMC-ODS) Regional Model?
DHCS recognizes that there are unique implementation considerations for DMC-ODS Regional model counties. In Phase 1 (present – 12/31/24: Voluntary Integration of County Functions Under Existing Contracts), DHCS will conduct targeted stakeholder engagement with counties participating in the DMC-ODS Regional Model to inform implementation of Behavioral Health Administrative Integration for participants in this model. Additional information is forthcoming.
Will Behavioral Health Administrative Integration require integrated Memoranda of Understanding (MOU) between MCPs and Behavioral Health Plans?
Behavioral Health Administrative Integration does not require a new MOU between MCPs and Behavioral Health Plans (BHPs). BHPs may submit one integrated MOU template inclusive of MHP and DMC-ODS requirements that fulfills all requirements outlined in both enclosed templates.
How does Behavioral Health Administrative Integration align with other CalAIM policy reforms like No Wrong Door, Documentation Redesign, and Standardized Screening and Transition Tools?
DHCS developed the Behavioral Health Administrative Integration framework and phased implementation approach to align with and create opportunities to support and leverage implementation of existing CalAIM initiatives, clarify existing requirements, and promote best practices at the point of care for screening, assessments, and treatment planning. These CalAIM initiatives already include policy changes that align administrative requirements for Medi-Cal SMHS and Substance Use Disorder (SUD) services. For example, CalAIM included member access criteria updates that clarified that a clinical diagnosis is not a prerequisite to receive behavioral health services in either the SMH or DMC/DMC-ODS delivery systems; individuals with MH or SUD symptoms may receive care while a diagnosis is determined. Many Documentation Redesign policy changes also apply across specialty BH delivery systems, including the elimination of static treatment plans and adoption of problem lists.
How will payment work with Behavioral Health Administrative Integration?
Effective July 1, 2023 under the CalAIM Behavioral Health Payment Reform initiative, county Behavioral Health Plans transitioned from cost-based reimbursement funded via Certified Public Expenditures (CPEs) to fee-for-service reimbursement funded via Intergovernmental Transfers (IGTs), eliminating the need for reconciliation to actual costs. As part of payment reform, both Specialty Mental Health (SMH) and SUD services transitioned from existing Healthcare Common Procedure Coding System (HCPCS) Level II coding to Level I coding, known as Current Procedural Terminology (CPT) coding, when possible. Behavioral Health Administrative Integration will not change covered Medi-Cal BH benefits or modify the components of payment reform for SMH, DMC, or DMC-ODS. Behavioral Health Administrative Integration Initiative also does not change the way Medi-Cal SMHS and SUD services are financed in California; in other words, it will not change existing allocation methods or spending requirements for MH and SUD funding sources including 1991 and 2011 Realignment and MHSA. More information about Behavioral Health Payment Reform, including technical assistance materials, is available on the CalAIM BH Webpage.
How will Behavioral Health Administrative Integration improve the member experience?
Aligning or merging administrative requirements across mental health and substance use disorder programs under Behavioral Health Administrative Integration will reduce complexity and administrative burden for Behavioral Health Plans and providers, thereby improving the quality of care that members experience because changes will enable providers to focus on improving care delivery, including the provision of care for co-occurring mental health and substance use disorder conditions. Aligning administrative requirements across SMH and DMC/DMC-ODS may also make it easier for providers to participate in both delivery systems, which can facilitate more integrated care for individuals that need both SMH and DMC/DMC-ODS services.
Members will also have access to an integrated member handbook, so will be able to search for SUD and SMH services in one location rather than two. In addition, there will be a single integrated process for appeals/grievances, again offering members one place to access for completing this process, rather than two different processes for SMH and SUD services. Lastly, QI/EQRO activities will have an enhanced focus on the quality of care for members with co-occurring BH needs, acknowledging the frequent overlap of the two conditions among members.
How will the Department of Health Care Services (DHCS) navigate the differences in requirements and regulations between specialty mental health services (SMHS) and Drug Medi-Cal (DMC)/Drug Medi-Cal Organized Delivery System (DMC-ODS) programs in the integrated contract?
DHCS used the existing Mental Health Plan (MHP) contract boilerplate as a starting point for developing the integrated contract boilerplate and then modified and added content as necessary to capture all of the relevant requirements for DMC-ODS or DMC. Whereas the DMC-ODS/SMHS contract will be structured as a single Prepaid Inpatient Health Plan (PIHP) managed care program, DMC counties will continue to operate an SMHS PIHP and a non-managed-care DMC program. Certain portions of the integrated contract are identified as program-specific (e.g., medical necessity and service definitions) and those sections are generally copied directly from the current contracts for SMHS, DMC-ODS, and/or DMC. For “integrated” sections of the contract that apply equally to both SMHS and DMC-ODS or DMC programs, DHCS has made modest adjustments as needed to align standards across programs. For DMC counties, certain SMHS managed care functions have been adjusted to require special attention to members with co-occurring behavioral health needs.
Does Behavioral Health Administrative Integration mean that counties need to restructure so that the mental health and substance use disorder systems are all under a single Behavioral Health department within the county?
No. Although counties (or regional groups of counties) will operate one integrated Medi-Cal behavioral health program from the perspective of state and federal law, counties may continue to structure their internal operations as they see fit. For example, some counties have opted to consolidate their behavioral health staff under a single county department, while other counties maintain separate departments (or divisions within a department) for specialty mental health and substance use disorder operations.
Will there be an annual spending limit specified in the integrated contracts, similar to the current approach for counties' DMC and DMC-ODS contracts? If not, will the removal of those annual limits affect State General Fund (SGF) contributions for, or any limits that may exist on, specific DMC or DMC-ODS services?
Currently, counties' DMC and DMC-ODS contracts contain an annual spending limit, which must be amended if actual spending exceeds projections. By contrast, MHP contracts are “zero dollar" contracts with no limit.
The integrated behavioral health contracts will be “zero dollar" contracts with no specified limit, similar to the current approach for MHP contracts. All eligible county claims will be paid in accordance with the contract and applicable law.
A “zero dollar" approach means there is no need for a fiscal amendment if overall spending under the contract is higher than expected. Implementing “zero dollar" does not modify SGF contributions for specific services (e.g., intensive outpatient and residential DMC-ODS services) and populations (e.g., ACA Optional Expansion).
For additional information on funding for various specialty behavioral health services and populations, please see the DMC, DMC-ODS, and Specialty Mental Health billing manuals available at
https://www.dhcs.ca.gov/services/MH/Pages/MedCCC-Library.aspx. Chapter 6 of the current DMC/DMC-ODS manuals contain detailed discussion of funding, including SGF contributions.
Under the integrated contracts, how will counties claim for expenses related to covered Medi-Cal services, quality assurance & utilization review (QA/UR), contract-related administrative activities, and
Mental Health Medi-Cal Administrative Activities (MH MAA)?
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Covered Medi-Cal Services for Members. Under the integrated contract, providers will continue to bill Medi-Cal behavioral health services to the appropriate program SMHS, DMC, or DMC-ODS), and counties will continue to use program-specific codes when they submit claims to DHCS for expenses related to those covered services. Adopting an integrated contract under Behavioral Health Administrative Integration does not require counties to make any changes to provider reimbursement rates, nor to the financing approach for the county's share of Medi-Cal expenses.
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QA/UR and Contract-Related Administrative Activities. DHCS will implement integrated claiming for QA/UR and administrative activities. In each category, counties will report total eligible expenses under the integrated contract (although counties may continue to track program-specific subtotals for their own purposes if they so wish). Counties will be required to separately report expenditures that are eligible for state funding under Proposition 30.
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MH MAA. Counties will continue to claim reimbursement through the MH MAA claiming process in the same way they are currently claiming reimbursement.
For the integrated 24/7 access line, will the Department of Health Care Services (DHCS) require counties to use a local phone number, or can they use a toll-free number?
Under DHCS Behavioral Health Administrative Integration, counties with
integrated contracts will operate an integrated 24/7 access line, meaning that
members can call a single number to access information about both specialty
mental health services (SMHS) and substance use disorder (SUD) services. For
voluntary integration in 2025, DHCS is not currently proposing any other
changes to access line requirements. Counties may continue to utilize a local
phone number or a toll-free number for their integrated 24/7 access lines,
consistent with current requirements, as long as they offer a single toll-free
number for both SMHS and SUD services.
Does the integrated 24/7 access line need to be operated by the county, or can counties continue to utilize vendors/subcontractors?
Counties with integrated contracts will be expected to operate a single, 24-hour access line for all Medi-Cal members seeking behavioral health services, so that they can be appropriately triaged and screened for both mental health and substance use disorder needs, and scheduled for appropriate follow-up appointments as part of the same call, without needing to hang up and dial any additional numbers. Counties may continue to utilize vendors/subcontractors to staff and operate their 24/7 toll free access line.
As counties implement Behavioral Health Administrative Integration, what resources can DHCS provide to support counties in maintaining compliance with 42 CFR Part 2 regulations around substance use disorder data privacy?
DHCS is committed to ensuring that behavioral health data are shared and stored as efficiently as possible while maintaining privacy protections for members, including the federal “Part 2" confidentiality rules for substance use disorder-related information. To support county programs and behavioral health providers in maintaining compliance with 42 CFR Part 2 and other privacy laws as they advance data sharing capabilities and practices, DHCS plans to publish a template “universal release" form (the ASCMI form, see question below) that can be used to obtain individual authorizations for data sharing, including sharing with MCPs and other service providers. DHCS will also consider other opportunities for guidance, and potentially shared learning or other technical assistance, throughout the implementation period.
How does the Authorization to Share Confidential Medi-Cal Information (ASCMI) Pilot currently underway align with Behavioral Health Administrative Integration?
DHCS is piloting the
ASCMI Form in early 2023. The ASCMI form is a voluntary universal release of information that supports the sharing of Medi-Cal members' physical, mental, and social health information through a standard consent process and a consent management service, with an electronic platform to store and manage Medi-Cal members' consent. Providers will be able to access the consent management service online and/or via their existing electronic health record (her) system. Medi-Cal members will also be able to access the consent management service through the web to amend their consent. Lessons learned from the ASCMI pilot should enable more seamless data sharing under Behavioral Health Administrative Integration.
How does the Comprehensive Behavioral Health Data Systems Project align with Behavioral Health Administrative Integration?
The
Comprehensive Behavioral Health Data Systems Project is intended to identify technology solutions to modernize and streamline data collection and reporting, analysis, and other data-related functions, and develop a consolidated reporting and analysis platform that integrates data from 12 existing behavioral health data systems. DHCS will coordinate internally and with stakeholders to ensure alignment between the implementation of the Comprehensive Behavioral Health Data Systems Project and Behavioral Health Administrative Integration.
Will counties receive templates or guidance to help develop consistent and impactful cultural competency plans?
Yes. DHCS is developing integrated Cultural Competence Plan templates for county use.
How will External Quality Reviews (EQRs) work under integrated contracts?
Under integrated contracts, Drug Medi-Cal Organized Delivery System (DMC-ODS) counties will undergo a single, integrated EQR that addresses both Specialty Mental Health Services (SMHS) and DMC-ODS programs. Drug Medi-Cal (DMC) counties will continue to receive EQR solely for their SMHS activities.
How will DHCS ensure that the integrated EQR process includes adequate focus on both mental health and substance use disorder priorities aren't lost in the aim to have an integrated EQR?
DHCS designs its EQR approach across all programs (SMHS, SUD, Managed Care and Dental) in compliance with federal regulations at
Title 42, Part 437, Subpart E of the Code of Federal Regulations.
With respect to the integrated behavioral health EQR under Behavioral Health Administrative Integration, DHCS will work with stakeholders to ensure that EQR—and other oversight mechanisms—include appropriate measures regarding the provision of high-quality mental health and substance use disorder treatment services, including services to treat co-occurring conditions.
What will counties' compliance reviews look like under Behavioral Health Administrative Integration?
As part of Behavioral Health Administrative Integration, DHCS will develop a streamlined compliance review for both SMHS and SUD. Adopting integrated reviews will be one of several policy changes that DHCS will implement to restructure and refocus SMHS and DMC/DMC-ODS compliance reviews (or “audits") to support CalAIM goals. DHCS will continue to release guidance on these policy updates, and will seek feedback on options for streamlining or integrating compliance monitoring during stakeholder engagement for BH Administrative Integration.
How will integrated network adequacy certifications work? Will the Department of Health Care Services (DHCS) require counties to submit both the annual Network Adequacy Certification Tool (NACT) and timely access data in addition to the monthly 274 Electronic Data Interchange (274 standard) provider network data?
For counties with integrated contracts, DHCS will conduct annual network adequacy certification through a single, integrated reporting process. Counties will complete a single, integrated submission for network adequacy (using the 274 standard described in BHIN 23-042) and timely access reporting. These submissions will continue to follow the state fiscal year (SFY). For voluntary integration in 2025, DHCS is not currently proposing any substantive changes to the standards for network adequacy or timely access.
- Drug Medi-Cal Organized Delivery System (DMC-ODS) counties and Mental Health Plans (MHPs) will be required to submit integrated Network Adequacy certification documentation for both specialty mental health services (SMHS) and substance use disorder (SUD) services on an annual basis as described in a forthcoming Behavioral Health Information Notice (BHIN). DHCS will conduct annual network certification through a single, integrated reporting process, including the collection of integrated 274 Electronic Data Interchange (274 standard) provider network data.
- DMC-ODS counties will also be required to submit provider network data to DHCS using the 274 standard on a monthly basis as described in a forthcoming BHIN that will address the integrated 274 file submission using a process similar to the files currently being submitted by the DMC-ODS and MHPs. While DHCS will use the 274 standard data to evaluate network adequacy compliance for DMC-ODS counties with integrated contracts, the 274 standard will not formally replace the NACT as the primary source for analysis for non-integrated DMC-ODS counties until DHCS issues a BHIN or other formal guidance to inform counties of this change. Following the submission period, DHCS will provide each county with a combined findings report that describes whether network adequacy standards have been met for each required element.
- For Drug Medi-Cal (DMC) counties, DHCS will only require submission of the integrated Timely Access Data Tool (TADT), which will include timely access data for SUD and SMHS. DHCS will still require the remaining network adequacy data and documentation to be submitted for SMHS. Integrated reports detailing network certification findings will be sent to DMC counties with integrated contracts, but only the timely access standards results will apply to SUD services. The remaining results will apply only to SMHS.
Will the Department of Health Care Services (DHCS) adjust or change the methodology used to evaluate network adequacy under integrated contracts?
DHCS will not change the methodology used to determine network adequacy compliance for Drug Medi-Cal Organized Delivery System (DMC-ODS) counties that voluntarily choose to implement integrated contracts effective January 1, 2025. DHCS is open to feedback from counties and other stakeholders on the merits of potential substantive revisions to the network adequacy standards currently outlined in BHIN 23-041, such as aligning the capacity methodologies across specialty mental health services (SMHS) and substance use disorder (SUD) services, as well as additional alignment with the network adequacy methodologies for Medi-Cal managed care plans.
If counties do not meet network adequacy requirements, will the Department of Health Care Services (DHCS) issue Corrective Action Plans (CAPs)? Will reporting and potential CAPs be singular, or will one be required for both the Mental Health Plan (MHP) and Drug Medi-Cal Organized Delivery System (DMC-ODS) separately?
For counties with integrated contracts that do not meet compliance with one or more network adequacy requirements, DHCS will approve a single, integrated CAP that addresses deficiencies for both specialty mental health services (SMHS) and substance use disorder (SUD) programs, as applicable. Depending on the approved CAP, DHCS may require subsequent submission(s) of additional documentation to demonstrate compliance. The county will remain on a CAP until all deficiencies are cleared.
If a Drug Medi-Cal Organized Delivery System (DMC-ODS) county has not fully implemented monthly 274 Electronic Data Interchange (274 standard) provider network data submissions, would that exclude them from participating in Phase 2 voluntary contract integration?
DMC-ODS counties participating in Phase 2 voluntary contract integration will be expected to submit monthly 274 Electronic Data Interchange (274 standard) provider network data for both specialty mental health (SMHS) and DMC-ODS programs starting January 1, 2025. If the county is working through implementation challenges but anticipates being ready by 2025, then the county would be eligible for participation in Phase 2 contract integration. If the county is unable to submit monthly 274 data as of 2025, that would exclude the county from participating in Phase 2.
How will DHCS ensure that the new Network Adequacy process still ensures adequate focus on both substance use disorder and mental health priorities?
When counties adopt integrated contracts under Behavioral Health Administrative Integration, they will remain subject to the same network adequacy standards that govern existing Mental Health Plans and DMC-ODS programs, which require that plans have a sufficient and robust network of, respectively, mental health or substance use disorder providers. Existing network adequacy methodologies incorporate estimated mental health and substance use disorder prevalence rates in their evaluation of network capacities. DHCS will work with stakeholders to monitor concerns to ensure mental health and substance use disorder services retain adequate networks while also enabling the provision of treatment for co-occurring conditions.
How will Behavioral Health Administrative Integration impact providers?
This initiative will not mandate changes in care models at the provider level, and providers will still be able to choose whether to offer SMHS, DMC/DMC-ODS services, or both. DHCS anticipates that the administrative simplifications implemented as part of this initiative will create efficiencies for providers that can make it easier to participate in both SMH and DMC/DMC-ODS programs and offer co-occurring specialty behavioral health services if a provider chooses to do so.
How will Behavioral Health (BH) audits work under integrated contracts in terms of structure and frequency?
Counties with integrated contracts will receive an annual integrated BH audit that assesses compliance with the integrated contract, including the elements specific to specialty mental health services (SMHS) and substance use disorder (SUD) services. This integrated process will apply to both Drug Medi-Cal Organized Delivery System (DMC-ODS) and Drug Medi-Cal (DMC) counties and will continue to follow the state fiscal year (SFY) in terms of both scheduling and review periods. Integrated BH audits will follow the systemic approach that is county-specific as described in
BHIN 23-044.
Will the integrated Behavioral Health (BH) audits include a review of Substance Use Prevention, Treatment and Recovery Services Block Grant (SUBG) services in addition to Specialty Mental Health Services (SMHS) and Drug Medi-Cal (DMC)/Drug Medi-Cal Organized Delivery System (DMC-ODS) services?
Currently, the Department of Health Care Services (DHCS) expects that integrated BH audits will remain separate from SUBG audit activities. DHCS will aim to conduct these audits at the same time to help minimize administrative burden for counties.
