23-1099 No Wrong Door for Mental Health Services Policy Ensures Coordinated Care

Date: 09/22/23

Medi-Cal members can maintain treatment relationships with trusted physicians without interruption

On March 30, 2022, as per All Plan Letter (APL) 22-005, the Department of Health Care Services (DHCS) provided updated guidance for mental health services as outlined below. The No Wrong Door for Mental Health Services Policy allows Medi-Cal members to receive timely mental health services without delay regardless of where they seek care and remain with their current clinician, if preferred.

Updated guidelines are part of the California Advancing and Innovating Medi-Cal (CalAIM) initiative to ensure that all Medi-Cal beneficiaries receive coordinated services and improve their health outcomes.

Screening and transition of care tools

Per APL 22-028, DHCS developed the following standardized adult and youth (under age 21) screening and transition of care tools for Medi-Cal managed care plans (MCPs) and county mental health plans to use:

• Screening tools to determine the most appropriate Medi-Cal mental health delivery system referral for members who are not currently receiving mental health services when they contact the MCP or county mental health plan seeking mental health services.
• Transition of care tool to ensure Medi-Cal members receive timely and coordinated care when completing a transition of services to the other delivery system or when adding a service from the other delivery system to their existing mental health treatment.

No Wrong Door for Mental Health Services Policy

This policy allows members 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 member is transferred to the other delivery system due to their level of impairment and mental health needs. In certain situations, members may receive coordinated, non-duplicative services in multiple delivery systems, such as when a member has an ongoing therapeutic relationship with a therapist or psychiatrist in one delivery system while requiring medically necessary services in the other.

California Health & Wellness Plan (CHWP) provides or arranges for the provision of the following:

• Non-specialty mental health services (NSMHS):
  • Mental health evaluation and treatment, including individual, group and family psychotherapy.
  • Psychological and neuropsychological testing when clinically indicated to evaluate a mental health condition.
  • Outpatient services for purposes of monitoring drug therapy.
  • Psychiatric consultation.
  • Outpatient laboratory, drugs, supplies and supplements.
• Medications for Addiction Treatment, (also known as medication-assisted treatment) provided in primary care, inpatient hospital, emergency departments, and other contracted medical settings.
• Emergency services necessary to stabilize the member.

NSMHS listed above applies to the following populations:

• Members ages 21 and older with mild to moderate distress, or mild to moderate impairment of mental, emotional, or behavioral functioning resulting from mental health disorders, as defined by the current Diagnostic and Statistical Manual of Mental Disorders.
• Members under age 21, to the extent they are eligible for services through the Medicaid Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit, regardless of the level of distress or impairment, or the presence of a diagnosis.
• Members of any age with potential mental health disorders not yet diagnosed.

Covered non-specialty mental health services

CHWP covers clinically appropriate NSMHS, including situations listed below:

• Services provided during the assessment period prior to a determination of a diagnosis, during the assessment period or prior to determination of whether NSMHS criteria are met.
• Services not included in an individual treatment plan.
• The member has a co-occurring mental health condition and substance use disorder.
• Members may concurrently receive NSMHS from a CHWP provider and specialty mental health services (SMHS) via a county mental health plan provider when the services are clinically appropriate, coordinated and not duplicative. Any concurrent NSMHS and SMHS for adults and children under ages 21, will be coordinated between CHWP and the local county mental health plan to ensure member choice. Decisions are made via a patient-centered shared decision-making process.

For more information on the No Wrong Door for Mental Health Services Policy, go to the provider portal > Provider Manual/Billing Manual – English (PDF).

Additional information

Relevant sections of the provider operations manuals have been revised to reflect the information contained in this update as applicable. Provider operations manuals are available in the Provider Resources section of the provider website.

If you have questions regarding the information contained in this update, contact CHWP at 877-658-0305.

 

This information applies to Physicians, Independent Practice Associations (IPAs), Hospitals, Ancillary providers, Community Supports (CS) Providers, and Enhanced Care Management (ECM) Providers.