CalAIM Behavioral Health Initiative
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CalAIM is a multi-year DHCS initiative 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. For more information about CalAIM more broadly, please go to the CalAIM webpage.
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. The majority of these policy changes launched in 2022, but implementation will continue through 2027. See below for more details on each initiative, including policy guidance, past webinars, and information on upcoming technical assistance opportunities.
DHCS has also launched the California Behavioral Health Community-Based Continuum (CalBH-CBC) demonstration webpage to provide more information about the planned Medicaid Section 1115 Demonstration application, coming in 2023, to increase access to and improve mental health services for Medi-Cal members statewide.
Download the factsheet about the CalAIM initiative to advance Behavioral Health.
Policy:
| Go-Live Date:
|
Criteria for Specialty Mental Health Services (SMHS)
| January 2022
|
Drug Medi-Cal Organized Delivery System (DMC-ODS) Policy Improvements
| January 2022
|
| Drug Medi-Cal American Society of Addiction Medicine (ASAM) Level of Care Determination | January 2022 |
Updated Reasons for Recoupment
| January 2022
|
| Documentation Redesign for Substance Use Disorder & Specialty Mental Health Services | July 2022
|
| No Wrong Door | July 2022 |
Standardized Screening and Transition Tools
| January 2023
|
| Behavioral Health Payment Reform | July 2023 |
Administrative Integration of Specialty Mental Health and Substance Use Disorder Services
| January 2027 |
Resources
Criteria for Specialty Mental Health Services
As of January 1, 2022, DHCS updated and clarified the responsibilities of specialty Mental Health Plans (MHPs), including updates to the criteria for access to Specialty Mental Health Services (SMHS), both for adults and beneficiaries under age 21 through BHIN 21-073. 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
Guidance
Webinars
- Informational webinar, November 18, 2021
Drug Medi-Cal Organized Delivery System (DMC-ODS) Policy Improvements
As of January 1, 2022, DHCS made updates to 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 through BHIN 21-075. DHCS proposed a set of updates to Drug Medi-Cal Organized Delivery System (DMC-ODS) to the Centers for Medicare and Medicaid Services (CMS), some of which Centers for Medicare and Medicaid Services (CMS) approved for the January – December 2021 extension period and others which went into effect in January 2022, with Centers for Medicare and Medicaid Services (CMS) approval. This includes the following policy changes:
- Treatment is reimbursable during the assessment period prior to diagnosis.
- The criteria for receiving Substance Use Disorder (SUD) treatment services (medical necessity) are met by a Substance Use Disorder (SUD) diagnosis from a licensed provider- no authorization is required for nonresidential services.
- The full American Society of Addiction Medicine (ASAM) assessment must be completed within 30 days of the start of treatment in nonresidential settings (60 days for those under 21 years of age or experiencing homelessness), and the American Society of Addiction Medicine (ASAM) assessment is used to determine the appropriate level of care.
- A physician history, physical exam, and determination of opioid addiction are sufficient to determine eligibility for Narcotic Treatment Program (NTP) services.
- All Drug Medi-Cal Organized Delivery System (DMC-ODS) providers must offer or arrange referrals 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 American Society of Addiction Medicine (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 Substance Use Disorder (SUD) are eligible for recovery services immediately upon release, regardless of the length of incarceration and whether treatment was received during incarceration, as are individuals receiving medication-assisted treatment (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. Please find more information about Medi-Cal Peer Support Specialists in the Medi-Cal Peer Support Services Specialist Program FAQs.
The Department continues to pursue the following proposed policy change:
- Including Traditional Healers and Natural Helpers to deliver culturally appropriate care for American Indian and Alaska Native individuals with Substance Use Disorder (SUD)
The Drug Medi-Cal Organized Delivery System (DMC-ODS) guidance outlined in BHIN 21-075 will be updated to align with the CalAIM Behavioral Health Initiatives that went live in July 2022. For additional information on the Drug Medi-Cal Organized Delivery System (DMC-ODS) program, please visit: Drug Medi-Cal Organized Delivery System.
Resources
Guidance
Webinars
- Informational webinar, December 2, 2021
Drug Medi-Cal American Society of Addiction Medicine (ASAM) Level of Care Determination
As of January 1, 2022, to align access to Substance Use Disorder (SUD)) service delivery across the state, DHCS issued guidance through BHIN 21-071 establishing that the American Society of Addiction Medicine (ASAM) Criteria be used to determine the appropriate level of care for covered Substance Use Disorder (SUD) treatment services in both Drug Medi-Cal Organized Delivery System (DMC-ODS) counties and Drug Medi-Cal (DMC) State Plan counties.
Resources
Guidance
Updated Reasons for Recoupment
As of July 1, 2022, DHCS simplified behavioral health documentation standards to remove outdated requirements and align standards across physical and behavioral health. To facilitate the transition to the new documentation standards (effective July 1, 2022), DHCS revised the audit protocols and reasons for recoupment, limiting recoupment to findings of fraud, waste, and abuse.
Resources
Guidance
Information
Behavioral Health Documentation Redesign
As of July 1, 2022, DHCS streamlined behavioral health documentation requirements for Substance Use Disorders (SUD) and Specialty Mental Health Services (SMHS) to align more closely with national standards. DHCS removed client plan requirements from Specialty Mental Health Services (SMHS) and treatment plan requirements from Drug Medi-Cal (DMC) and Drug Medi-Cal Organized Delivery System (DMC-ODS), except for the continued requirements specifically noted in the attachment in the Resources section below. The new behavioral health documentation requirements include the use of an active and ongoing problem list with progress notes reflecting the care given, aligning with the appropriate billing codes.
Resources
Guidance
Webinars
- Informational webinar, May 26, 2022
No Wrong Door & Co-Occurring Treatment
As of July 1, 2022, DHCS implemented 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 (MCP), or the fee-for-service delivery system). This policy allows 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 also clarified that patients with co-occurring mental health and Substance Use Disorder (SUD) 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.
Resources
Guidance
Materials
Webinars
- Technical Assistance Webinar, June 9, 2022
- Informational Webinar, April 28, 2022
Standardized Screening & Transition of Care Tools
Previously, multiple behavioral health screening and transition of care tools were in use for Medi-Cal beneficiaries across the state, leading to inconsistencies for when beneficiaries were referred to mental health plan networks versus managed care networks. CalAIM seeks to streamline this process and improve patient care by creating standardized statewide tools.
DHCS conducted a robust stakeholder process to develop statewide Screening and Transition of Care Tools for both adults and individuals under 21 years old (youth) for use by County Mental Health Plans (MHPs) and Medi-Cal Managed Care Plans (MCPs). DHCS developed standardized Adult and Youth Screening Tools to determine the most appropriate Medi-Cal mental health delivery system referral (i.e., Mental Health Plans (MHP) or Medi-Cal Managed Care Plans (MCP)) for beneficiaries who are not currently receiving mental health services when they contact the Medi-Cal Managed Care Plans (MCP) or Mental Health Plans (MHP) seeking mental health services. In addition, DHCS developed a standardized Transition of Care Tool to ensure that Medi-Cal beneficiaries 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. The Screening and Transition of Care Tools were developed with robust stakeholder input, including beta and pilot testing with participating Medi-Cal Managed Care Plans (MCPs) and Mental Health Plans (MHPs) in a variety of counties across the state, including counties with large urban areas, small population sizes, and large rural regions.
Statewide implementation of Screening and Transition of Care Tools launched January 1, 2023. For more information, please visit the Screening & Transition of Care Tools for Medi-Cal Mental Health Services webpage.
Behavioral Health Payment Reform
Through realignment efforts in 1991 and 2011, funding for the majority of the non-federal share of costs associated with the Specialty Mental Health Services (SMH) 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 Certified Public Expenditure (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 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, Specialty Mental Health (SMH) and Substance Use Disorder (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)
| Date: | Policy Update: |
July 2023
| Payment reform effective July 1, 2023 |
Resources
Guidance
Materials
Administrative Integration of Specialty Mental Health and Substance Use Disorder Services
Medi-Cal Specialty Mental Health (SMH) 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 (SMH) and Substance Use Disorder (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 Drug Medi-Cal Organized Delivery System (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 (SMH) and Substance Use Disorder (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.
Concept Paper for CalAIM Behavioral Health Administrative Integration: Overview and Opportunity for Comment
DHCS has released a concept paper describing Behavioral Health Administrative Integration, one of several California Advancing and Innovating Medi-Cal (CalAIM) initiatives to transform and strengthen the Medi-Cal behavioral health delivery system. Counties currently operate separate Medi-Cal programs for Specialty Mental Health Services (SMHS) and Drug Medi-Cal (DMC) or Drug Medi-Cal Organized Delivery System (DMC-ODS) services. Through Behavioral Health Administrative Integration, these programs will be consolidated into a single county-based behavioral health program by 2027, with the goal of improving the experience of care for Medi-Cal beneficiaries while reducing administrative complexity for behavioral health providers, counties, and the state. This initiative focuses on integrating administrative and oversight processes (such as beneficiary access lines, county contracts with DHCS, and DHCS compliance reviews), and aligns with other CalAIM behavioral health initiatives that are designed to streamline and simplify access criteria, reimbursement, and documentation requirements for behavioral health services.
The Behavioral Health Administrative Integration concept paper, which was developed with input from counties and other stakeholders, provides additional detail regarding this initiative's framework, goals, the steps needed at the state and county level to achieve those goals, and a phased approach for sequencing these steps between now and 2027. DHCS will host a webinar on January 26, 2023, that provides an overview of the initiative and phased approach. Please see the webinar registration link and agenda.
DHCS is accepting stakeholder feedback on the approach described in the concept paper through February 21, 2023. Please submit all comments in writing to bhcalaim@dhcs.ca.gov. Although DHCS does not plan to release a revised concept paper, feedback received during the comment period will inform DHCS' policy decisions, implementation strategy, and consideration of potential guidance and other technical assistance materials.
Timeline (Subject to Change)
| Date: | Policy Update: |
| January 24, 2023 | Concept Paper |
| 2022-2026 | CalAIM Project Period |
| January 2027 | 1915 (b) Waiver Renewal |
Informational Webinar
Mobile Crisis Services
Mobile crisis services are a community-based intervention designed to provide de-escalation and relief to individuals experiencing a behavioral health crisis wherever they are, including at home, work, school, or in the community. Mobile crisis services are provided by a multidisciplinary team of trained behavioral health professionals in the least restrictive setting. Mobile crisis services include screening, assessment, stabilization, de-escalation, follow-up, and coordination with health care services and other supports. Mobile crisis services are intended to provide community-based crisis resolution and reduce unnecessary law enforcement involvement and emergency department utilization. The mobile crisis services benefit will ensure that Medi-Cal beneficiaries have access to coordinated crisis care 24 hours a day, 7 days a week, 365 days per year. For more information regarding the Mobile Crisis Services, please visit the CalAIM Mobile Crisis Services Webpage.
In 2022, DHCS submitted State Plan Amendment (SPA) 22-0043 to add qualifying community-based mobile crisis intervention services ("mobile crisis services") as a Medi-Cal benefit, effective January 2023. Implementing mobile crisis services is an integral part of California's broader efforts to strengthen the continuum of community-based care for Medi-Cal beneficiaries who are experiencing a mental health or substance use disorder crisis.
Please note, the mobile crisis services benefit is distinct from the Crisis Care Mobile Units (CCMU) funding opportunity. More information about the CCMU program is available on the DHCS website.
Important Updates
In December 2022, DHCS released Behavioral Health Information Notice (BHIN) 22-064 to provide guidance on the implementation of mobile crisis services.
Resources
Materials
