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​​​CalAIM Behavioral Health Initiative Frequently Asked Questions

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Below is a list of frequently asked questions have been collected from technical assistance and informational webinars and submissions to the BHCalAIM@dhcs.ca.gov email. DHCS will update this list on a quarterly basis. ​

DMC-ODS

If a client is stepping down from residential to outpatient DMC-ODS services, can the outpatient provider and the residential provider bill for care coordination while the person is still technically enrolled in residential services?

The outpatient provider can bill for Care Coordination services while the beneficiary is still receiving residential treatment services for the purposes of facilitating effective care transitions to the next level of care and to support the beneficiary with linkages to services and supports to restore their level of functioning. However, residential providers should not bill for Care Coordination services in addition to billing for residential treatment, as care coordination is included the reimbursement rates. The CalAIM billing manuals, for services beginning 7/1/23, are currently being updated to clarify the distinction for residential providers.  

Can care coordination for residential clients be claimed as an unbundled service on top of the residential per diem rate, assuming the residential per diem rate does not account for care coordination activities?

No. Care Coordination is included in the Residential provider's rate. Care Coordination can be claimed as standalone services by an outpatient provider for a beneficiary receiving Residential care services for the purposes of facilitating effective care transitions to the next level of care and to support the beneficiary with linkages to services and supports to restore their level of functioning.​

For DMC-ODS, are discharge plans and discharge summaries still required?

Reference BHIN19-003  BHIN 22-019 

DMC-ODS plans and providers should follow documentation requirements set forth in BHIN 22-019, which does not include discharge plans and discharge summaries. However, discharge planning, including coordinating with SUD treatment providers to support transitions between levels of care and to recovery resources, referrals to mental health providers, and referrals to primary or specialty medical providers, is a component of Care Coordination services for DMC-ODS and should be provided based on beneficiary need. For certified only programs, discharge plans and summaries are required per AOD Certification Standard 7120.

Further, licensed residential programs shall update resident records as necessary to ensure current accuracy and include data and reason for termination of services, per CCR Title 9, Chapter 5, Section 10568. Additionally, BHIN 19-003 updates H&S Code 11834.26(d) to include resident discharge and continuation of care as part of the required written plan to address resident relapse.​

​Can homelessness be a justification for extending SUD treatment or even increased level of care (LOC)?

Reference BHIN 21-071 BHIN 21-075

Beneficiaries must meet the access criteria for DMC or DMC-ODS to access SUD services through the DMC/DMC-ODS program. The ASAM Criteria is used to determine placement into the appropriate level of care for all beneficiaries receiving services through the DMC or DMC-ODS. Dimension 6 (Recovery / Living Environment) of the multidimensional ASAM assessment includes factors that can impact recovery, such as homelessness, to help determine the appropriate placement. Beneficiary placement and level of care determinations shall ensure that beneficiaries are able to receive care in the least intensive level of care that is clinically appropriate to treat their condition.​

Can the requirement to offer naloxone at a Narcotic Treatment Program (NTP) / Opioid Treatment Program (OTP) be met by offering a form of buprenorphine (Suboxone®) that contains both buprenorphine and naloxone?

Reference BHIN 21-075 

No. While NTPs/OTPs may offer formulations of buprenorphine that contain naloxone, this is not a replacement for naloxone. Naloxone (by itself) is used to reverse an opioid-involved overdose. The inclusion of naloxone in the combination buprenorphine/naloxone product is intended to prevent diversion and misuse of the buprenorphine medication; it is not intended to reverse an opioid-involved overdose.

How can DMC-ODS providers leverage Medi-Cal for prescribing and dispensing naloxone to patients?

Reference BHIN 21-075 

DMC-ODS providers have flexibility to provide or arrange for naloxone to be provided for all DMC-ODS beneficiaries. For example, DMC-ODS providers can simply prescribe naloxone to all DMC-ODS beneficiaries who are receiving care at their program. The DMC-ODS beneficiaries would be able to fill the prescription at a pharmacy. DMC-ODS providers can also refer patients to community pharmacists who can furnish naloxone directly to the patient.

In addition, DMC-ODS providers are able to dispense naloxone onsite to DMC-ODS beneficiaries by leveraging the Medi-Cal pharmacy benefit. As a best practice overdose prevention measure, DMC-ODS providers can prescribe naloxone to all DMC-ODS beneficiaries who are receiving treatment, and arrange for staff to routinely fill these naloxone prescriptions at a pharmacy on behalf of DMC-ODS beneficiaries. The community pharmacy would bill these naloxone prescriptions to the Medi-Cal pharmacy benefit. The staff could bring the dispensed naloxone back to the DMC-ODS provider site for furnishing directly to patients. This method would enable the DMC-ODS provider to better facilitate onsite access to naloxone reimbursed through the Medi-Cal pharmacy benefit.

Can Medications for Addiction Treatment (MAT) be provided in settings other than NTPs?

Reference BHIN 21-075 

Yes. While NTPs are the only providers that can provide methadone, all DMC-ODS providers are able to deliver other forms of MAT for opioid use disorder, such as buprenorphine and naltrexone, as well as MAT for alcohol use disorder.1​

In the DMC-ODS program, MAT is covered, reimbursable, and can be provided in most DMC-ODS levels of care, including outpatient treatment, intensive outpatient treatment, partial hospitalization, residential treatment,2​ inpatient treatment, and withdrawal management. In addition, MAT is covered, reimbursable, and can be provided by DMC-ODS providers as a standalone service outside of these levels of care – for example, beneficiaries do not have to participate in a formal intensive outpatient treatment program in order to receive MAT from a DMC-ODS provider. DMC-ODS providers can also deliver MAT in non-clinical settings, such as mobile clinics and street medicine teams.

As described in BHIN 21-075, DMC-ODS counties shall ensure that all DMC-ODS providers, at all levels of care, demonstrate that they either directly offer or have an effective referral mechanism to the most clinically appropriate MAT services for beneficiaries with SUD diagnoses that are treatable with medications or biological products. (Effective referral mechanism is defined as facilitating access to MAT off-site for beneficiaries if not provided on-site. Providing a beneficiary the contact information for a treatment program is insufficient.)

In addition, MAT may be offered and is also available to Medi-Cal beneficiaries in various settings outside of the DMC-ODS program, including:

  • ​Primary care settings. MAT can be provided in doctor's offices, community clinics, federally qualified health centers, and other primary care settings.
  • Emergency departments (EDs) and hospitals. EDs can be a stabilization point for beneficiaries. Any provider in a hospital or emergency department may administer buprenorphine for up to three days in order to relieve acute withdrawal symptoms and facilitate patient referral to treatment. Over 150 EDs in California offer MAT, including through onsite MAT induction in the ED and short-term prescriptions to bridge the beneficiary until their first follow-up visit in the community with an MAT provider. Please visit the California Bridge Program website to find EDs that offer MAT throughout California.
​​In addition, the California MAT Expansion Project aims to increase access to MAT, reduce unmet treatment needs, and reduce opioid overdose related deaths through more than 30 programs focused on prevention, treatment, and recovery activities. The project has a special focus on populations with limited MAT access, including youth, rural areas, and American Indian & Alaska Native Tribal communities. For a list of providers and facilities offering MAT in your area, visit: http://choosemat.org/.

How are collateral services covered under DMC-ODS?

Reference BHIN 21-075 

“Collateral services" is no longer defined as a unique service component of the DMC-ODS service modalities.  In accordance with SPA 21-0058 and as described in BHIN 21-075, the concept of including a collateral in a beneficiary's substance use disorder treatment has been incorporated into assessment services, individual counseling, and family therapy. 

Assessment services may include contact with family members or other collaterals if the purpose of the collateral's participation is to focus on the treatment needs of the beneficiary.

Additionally, individual counseling services can include contact with family members or other collaterals if the purpose of the collateral's participation is to focus on the treatment needs of the beneficiary by supporting the achievement of the beneficiary's treatment goals.

Finally, family therapy is a rehabilitative service that includes family members in the treatment process, providing education about factors that are important to the beneficiary's recovery as well as the holistic recovery of the family system. Family members can provide social support to the beneficiary and help motivate their loved one to remain in treatment. There may be times when, based on clinical judgment, the beneficiary is not present during the delivery of this service, but the service is for the direct benefit of the beneficiary.

SPA 21-0058 and BHIN 21-075 detail which DMC-ODS service modalities include assessment services, individual counseling services, and family therapy as billable service components.

What certification requirements must be met in order for a DMC-ODS county to offer Partial Hospitalization services through the DMC-ODS Program?

Reference BHIN 21-075

There is no DMC certification category specific to partial hospitalization. In order to provide partial hospitalization services through DMC-ODS, counties, or contracted network providers in counties, must be certified as DMC Intensive Outpatient Treatment (IOT) providers, must be able to offer 20 or more hours of clinically intensive programming per week, and must demonstrate the ability to facilitate access to the psychiatric, medical, and laboratory services, as needed.

What are the plan documentation requirements relating to grievances?

As specified in the Intergovernmental Agreement, each DMC-ODS county shall maintain records of grievances and appeals and shall review the information as part of its ongoing monitoring procedures, as well as for updates and revisions to the Department quality strategy.

The record of each grievance or appeal shall contain, at a minimum, all of the following information:
  • A general description of the reason for the appeal or grievance.
  • The date received.
  • The date of each review or, if applicable, review meeting.
  • Resolution at each level of the appeal or grievance, if applicable.
  • Date of resolution at each level, if applicable.
  • Name of the covered person for whom the appeal or grievance was filed.
​​​Each​ record shall be accurately maintained in a manner accessible to the Department and available upon request to CMS.

The written record of grievances and appeals shall be submitted at least quarterly to the plan's quality improvement committee for systematic aggregation and analysis for quality improvement. Grievances and appeals reviewed shall include, but not be limited to, those related to access to care, quality of care, and denial of services. Appropriate action shall be taken to remedy any problems identified.​​​​​

What are the requirements for appeals?

The beneficiary or a provider and/or authorized representative, may file an appeal in-person, orally, or in writing. If they request expedited resolution, the beneficiary or representative must follow an in-person or oral filing with a written, signed appeal. The appeal must not count against the beneficiary or authorized representative in any way. Individuals deciding on the appeals resolution must be qualified to do so and not involved in any previous level of review or decision-making.

Beneficiaries and/or their authorized representative must:
  • Have the right to examine their case files, including their medical record and any other documents or records considered during the appeal process, before and during the appeal process.
  • Have a reasonable opportunity to present evidence and allegations of fact or law, in person or in writing.
  • Be allowed to have a legal representative and/or legal representative of a deceased member's estate included as parties to the appeal.
  • Be informed that their appeal is being reviewed using written confirmation.
  • Be informed of their right to request a State Hearing, following the completion of the appeal process.

​What are the requirements and timeframes for State Hearings?

Beneficiaries may request a State Hearing only after receiving notice that the plan is upholding an adverse benefit determination.

Beneficiaries have 120 days to request a State Hearing, beginning from the date that the plan gave the decision to the beneficiary in person, or the day after an appeal decision is postmarked. If the beneficiary did not receive a Notice of Adverse Benefit Determination (NOABD), they may file for a State Hearing at any time.

The California Department of Social Services will conduct an independent review within 90 days of receiving the request. Beneficiaries may request an expedited State Hearing. If a request qualifies for an expedited State Hearing, the decision will be issued within three working days from the date that the request is received by the State Hearings Division.

Can counties update the NOABDs? If not, will DHCS be issuing a NOABD that is specific to SUD services?

NOABD template language cannot be amended or modified. All templates must be used with the approved language and approved font. The section of each NOABD pertaining to the availability of large font, braille or electronic formats must not smaller than 20-point font; the rest of the NOABD should be in 12-point font.

The #4 Delivery System NOABD does not apply to SUD services. All of the other NOABDs apply to SUD services and should be used accordingly.

Should network providers send NOABDs when discharging clients for noncompliance? Do providers issue NOABD letters or only plans?

A NOABD must be sent to the beneficiary when discharging for non-compliance. The plan is ultimately responsible for ensuring that the NOABD letters appropriately reach the beneficiary. However, if they choose to make it a requirement of their providers, the plan must have a mechanism in place to be notified of their occurrences to ensure compliance.​

What happens if a beneficiary never shows up for treatment after admission or never returns to treatment?

​The plan is responsible for issuing a NOABD to the benefi​ciary, specifically a termination notice for non-compliance.

If a beneficiary's course of treatment is modified by the provider (e.g., change in level, frequency or type of service) must a Modification of Requested Service NOABD be issued to the beneficiary?

DMC-ODS treatment services are not required to be authorized by the Plan. If the provider determines a change in level of care or frequency of services is appropriate, they do not need to receive authorization from the Plan. Because the provider is modifying the services, and not the Plan, a modification notice is not required.​3 In this case, however, a beneficiary can appeal the provider decision to modify services, even without receiving a NOABD.

If a plan has an integrated behavioral health department (i.e., mental health and SUD treatment services are overseen by a single director), can it combine certain requirements of the DMC-ODS QI Plan with the Mental Health Plan (MHP) QI Plan?

Yes, for counties that have an integrated behavioral health department, the DMC-ODS QI Plan may be combined with MHP QI Plan.

What grievance and appeal information must be in the QI Plan?

The QI Plan must include information on how beneficiary complaints data will be collected, categorized, and assessed for monitoring. At a minimum, the QI Plan must include information on:
​
​How to submit a grievance, appeal, and request for a state hearing;
  • The time frame for resolution of appeals;
  • The content of an appeal resolution;
  • Record keeping;
  • Continuation of benefits; and
  • Requirements of state hearings​

If a plan has an integrated behavioral health department, can it use the same QI Committee required by the MHP contract to fulfill the DMC-ODS QI Committee requirements?

Yes​, for counties with an integrated behavioral health department, the plan may use the same committee, with SUD participation.

Are student interns or trainees considered licensed practitioners of the healing arts (LPHAs), or considered license-eligible?

No. As described in SPA 21-0058, LPHAs include Physicians, Nurse Practitioners, Physician Assistants, Registered Nurses, Registered Pharmacists, Licensed Clinical Psychologists, Licensed Clinical Social Workers, Licensed Professional Clinical Counselors, Licensed Marriage and Family Therapists, and licensed-eligible practitioner working under the supervision of a licensed clinician.  To be considered “license-eligible," the individual must be registered with the appropriate state licensing authority for their respective field. Interns who have not yet received their advanced degree within their specific field and/or have not registered with the appropriate state board are not considered LPHAs.

What does it mean to be a “registered" counselor?

According to 9 CCR 13005(a)(8), “registrant" means an individual registered to obtain certification as an AOD counselor with the California Association for Alcohol and Drug Educators (CAADE), California Association of DUI Treatment Programs (CADTP) or California Consortium for Addiction Programs and Professionals (CCAPP).

Can a non-perinatal provider serve a pregnant beneficiary? What is the process to claim for these services?

​Yes, a pregnant beneficiary can choose to receive services from a non-perinatal provider. If the beneficiary receives eligibility through a pregnancy aid code, the claim must include the PAT 9 pregnancy indicator to be valid. Please refer to the Perinatal Practice Guidelines for providers working with pregnant and parenting women seeking or referred to SUD treatment.

Can you submit a claim for residential treatment if the beneficiary received no residential covered services on the date of service for the claim?

Reference BHIN 21-075 

No. In order to claim for residential treatment, beneficiaries must receive at least one residential covered service (i.e. required structured activity) on the date of service for the claim. BHIN 21-075 outlines the services covered under Residential Treatment.

Are revenues other than 2011 realignment funds eligible for federal match?

Yes. Other local funds are eligible to be used as the non-federal match as long as they are non-federal public funds and are otherwise eligible to be used as match consistent with the requirements outlined in SSA §1903(w)(6) and 42 CFR §433.51.​

1 ​A waiver from SAMHSA is required to prescribe buprenorphine.

2 Licensed residential treatment programs that are authorized to provide incidental medical services (IMS) may also offer MAT using IMS.
  
3 Additional changes to documentation and treatment planning requirements are forthcoming and will be effective July 1, 2022.​​​

Last modified date: 3/16/2023 1:38 PM