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.
SMHS Access Criteria
The criteria for Beneficiaries under age 21 to access the Specialty Mental Health Services Delivery System identified in BHIN 21-073 states that a licensed mental health professional can provide an assessment showing that the beneficiary's condition includes significant trauma. Can a waivered or registered professional provide this assessment?
Reference BHIN 20-069
No, waivered or registered professionals are not licensed. For details regarding the Mental Health Professional Licensure Waiver, please see BHIN 20-069.
For clients who begin specialty mental health services with Z codes (e.g., Z55-Z65), will they eventually require a mental health diagnosis, or can Z or V codes be the only diagnosis that is submitted for reimbursement? Can a Z code be the primary diagnosis?
Reference BHIN 21-073 BHIN 22-013
As point of clarification, a mental health disorder diagnosis is not required to receive medically necessary SMHS. However, ICD diagnostic codes are required on claims in order for DHCS to receive federal financial participation. Z codes meet the federal requirement for claims and do not indicate a diagnosis of a mental health disorder or a substance use disorder (see BHIN 22-013).
Z codes can be used during the assessment phase of a beneficiary's treatment, including before a mental health disorder diagnosis has been established. Z codes can be used after the assessment phase, including after a mental health disorder has been established. Z codes can also be used after the assessment phase even if a mental health disorder diagnosis has not been established, as a mental health disorder diagnosis is not a prerequisite to receive medically necessary SMHS as set forth in W&I Code section 14184.402(f)(1)(A). This is especially relevant for medically necessary SMHS provided to beneficiaries under age 21, for whom access criteria to SMHS includes the ability to receive medically necessary SMHS based on high risk for a mental health disorder due to the experience of trauma as specified in BHIN 21-073. All SMHS must be medically necessary. The assessment or other documentation in the medical record should substantiate the use of a Z code. Please refer to the CMS coding guidelines for additional information about Z codes, including when Z codes can be used as a primary diagnosis.
For additional information about the criteria for beneficiaries to access Specialty Mental Health Services, please refer to BHIN 21-073.
Can SMHS provider submit a claim for a SMHS provided to a beneficiary who also has a Substance Use Disorder (SUD) diagnosis?
Reference BHIN 21-073
Yes. As described in the “Co-Occurring Substance Use Disorder" section of BHIN 22-011, SMHS are covered when provided to beneficiaries who meet SMHS criteria even if they also have a substance use disorder (SUD) diagnosis.
Please note that substance-related and addictive disorders (e.g., stimulant use disorder) are not “mental health disorders" for the purpose of determining whether a beneficiary meets criteria for access to the SMHS delivery system. However, MHPs must cover SMHS for beneficiaries with a substance use disorder if they also have a mental health condition (or suspected mental health condition not yet diagnosed) and meet criteria for access to SMHS as described in BHIN 21-073. The service provided must match the reason for the service encounter using the CMS ICD-10-CM codes.
If a mental health provider is serving clients with a co-occurring substance use disorder, will that impact clients getting to the correct level of care for SUD treatment?
Reference BHIN 21-073
Mental health providers serving Beneficiaries with a co-occurring SUD should provide a referral to the DMC or DMC-ODS county or provider for an initial screening or assessment using the American Society of Addiction Medicine (ASAM) criteria to determine the appropriate level of SUD treatment. For DMC counties, see BHIN 21-071. For DMC-ODS counties, see BHIN 21-075. Beneficiaries are not obligated to start or enroll in DMC/DMC-ODS services for their SUD condition as a requirement to receive SMHS for their mental health condition.
What is the difference between “medical necessity" and criteria for beneficiaries to access specialty mental health services (SMHS)?
Reference BHIN 21-073
BHIN 21-073 separately addresses access criteria and “medical necessity" requirements. Beneficiaries must meet specific criteria to access SMHS through the county Mental Health Plan (MHP) delivery system, as identified in Welfare & Institutions Code (WIC) section 14184.402(c)-(d). Services provided to a beneficiary through the MHP delivery system must be “medically necessary" or be a “medical necessity," as set forth in WIC section 14059.5(a)-(b)(1).
As context, CalAIM updated the definition of medical necessity for SMHS. Previously, in the former 1915(b) SMHS waiver that was authorized from 2015 through 2021, medical necessity for SMHS was defined in comprehensive detail, predicated on the establishment of specific diagnoses and expected outcomes of proposed interventions. This former 1915(b) waiver definition of medical necessity corresponded to California Code of Regulations (CCR), title 9, sections 1830.205 and 1830.210. Prior to CalAIM, beneficiaries were required to meet these diagnostic criteria, and SMHS services were required to meet the expected outcome criteria, in order for SMHS services to be covered and reimbursable. If, following assessment, these comprehensive medical necessity criteria were not documented as met for each service provided, the county MHPs were at risk of recoupment because the services would be determined to be an overpayment based on the beneficiary not meeting medical necessity requirements for SMHS.
To streamline policies and improve access to care, CalAIM supersedes the definition of medical necessity for SMHS at CCR, title 9, sections 1830.205 and 1830.210 and in the former 1915(b) waiver. As a result of the CalAIM trailer bill AB 133, medical necessity for SMHS services is now defined at W&I Code section 14059.5.
For individuals 21 years of age or older, a service is "medically necessary" or a "medical necessity" when it is reasonable and necessary to protect life, to prevent significant illness or significant disability, or to alleviate severe pain. For beneficiaries under 21, medical necessity for SMHS services as defined as meeting the standards set forth in Section 1396d(r)(5) of Title 42 of the United States Code, commonly referred to as the EPSDT mandate. As described in
BHIN 21-073,
“This section requires provision of all Medicaid-coverable services necessary to correct or ameliorate a mental illness or condition discovered by a screening service, whether or not such services are covered under the State Plan. Furthermore, federal guidance from the Centers for Medicare & Medicaid Services makes it clear that mental health services need not be curative or restorative to ameliorate a mental health condition. Services that sustain, support, improve, or make more tolerable a mental health condition are considered to ameliorate the mental health condition are thus medically necessary and covered as EPSDT services." DHCS has consistently included this description of the EPSDT mandate in all pertinent guidance it has issued under CalAIM with the goal of providing clear, plain-English information about medical necessity for beneficiaries under 21.
Is a mental health diagnosis required for access to covered SMHS?
Reference BHIN 21-073
No. Per WIC section 14184.402, subdivision (f)(1)(a), a mental health diagnosis is not a prerequisite to accessing covered SMHS.How long can SMHS be provided prior to a beneficiary receiving a mental health diagnosis?
Reference BHIN 22-019
DHCS has not set an exact time limit for an assessment period for SMHS. However, providers shall complete assessments within a reasonable time and in accordance with generally accepted standards of practice. Which trauma screening tools have been approved by DHCS?
Reference BHIN 21-073
DHCS has not approved any specific trauma screening tool for purposes of implementing SMHS access criteria. The Pediatric ACES and Related Life-Events Screener (PEARLS) tool is an example of a standard way of measuring trauma for children and adolescents through age 19. The ACE Questionnaire is one example of a standard way of measuring trauma for adults beginning at age 18. DHCS will explore the approval process and standards for trauma screening tools for beneficiaries under 21 years of age through continued stakeholder engagement. DHCS will issue additional guidance in the future regarding approved trauma screening tool(s) for purposes of determining access to SMHS. What is the difference between a beneficiary under the age of 21 (1) having a condition placing them at high risk for a mental health disorder due to experience of trauma; and (2) scoring in the high-risk range under a trauma screening tool?
Reference BHIN 21-073
Covered SMHS shall be provided to enrolled beneficiaries under the age of 21 who meet one of two access criteria.
The first criteria requires the beneficiary to have a condition that places them at high risk of a mental health disorder due to experiencing trauma. Scoring in the high-risk range under a trauma screening tool approved by DHCS is one way of evidencing that this criteria is met. Other evidence includes involvement in the child welfare system, juvenile justice involvement, and experiencing homelessness. (Please see BHIN 21-073 for additional information, including definitions.)
Beneficiaries under the age of 21 who have experienced trauma who do not meet the first criteria to access SMHS may meet the second SMHS access criteria. The second criteria clarifies that beneficiaries with significant trauma placing the beneficiary at risk of a future mental health condition, based on the assessment of a licensed mental health professional, meet SMHS access criteria if they also have one of the following: a significant impairment; a reasonable probability of significant deterioration in an important area of life functioning; a reasonable probability of not progressing developmentally as appropriate; or a need for SMHS, regardless of presence of impairment, that are not included within the mental health benefits that a Medi-Cal managed care plan is required to provide.
Beneficiaries under the age of 21 only need to meet one of the two criteria described above and outlined in BHIN 21-073. They do not need to meet both criteria.
Do the new access criteria for beneficiaries under 21 add to or replace the criteria for admission to an STRTP?
Reference BHIN 21-073
No. The SMHS access criteria identified in BHIN 21-073 do not replace the admission criteria for STRTPs. Please see WIC section 11462.01, subdivision (b) and Section 9 of the Interim STRTP Regulations, Version II for further information regarding admission criteria for STRTPs. 