14680. (a) The Legislature finds and declares that there is a need
to establish a standard set of guidelines that governs the provision
of managed Medi-Cal mental health services at the local level,
consistent with federal law.
(b) Therefore, in order to ensure quality and continuity, and to
efficiently utilize mental health services under the Medi-Cal
program, there shall be developed mental health plans for the
provision of those services that are consistent with guidelines
established by the State Department of Mental Health.
(c) It is the intent of the Legislature that mental health plans
be developed and implemented regardless of whether other systems of
Medi-Cal managed care are implemented.
(d) It is further the intent of the Legislature that Sections
14681 to 14685, inclusive, shall not be construed to mandate the
participation of counties in Medi-Cal managed mental health care
plans.
14681. The State Department of Health Services, in consultation
with the State Department of Mental Health, shall ensure that all
contracts for Medi-Cal managed care include a process for screening,
referral, and coordination with any mental health plan established
pursuant to Section 14682, of medically necessary mental health care
services.
14682. (a) Notwithstanding any other provision of state law, and to
the extent permitted by federal law, the State Department of Mental
Health shall be designated as the state agency responsible for
development, consistent with the requirements of Section 4060, and
implementation of mental health plans for Medi-Cal beneficiaries.
(b) The department shall convene a steering committee for the
purpose of providing advice and recommendations on the development of
Medi-Cal mental health managed care systems pursuant to subdivision
(a). The committee shall include work groups to advise the department
of major issues to be addressed in the managed mental health care
plan. Representatives of concerned groups, including, but not limited
to, beneficiaries, their families, providers, mental health
professionals, statewide representatives of health care service
plans, the California Mental Health Planning Council, public and
private organizations, and county mental health directors, shall be
invited to participate in the steering committee process.
14683. The State Department of Mental Health shall ensure the
following in the development of mental health plans:
(a) That mental health plans include a process for screening,
referral, and coordination with other necessary services, including,
but not limited to, health, housing, and vocational rehabilitation
services. For Medi-Cal eligible children, the mental health plans
shall also provide coordination with education programs and any
necessary medical or rehabilitative services, including, but not
limited to, those provided under the California Children's Services
Program (Article 5 (commencing with Section 123800) of Chapter 3 of
Part 2 of Division 106 of the Health and Safety Code) and the Child
Health and Disability Prevention Program (Article 6 (commencing with
Section 124025) of Chapter 3 of Part 2 of Division 106 of the Health
and Safety Code), and those provided by a fee-for-service provider or
a Medi-Cal managed care plan. This subdivision shall not be
construed to establish any higher level of service from a county than
is required under existing law. The county mental health department
and the mental health plan, if it is not the county department, shall
not be liable for the failure of other agencies responsible for the
provision of nonmental health services to provide those services or
to participate in coordination efforts.
(b) That mental health plans include a system of outreach to
enable beneficiaries and providers to participate in and access
mental health services under the plans, consistent with existing law.
(c) That standards for quality and access developed by the
department, in consultation with the steering committee established
pursuant to Section 14682, are included in mental health plans.
14684. Notwithstanding any other provision of state law, and to the
extent permitted by federal law, mental health plans, whether
administered by public or private entities, shall be governed by the
following guidelines:
(a) State and federal Medi-Cal funds identified for the diagnosis
and treatment of mental disorders shall be used solely for those
purposes. Administrative costs shall be clearly identified and shall
be limited to reasonable amounts in relation to the scope of services
and the total funds available. Administrative requirements shall not
impose costs exceeding funds available for that purpose.
(b) The development of the mental health plan shall include a
public planning process that includes a significant role for Medi-Cal
beneficiaries, family members, mental health advocates, providers,
and public and private contract agencies.
(c) The mental health plan shall include appropriate standards
relating to quality, access, and coordination of services within a
managed system of care, and costs established under the plan, and
shall provide opportunities for existing Medi-Cal providers to
continue to provide services under the mental health plan, as long as
the providers meet those standards.
(d) Continuity of care for current recipients of services shall be
ensured in the transition to managed mental health care.
(e) Medi-Cal covered mental health services shall be provided in
the beneficiary's home community, or as close as possible to the
beneficiary's home community. Pursuant to the objectives of the
rehabilitation option described in subdivision (a) of Section
14021.4, mental health services may be provided in a facility, a
home, or other community-based site.
(f) Medi-Cal beneficiaries whose mental or emotional condition
results or has resulted in functional impairment, as defined by the
department, shall be eligible for covered mental health services.
Emphasis shall be placed on adults with serious and persistent mental
illness and children with serious emotional disturbances, as defined
by the department.
(g) Each mental health plan shall include a mechanism for
monitoring the effectiveness of, and evaluating accessibility and
quality of, services available. The plan shall utilize and be based
upon state-adopted performance outcome measures and shall include
review of individual service plan procedures and practices, a
beneficiary satisfaction component, and a grievance system for
beneficiaries and providers.
(h) Each mental health plan shall provide for culturally competent
and age-appropriate services, to the extent feasible. The mental
health plan shall assess the cultural competency needs of the
program. The mental health plan shall include, as part of the quality
assurance program required by Section 4070, a process to accommodate
the significant needs with reasonable timeliness. The department
shall provide demographic data and technical assistance. Performance
outcome measures shall include a reliable method of measuring and
reporting the extent to which services are culturally competent and
age-appropriate.
14684.1. (a) The State Department of Mental Health shall establish
a process for second level treatment authorization request appeals to
review and resolve disputes between mental health plans and
hospitals.
(b) When the department establishes an appeals process, the
department shall comply with all of the following:
(1) The department shall review appeals initiated by hospitals and
render decisions on appeals based on findings that are the result of
a review of supporting documents submitted by mental health plans
and hospitals.
(2) If the department upholds a mental health plan denial of
payment of a hospital claim, a review fee shall be assessed on the
provider.
(3) If the State Department of Mental Health reverses a mental
health plan denial of payment of a hospital claim, a review fee shall
be assessed on the mental health plan.
(4) If the department decision regarding a mental health plan
denial of payment upholds the claim in part and reverses the claim in
part, the department shall prorate the review fee between the
parties accordingly.
(c) The amount of the review fees shall be calculated and adjusted
annually. The methodology and calculation used to determine the fee
amounts shall result in an aggregate fee amount that, in conjunction
with any other outside source of funding for this function, may not
exceed the aggregate annual costs of providing second level treatment
authorization request reviews.
(d) Fees collected by the department shall be retained by the
department and used to offset administrative and personnel services
costs associated with the appeals process.
(e) The department may use the fees collected, in conjunction with
other available appropriate funding for this function, to contract
for the performance of the appeals process function.
14685. Counties shall have the right of first refusal to serve as a
mental health plan. If a county elects not to serve as a mental
health plan, the State Department of Mental Health shall ensure that
these services are provided.
14680. (a) The Legislature finds and declares that there is a need
to establish a standard set of guidelines that governs the provision
of managed Medi-Cal mental health services at the local level,
consistent with federal law.
(b) Therefore, in order to ensure quality and continuity, and to
efficiently utilize mental health services under the Medi-Cal
program, there shall be developed mental health plans for the
provision of those services that are consistent with guidelines
established by the State Department of Mental Health.
(c) It is the intent of the Legislature that mental health plans
be developed and implemented regardless of whether other systems of
Medi-Cal managed care are implemented.
(d) It is further the intent of the Legislature that Sections
14681 to 14685, inclusive, shall not be construed to mandate the
participation of counties in Medi-Cal managed mental health care
plans.
14681. The State Department of Health Services, in consultation
with the State Department of Mental Health, shall ensure that all
contracts for Medi-Cal managed care include a process for screening,
referral, and coordination with any mental health plan established
pursuant to Section 14682, of medically necessary mental health care
services.
14682. (a) Notwithstanding any other provision of state law, and to
the extent permitted by federal law, the State Department of Mental
Health shall be designated as the state agency responsible for
development, consistent with the requirements of Section 4060, and
implementation of mental health plans for Medi-Cal beneficiaries.
(b) The department shall convene a steering committee for the
purpose of providing advice and recommendations on the development of
Medi-Cal mental health managed care systems pursuant to subdivision
(a). The committee shall include work groups to advise the department
of major issues to be addressed in the managed mental health care
plan. Representatives of concerned groups, including, but not limited
to, beneficiaries, their families, providers, mental health
professionals, statewide representatives of health care service
plans, the California Mental Health Planning Council, public and
private organizations, and county mental health directors, shall be
invited to participate in the steering committee process.
14683. The State Department of Mental Health shall ensure the
following in the development of mental health plans:
(a) That mental health plans include a process for screening,
referral, and coordination with other necessary services, including,
but not limited to, health, housing, and vocational rehabilitation
services. For Medi-Cal eligible children, the mental health plans
shall also provide coordination with education programs and any
necessary medical or rehabilitative services, including, but not
limited to, those provided under the California Children's Services
Program (Article 5 (commencing with Section 123800) of Chapter 3 of
Part 2 of Division 106 of the Health and Safety Code) and the Child
Health and Disability Prevention Program (Article 6 (commencing with
Section 124025) of Chapter 3 of Part 2 of Division 106 of the Health
and Safety Code), and those provided by a fee-for-service provider or
a Medi-Cal managed care plan. This subdivision shall not be
construed to establish any higher level of service from a county than
is required under existing law. The county mental health department
and the mental health plan, if it is not the county department, shall
not be liable for the failure of other agencies responsible for the
provision of nonmental health services to provide those services or
to participate in coordination efforts.
(b) That mental health plans include a system of outreach to
enable beneficiaries and providers to participate in and access
mental health services under the plans, consistent with existing law.
(c) That standards for quality and access developed by the
department, in consultation with the steering committee established
pursuant to Section 14682, are included in mental health plans.
14684. Notwithstanding any other provision of state law, and to the
extent permitted by federal law, mental health plans, whether
administered by public or private entities, shall be governed by the
following guidelines:
(a) State and federal Medi-Cal funds identified for the diagnosis
and treatment of mental disorders shall be used solely for those
purposes. Administrative costs shall be clearly identified and shall
be limited to reasonable amounts in relation to the scope of services
and the total funds available. Administrative requirements shall not
impose costs exceeding funds available for that purpose.
(b) The development of the mental health plan shall include a
public planning process that includes a significant role for Medi-Cal
beneficiaries, family members, mental health advocates, providers,
and public and private contract agencies.
(c) The mental health plan shall include appropriate standards
relating to quality, access, and coordination of services within a
managed system of care, and costs established under the plan, and
shall provide opportunities for existing Medi-Cal providers to
continue to provide services under the mental health plan, as long as
the providers meet those standards.
(d) Continuity of care for current recipients of services shall be
ensured in the transition to managed mental health care.
(e) Medi-Cal covered mental health services shall be provided in
the beneficiary's home community, or as close as possible to the
beneficiary's home community. Pursuant to the objectives of the
rehabilitation option described in subdivision (a) of Section
14021.4, mental health services may be provided in a facility, a
home, or other community-based site.
(f) Medi-Cal beneficiaries whose mental or emotional condition
results or has resulted in functional impairment, as defined by the
department, shall be eligible for covered mental health services.
Emphasis shall be placed on adults with serious and persistent mental
illness and children with serious emotional disturbances, as defined
by the department.
(g) Each mental health plan shall include a mechanism for
monitoring the effectiveness of, and evaluating accessibility and
quality of, services available. The plan shall utilize and be based
upon state-adopted performance outcome measures and shall include
review of individual service plan procedures and practices, a
beneficiary satisfaction component, and a grievance system for
beneficiaries and providers.
(h) Each mental health plan shall provide for culturally competent
and age-appropriate services, to the extent feasible. The mental
health plan shall assess the cultural competency needs of the
program. The mental health plan shall include, as part of the quality
assurance program required by Section 4070, a process to accommodate
the significant needs with reasonable timeliness. The department
shall provide demographic data and technical assistance. Performance
outcome measures shall include a reliable method of measuring and
reporting the extent to which services are culturally competent and
age-appropriate.
14684.1. (a) The State Department of Mental Health shall establish
a process for second level treatment authorization request appeals to
review and resolve disputes between mental health plans and
hospitals.
(b) When the department establishes an appeals process, the
department shall comply with all of the following:
(1) The department shall review appeals initiated by hospitals and
render decisions on appeals based on findings that are the result of
a review of supporting documents submitted by mental health plans
and hospitals.
(2) If the department upholds a mental health plan denial of
payment of a hospital claim, a review fee shall be assessed on the
provider.
(3) If the State Department of Mental Health reverses a mental
health plan denial of payment of a hospital claim, a review fee shall
be assessed on the mental health plan.
(4) If the department decision regarding a mental health plan
denial of payment upholds the claim in part and reverses the claim in
part, the department shall prorate the review fee between the
parties accordingly.
(c) The amount of the review fees shall be calculated and adjusted
annually. The methodology and calculation used to determine the fee
amounts shall result in an aggregate fee amount that, in conjunction
with any other outside source of funding for this function, may not
exceed the aggregate annual costs of providing second level treatment
authorization request reviews.
(d) Fees collected by the department shall be retained by the
department and used to offset administrative and personnel services
costs associated with the appeals process.
(e) The department may use the fees collected, in conjunction with
other available appropriate funding for this function, to contract
for the performance of the appeals process function.
14685. Counties shall have the right of first refusal to serve as a
mental health plan. If a county elects not to serve as a mental
health plan, the State Department of Mental Health shall ensure that
these services are provided.
14680. (a) The Legislature finds and declares that there is a need
to establish a standard set of guidelines that governs the provision
of managed Medi-Cal mental health services at the local level,
consistent with federal law.
(b) Therefore, in order to ensure quality and continuity, and to
efficiently utilize mental health services under the Medi-Cal
program, there shall be developed mental health plans for the
provision of those services that are consistent with guidelines
established by the State Department of Mental Health.
(c) It is the intent of the Legislature that mental health plans
be developed and implemented regardless of whether other systems of
Medi-Cal managed care are implemented.
(d) It is further the intent of the Legislature that Sections
14681 to 14685, inclusive, shall not be construed to mandate the
participation of counties in Medi-Cal managed mental health care
plans.
14681. The State Department of Health Services, in consultation
with the State Department of Mental Health, shall ensure that all
contracts for Medi-Cal managed care include a process for screening,
referral, and coordination with any mental health plan established
pursuant to Section 14682, of medically necessary mental health care
services.
14682. (a) Notwithstanding any other provision of state law, and to
the extent permitted by federal law, the State Department of Mental
Health shall be designated as the state agency responsible for
development, consistent with the requirements of Section 4060, and
implementation of mental health plans for Medi-Cal beneficiaries.
(b) The department shall convene a steering committee for the
purpose of providing advice and recommendations on the development of
Medi-Cal mental health managed care systems pursuant to subdivision
(a). The committee shall include work groups to advise the department
of major issues to be addressed in the managed mental health care
plan. Representatives of concerned groups, including, but not limited
to, beneficiaries, their families, providers, mental health
professionals, statewide representatives of health care service
plans, the California Mental Health Planning Council, public and
private organizations, and county mental health directors, shall be
invited to participate in the steering committee process.
14683. The State Department of Mental Health shall ensure the
following in the development of mental health plans:
(a) That mental health plans include a process for screening,
referral, and coordination with other necessary services, including,
but not limited to, health, housing, and vocational rehabilitation
services. For Medi-Cal eligible children, the mental health plans
shall also provide coordination with education programs and any
necessary medical or rehabilitative services, including, but not
limited to, those provided under the California Children's Services
Program (Article 5 (commencing with Section 123800) of Chapter 3 of
Part 2 of Division 106 of the Health and Safety Code) and the Child
Health and Disability Prevention Program (Article 6 (commencing with
Section 124025) of Chapter 3 of Part 2 of Division 106 of the Health
and Safety Code), and those provided by a fee-for-service provider or
a Medi-Cal managed care plan. This subdivision shall not be
construed to establish any higher level of service from a county than
is required under existing law. The county mental health department
and the mental health plan, if it is not the county department, shall
not be liable for the failure of other agencies responsible for the
provision of nonmental health services to provide those services or
to participate in coordination efforts.
(b) That mental health plans include a system of outreach to
enable beneficiaries and providers to participate in and access
mental health services under the plans, consistent with existing law.
(c) That standards for quality and access developed by the
department, in consultation with the steering committee established
pursuant to Section 14682, are included in mental health plans.
14684. Notwithstanding any other provision of state law, and to the
extent permitted by federal law, mental health plans, whether
administered by public or private entities, shall be governed by the
following guidelines:
(a) State and federal Medi-Cal funds identified for the diagnosis
and treatment of mental disorders shall be used solely for those
purposes. Administrative costs shall be clearly identified and shall
be limited to reasonable amounts in relation to the scope of services
and the total funds available. Administrative requirements shall not
impose costs exceeding funds available for that purpose.
(b) The development of the mental health plan shall include a
public planning process that includes a significant role for Medi-Cal
beneficiaries, family members, mental health advocates, providers,
and public and private contract agencies.
(c) The mental health plan shall include appropriate standards
relating to quality, access, and coordination of services within a
managed system of care, and costs established under the plan, and
shall provide opportunities for existing Medi-Cal providers to
continue to provide services under the mental health plan, as long as
the providers meet those standards.
(d) Continuity of care for current recipients of services shall be
ensured in the transition to managed mental health care.
(e) Medi-Cal covered mental health services shall be provided in
the beneficiary's home community, or as close as possible to the
beneficiary's home community. Pursuant to the objectives of the
rehabilitation option described in subdivision (a) of Section
14021.4, mental health services may be provided in a facility, a
home, or other community-based site.
(f) Medi-Cal beneficiaries whose mental or emotional condition
results or has resulted in functional impairment, as defined by the
department, shall be eligible for covered mental health services.
Emphasis shall be placed on adults with serious and persistent mental
illness and children with serious emotional disturbances, as defined
by the department.
(g) Each mental health plan shall include a mechanism for
monitoring the effectiveness of, and evaluating accessibility and
quality of, services available. The plan shall utilize and be based
upon state-adopted performance outcome measures and shall include
review of individual service plan procedures and practices, a
beneficiary satisfaction component, and a grievance system for
beneficiaries and providers.
(h) Each mental health plan shall provide for culturally competent
and age-appropriate services, to the extent feasible. The mental
health plan shall assess the cultural competency needs of the
program. The mental health plan shall include, as part of the quality
assurance program required by Section 4070, a process to accommodate
the significant needs with reasonable timeliness. The department
shall provide demographic data and technical assistance. Performance
outcome measures shall include a reliable method of measuring and
reporting the extent to which services are culturally competent and
age-appropriate.
14684.1. (a) The State Department of Mental Health shall establish
a process for second level treatment authorization request appeals to
review and resolve disputes between mental health plans and
hospitals.
(b) When the department establishes an appeals process, the
department shall comply with all of the following:
(1) The department shall review appeals initiated by hospitals and
render decisions on appeals based on findings that are the result of
a review of supporting documents submitted by mental health plans
and hospitals.
(2) If the department upholds a mental health plan denial of
payment of a hospital claim, a review fee shall be assessed on the
provider.
(3) If the State Department of Mental Health reverses a mental
health plan denial of payment of a hospital claim, a review fee shall
be assessed on the mental health plan.
(4) If the department decision regarding a mental health plan
denial of payment upholds the claim in part and reverses the claim in
part, the department shall prorate the review fee between the
parties accordingly.
(c) The amount of the review fees shall be calculated and adjusted
annually. The methodology and calculation used to determine the fee
amounts shall result in an aggregate fee amount that, in conjunction
with any other outside source of funding for this function, may not
exceed the aggregate annual costs of providing second level treatment
authorization request reviews.
(d) Fees collected by the department shall be retained by the
department and used to offset administrative and personnel services
costs associated with the appeals process.
(e) The department may use the fees collected, in conjunction with
other available appropriate funding for this function, to contract
for the performance of the appeals process function.
14685. Counties shall have the right of first refusal to serve as a
mental health plan. If a county elects not to serve as a mental
health plan, the State Department of Mental Health shall ensure that
these services are provided.
