Source: https://www.global-regulation.com/law/united-states/365536/welfare-and-institutions-code%252c-division-9.-public-social-services-%252c-chapter-8.9.-transition-of-community-based-medi-cal-mental-health.html
Timestamp: 2020-02-24 14:39:21
Document Index: 357595965

Matched Legal Cases: ['ART 3', 'art 4', 'art 2', 'art 3', 'art 4', 'art 2', 'art 4', 'art 2']

Welfare And Institutions Code, Division 9. Public Social Services , Chapter 8.9. Transition Of Community-Based Medi-Cal Mental Health (United States)
Welfare And Institutions Code, Division 9. Public Social Services , Chapter 8.9. Transition Of Community-Based Medi-Cal Mental Health
( Division 9 added by Stats. 1965, Ch. 1784. )PART 3. AID AND MEDICAL ASSISTANCE [11000 - 15766]
CHAPTER 8.9. Transition of Community-Based Medi-Cal Mental Health [14700 - 14726]
(b) Effective July 1, 2012, the state administrative functions for the operation of Medi-Cal specialty mental health managed care, the EPSDT Program, and applicable functions related to federal Medicaid requirements, that were
performed by the State Department of Mental Health shall be transferred to the State Department of Health Care Services. This state administrative transfer shall conform to a state administrative transition plan provided to the fiscal and applicable policy committees of the Legislature as soon as feasible, but no later than October 1, 2011. This state administrative transition plan may also be updated by the Governor and provided to all fiscal and applicable policy committees of the Legislature upon its completion, but no later than May 15, 2012.
(Added by Stats. 2011, Ch. 29, Sec. 20. Effective June 29, 2011. Conditionally inoperative as provided in Section 14721.)
(b) (1) Commencing no later than July 15, 2011, the State Department of Health Care Services, together with the State Department of State Hospitals, shall convene a series of stakeholder meetings and forums to receive input from clients, family
members, providers, counties, and representatives of the Legislature concerning the transition and transfer of Medi-Cal specialty mental health managed care and the EPSDT Program. This consultation shall inform the creation of a state administrative transition plan and a programmatic transition plan that shall include, but is not limited to, the following components:
(E) A detailed organization chart that
reflects the planned staffing at the State Department of Health Care Services in light of the requirements of subparagraphs (A) to (C), inclusive, and includes focused, high-level leadership for behavioral health issues.
(2) The State Department of Health Care Services, together with the State Department of State Hospitals and the California Health and Human Services Agency, shall convene and consult with stakeholders at least twice following production of a draft of the transition plans and before submission of transition plans to the Legislature. Continued consultation with stakeholders shall occur in accordance with the requirement in
(Amended by Stats. 2014, Ch. 71, Sec. 200. Effective January 1, 2015. Conditionally inoperative as provided in Section 14721.)
(a) ?Department? means the State Department of Health Care Services.
(b) ?Director? means the Director of Health Care Services.
(Added by Stats. 2012, Ch. 34, Sec. 245. Effective June 27, 2012. Conditionally inoperative as provided in Section 14721.)
(Added by Stats. 2012, Ch. 34, Sec. 246. Effective June 27, 2012. Conditionally inoperative as provided in Section 14721.)
(Added by Stats. 2012, Ch. 34, Sec. 247. Effective June 27, 2012. Conditionally inoperative as provided in Section 14721.)
(a) (1) This section shall apply to specialty mental health services provided by counties to Medi-Cal eligible individuals. Counties shall provide services to Medi-Cal beneficiaries and seek the maximum federal reimbursement possible for services rendered to
persons with mental illnesses.
(2) To the extent permitted under federal law and Section 5892, funds distributed to the counties from the Mental Health Subaccount, the Mental Health Equity Subaccount, and the Vehicle License Collection Account of the Local Revenue Fund, funds from the Mental Health Account and the Behavioral Health Subaccount of the Local Revenue Fund 2011, funds from the Mental Health Services Fund, and any other funds from which the Controller makes distributions to the counties may
pay for services provided by these funds that the counties can then certify as public expenditures in order to achieve the maximum federal reimbursement possible for services pursuant to this chapter.
(b) With regard to each person receiving specialty
mental health services from a
mental health plan, the mental health plan shall verify whether the person is Medi-Cal eligible and, if determined to be Medi-Cal eligible, the person shall be referred when appropriate to a facility, clinic, or program that is certified for Medi-Cal reimbursement.
(c) With regard to county operated facilities,
clinics, or programs for which claims are submitted to the department for Medi-Cal reimbursement for specialty mental health services to Medi-Cal eligible individuals, the county shall ensure that all requirements necessary for Medi-Cal reimbursement for these services are complied with, including, but not limited to, utilization review and the submission of yearend cost reports by December 31 following the close of the fiscal year.
(d) Counties shall certify to the state that they have incurred public expenditures prior to
the reimbursement of federal funds.
(Added by renumbering Section 5718 (as added by Stats. 2011, Ch. 651, Sec. 2) by Stats. 2012, Ch. 34, Sec. 152. Effective June 27, 2012. Section operative July 1, 2012, by its own provisions. Conditionally inoperative as provided in Section 14721.)
Each public or private facility or agency providing local specialty mental health services pursuant to a county performance contract plan shall make a written certification within 30 days after a patient is admitted to the facility as a patient or first given services by such a facility or agency, to the local mental health director of the county, stating whether or not each of these patients is presumed to be eligible for
specialty mental health services under the Medi-Cal program.
(Added by renumbering Section 5719 by Stats. 2012, Ch. 34, Sec. 153. Effective June 27, 2012. Operative July 1, 2012, by Sec. 254 of Ch. 34. Conditionally inoperative as provided in Section 14721.)
Mental health plans may contract with providers on a negotiated net amount basis in the same manner as set forth in Section 5705. Negotiated net amounts or rates shall not be in contracts between the state and mental health plans for specialty mental health services. Reimbursement to mental health plans that have certified public expenditures shall be consistent with
federal Medicaid requirements for calculating upper payment limits, as specified in the approved Medicaid state plan and waivers.
(Added by renumbering Section 5716 by Stats. 2012, Ch. 34, Sec. 150. Effective June 27, 2012. Conditionally inoperative as provided in Section 14721.)
(a) The department shall have responsibility for conducting investigations and audits of claims and reimbursements for expenditures for specialty mental health services provided by mental health
plans to Medi-Cal eligible individuals.
(b) The amount of the payment or repayment of federal funds in accordance with audit findings pertaining to
Medi-Cal specialty mental health services shall be determined by the department pursuant to the existing administrative appeals process of the department.
(Added by renumbering Section 5722 by Stats. 2012, Ch. 34, Sec. 157. Effective June 27, 2012. Operative July 1, 2012, by Sec. 254 of Ch. 34. Conditionally inoperative as provided in Section 14721.)
(a) In the case of federal audit exceptions, the department shall follow federal audit appeal processes unless the department, in consultation with the California
Mental Health Directors Association, determines that those appeals are not cost beneficial.
(b) Whenever there is a final federal audit exception against the state resulting from expenditure of federal funds by individual counties, the department may offset federal reimbursement and request the Controller?s office to offset the
distribution of funds to the counties from the Mental Health Subaccount, the Mental Health Equity Subaccount, and the Vehicle License Collection Account of the Local Revenue Fund, funds from the Mental Health Account and the Behavioral Health Subaccount of the Local Revenue Fund 2011, and any other mental health realignment funds from which the Controller makes distributions to the counties by the amount of the exception. The
department shall provide evidence to the Controller
that the county has been notified of the amount of the audit exception no less than 30 days before the offset is to occur. The department shall involve the appropriate counties in developing responses to any draft federal audit reports that directly impact the county.
(Added by renumbering Section 5711 by Stats. 2012, Ch. 34, Sec. 146. Effective June 27, 2012. Conditionally inoperative as provided in Section 14721.)
(c) The State Department of Health Care Services shall provide the performance outcomes system plan, including milestones and timelines, for EPSDT mental health services described in subdivision (a) to all
fiscal committees and appropriate policy committees of the Legislature no later than October 1, 2013.
(e) Commencing no later than February 1, 2014, the department shall convene a stakeholder advisory committee comprised of advocates for and representatives of, child and youth clients, family members, managed care health plans, providers, counties, and the Legislature. The committee shall develop methods to routinely measure, assess, and communicate program information regarding informing, identifying, screening, assessing, referring, and linking Medi-Cal eligible beneficiaries to mental health services and supports. The committee shall also review health plan screenings
for mental health illness, health plan referrals to Medi-Cal fee-for-service providers, and health plan referrals to county mental health plans, among others. The committee shall make recommendations to the department regarding performance and outcome measures that will contribute to improving timely access to appropriate care for Medi-Cal eligible beneficiaries.
(2) The department shall propose how to implement the updated performance systems outcome plan described in paragraph (1) no later than January
(Amended by Stats. 2013, Ch. 23, Sec. 67. Effective June 27, 2013. Conditionally inoperative as provided in Section 14721.)
(a) For purposes of federal reimbursement to counties that have certified to the state that they have incurred certified public
expenditures, the reimbursement amounts shall be consistent with federal Medicaid requirements for calculating federal upper payment limits, as specified in the approved Medicaid state plan and waivers.
(b) If the reimbursement methodology utilizes federal upper payment limits and the total cost of services exceeds the state maximum rates in effect for the 2011?12 fiscal year, a county may use certified public expenditures to claim the costs of services that exceed the state maximum rates, up to the federal upper payment limits. If a county chooses to claim costs that exceed the state maximum rates with certified public expenditures, the county shall use only local funds, and not state funds, to claim the portion of the costs over the state maximum rates. As a condition of receiving reimbursement up to the federal upper payment limits, a
county shall enter into and maintain an agreement with the department implementing this subdivision.
(c) Notwithstanding this section, in the event that a health facility has entered into a negotiated rate agreement pursuant to Article 2.6 (commencing with Section 14081) of Chapter 7 of Part 4 of Division 9, the facility?s rates shall be governed by that agreement.
(Added by renumbering Section 5720 (as added by Stats. 2011, Ch. 651, Sec. 4) by Stats. 2012, Ch. 34, Sec. 155. Effective June 27, 2012. Section operative July 1, 2012, by its own provisions. Conditionally inoperative as provided in Section 14721.)
The provisions of subdivision (a) of Section 14000 shall not be construed to prevent providers of specialty mental health services pursuant to this chapter from also being providers of medical assistance mental health services for the purposes of Chapter 7 (commencing with Section 14000).
Medi-Cal specialty mental health services pursuant to this
chapter shall be required to be certified as a condition to reimbursement for providing those medical assistance mental health services.
(Added by renumbering Section 5723 by Stats. 2012, Ch. 34, Sec. 158. Effective June 27, 2012. Operative July 1, 2012, by Sec. 254 of Ch. 34. Conditionally inoperative as provided in Section 14721.)
Except as otherwise provided in this section, in determining the amounts which may be paid, fees paid by persons receiving services or fees paid on behalf of persons receiving services by the federal government, by the Medi-Cal program set forth in Chapter 7 (commencing with Section 14000),
and by other public or private sources, shall be deducted from the costs of providing services. However, a mental health plan may negotiate a contract that permits a specialty mental health care provider to retain unanticipated funds above the budgeted contract amount, provided that the unanticipated revenues are utilized for the specialty mental health services specified in the contract. If a provider is
permitted by contract to retain unanticipated revenues above the budgeted amount, the specialty mental health provider shall specify the services funded by those revenues in the
yearend cost report submitted to the mental health plan. A mental health plan shall not permit the retention of any fees paid by private resources on behalf of Medi-Cal beneficiaries without having those fees deducted from the costs of providing services. Whenever feasible, persons with mental illness who are eligible for
specialty mental health services under the Medi-Cal program shall be treated in a facility approved for reimbursement in that program. General unrestricted or undesignated private charitable donations and contributions made to charitable or nonprofit organizations shall not be considered as ?fees paid by persons? or ?fees paid on behalf of persons receiving services? under this section and the contributions shall not be applied in determining the amounts to be paid. These unrestricted contributions shall not be used in part or in whole to defray the costs or the allocated costs of the
(Added by renumbering Section 5721 by Stats. 2012, Ch. 34, Sec. 156. Effective June 27, 2012. Operative July 1, 2012, by Sec. 254 of Ch. 34. Conditionally inoperative as provided in Section 14721.)
(a) The department shall develop, in consultation with the California Mental Health Directors Association, a reimbursement methodology for use in the Medi-Cal claims processing and interim payment system that
maximizes federal funding and utilizes, as much as practicable, federal Medicaid and Medicare reimbursement principles. The department shall work with the federal Centers for Medicare and Medicaid Services in the development of the methodology required by this section.
(c) Administrative costs shall be claimed separately in a manner consistent with federal Medicaid requirements and the approved Medicaid state plan and waivers and shall be limited to 15 percent of the total actual cost of direct
(h) This section shall become operative on July 1,
(Added by renumbering Section 5724 (as added by Stats. 2011, Ch. 651, Sec. 6) by Stats. 2012, Ch. 34, Sec. 160. Effective June 27, 2012. Section operative July 1, 2012, by its own provisions. Conditionally inoperative as provided in Section 14721.)
(a) Notwithstanding any other provision of state law, the department shall implement managed mental health care for Medi-Cal beneficiaries through contracts with mental health plans.
Mental health plans may include individual counties, counties acting jointly, or an organization or nongovernmental entity determined by the department to meet mental health plan standards. A contract may be exclusive and may be awarded on a geographic basis.
(b) Two or more counties acting jointly may agree to deliver or subcontract for the delivery of specialty mental health services
subject to the approval by the department. The agreement may encompass all or any portion of the specialty mental health services provided pursuant to this chapter. This agreement shall not relieve the individual counties of fiscal responsibility for providing these services. Any agreement between counties shall delineate each county?s responsibilities and fiscal liability for
(c) (1) The department shall contract with a county or counties acting jointly for the delivery of specialty mental health services to
county?s eligible Medi-Cal beneficiary population. If a county decides not to contract with the department, does not renew its contract, or
is unable to meet the standards set by the department, the county shall inform the department of this decision in writing.
(4) The department may
contract with qualifying individual counties, counties acting jointly, or other qualified entities approved by the department for the delivery of specialty mental health services in any county that is unable or unwilling to contract with the department. The county may not subsequently contract to provide specialty mental health services under this chapter unless the department elects to contract with the county.
(d) If a county does not contract with the department or other department-approved entity to provide specialty mental health services, the
work with the Department of Finance and the Controller to sequester funds from the county that is unable or unwilling to contract in accordance with Section 30027.10 of the Government Code.
(e) Whenever the department determines that a mental health plan has failed to comply with this chapter or any regulations, contractual requirements, state plan, or waivers adopted pursuant to this chapter,
shall notify the mental health plan in writing within 30 days of its determination and may impose sanctions, including, but not limited to, fines, penalties, the withholding of payments, special requirements, probationary or corrective actions, or any other actions deemed necessary to promptly ensure contract and performance compliance. If
the department imposes fines or penalties, to the extent permitted by federal law and state law or contract, it may offset the fines from either of the following:
(2) Any other mental health realignment funds from which the Controller is
authorized to make distributions to the counties, if the funds described in paragraph (1) are insufficient for the purposes described in this subdivision.
(Added by renumbering Section 5775 by Stats. 2012, Ch. 34, Sec. 173. Effective June 27, 2012. Operative July 1, 2012, by Sec. 254 of Ch. 34. Conditionally inoperative as provided in Section 14721.)
(a) The department and mental health plans shall comply with all applicable federal laws, regulations, and the guidelines,
standards, and requirements specified in the state plan, waiver, and mental health plan contract, and, except as provided in this chapter, all applicable state statutes and regulations.
(b) If federal requirements that affect the provisions of this
chapter are changed, it is the intent of the Legislature that state requirements be revised to comply with those changes.
(Added by renumbering Section 5776 by Stats. 2012, Ch. 34, Sec. 174. Effective June 27, 2012. Operative July 1, 2012, by Sec. 254 of Ch. 34. Conditionally inoperative as provided in Section 14721.)
(a) (1) Except as otherwise specified in this chapter, a contract entered into pursuant to this chapter shall include a provision that the mental health plan contractor shall bear the financial risk for the cost of providing
specialty mental health services to Medi-Cal beneficiaries.
(2) If the mental health plan is not administered by a county, the mental health plan
shall not transfer the obligation for any specialty mental health services to Medi-Cal beneficiaries to the county. The mental health plan may purchase services from the county. The mental health plan shall establish mutually agreed-upon protocols with the county that clearly establish conditions under which beneficiaries may obtain non-Medi-Cal reimbursable services from the county. Additionally, the plan shall establish mutually agreed-upon protocols with the county for the conditions of transfer of beneficiaries who have lost Medi-Cal eligibility to the county for care under Part 2 (commencing with Section 5600), Part 3 (commencing with Section 5800), and Part 4 (commencing with Section 5850) of Division 5.
(3) The mental health plan shall be financially responsible for ensuring access and a minimum required scope of benefits and services, consistent with state and federal requirements, to Medi-Cal beneficiaries
who are residents of that county regardless of where the beneficiary resides. The department shall require that the same definition of medical necessity be used, and the minimum scope of benefits offered by each mental health
plan be the same, except to the extent that prior federal approval is received and is consistent with state and federal laws.
(b) (1) Any contract entered into pursuant to this chapter may be renewed if the mental health plan continues to meet the requirements of this chapter, regulations promulgated pursuant thereto, and the terms and conditions of the contract. Failure to meet these requirements shall be cause for nonrenewal of the contract. The department may base the decision to renew on timely completion of a mutually agreed-upon plan of correction of any deficiencies, submissions of required
information in a timely manner, or other conditions of the contract.
(2) In the event the contract is not renewed based on the reasons specified in paragraph (1), the department shall notify the Department of Finance, the fiscal and policy committees of the Legislature, and the Controller of the amounts to be sequestered from the Mental Health Subaccount, the Mental Health Equity Account, and the Vehicle License Fee Collection Account of the Local Revenue Fund and the Mental Health Account and the Behavioral Health Subaccount of the Local Revenue Fund 2011, and the Controller shall sequester those funds in the Behavioral Health Subaccount pursuant to Section 30027.10 of the
Government Code. Upon this sequestration, the department shall use the funds in accordance with the provisions of Section 30027.10 of the Government Code.
(3) A change may be made during a contract term or at the time of contract renewal,
when there is a change in obligations required by federal or state law or when required by a change in the interpretation or implementation of any law or regulation.
(4) To the extent permitted by federal law, either the department or the mental health plan may request that contract negotiations be reopened during the course of a contract due to substantial changes in the cost of covered benefits that
result from an unanticipated event.
(d) The department shall immediately terminate a contract when the director finds that there is an immediate threat to the health and safety of Medi-Cal beneficiaries. Termination of the contract for other reasons shall be subject to reasonable notice of the department?s intent to take that action and notification to affected beneficiaries. The plan may request a hearing by the Office of Administrative Hearings
(f) Upon the request of the director, the Director of the Department of
Managed Health Care may exempt a mental health plan
from the Knox-Keene Health Care Service Plan Act of 1975 (Chapter 2.2 (commencing with Section 1340) of Division 2 of the Health and Safety Code). These exemptions may be subject to conditions the director deems appropriate. Nothing in this chapter shall be construed to impair or diminish the authority of the Director of the Department of Managed Health Care under the Knox-Keene Health Care Service Plan Act of 1975, nor shall anything in this chapter be construed to reduce or otherwise limit the
obligation of a mental health plan contractor licensed as a health care service plan to comply with the requirements of the Knox-Keene Health Care Service Plan Act of 1975, and the rules of the Director of the Department of Managed Health Care promulgated thereunder. The director, in consultation with the Director of the Department of Managed Health Care, shall analyze the appropriateness of licensure or application of applicable standards of the Knox-Keene Health Care Service Plan Act of 1975.
department shall provide oversight to the mental health plans to ensure quality, access, cost efficiency, and compliance with data and reporting requirements. At a minimum, the department shall, through a method independent of any agency of the mental health plan contractor, monitor the level and quality of services provided, expenditures pursuant to the contract, and conformity with federal and state law.
(i) If a county discontinues operations as the mental health plan, the
department shall approve any new mental health plan. The new mental health plan shall give reasonable consideration to affiliation with nonprofit community mental health agencies that were under contract with the county and that meet the mental health plan?s quality and cost efficiency standards.
(j) Nothing in this chapter shall be construed to modify, alter, or increase the obligations of counties as otherwise limited and defined in Chapter 3 (commencing with Section 5700) of Part 2 of Division 5.
The county?s maximum obligation for services to persons not eligible for Medi-Cal shall be no more than the amount of funds remaining in the mental health subaccount pursuant to Sections 17600, 17601, 17604, 17605, and 17609 after fulfilling the Medi-Cal contract obligations.
(Added by renumbering Section 5777 by Stats. 2012, Ch. 34, Sec. 175. Effective June 27, 2012. Operative July 1, 2012, by Sec. 254 of Ch. 34. Conditionally inoperative as provided in Section 14721.)
this section, a ?Medi-Cal managed care plan? means any prepaid health plan or Medi-Cal managed care plan contracting with the department to provide services to enrolled Medi-Cal beneficiaries under Chapter 7 (commencing with Section 14000) or Chapter 8 (commencing with Section 14200), or Part 4 (commencing with Section 101525) of Division 101 of the Health and Safety Code.
(1) A process or entity to be designated by the local mental health plan to
receive notice of actions, denials, or deferrals from the Medi-Cal managed care plan, and to provide any additional information requested in the deferral notice as necessary for a medical necessity determination.
(d) This section shall apply to
any contracts entered into, amended, modified, extended, or renewed on or after January 1, 2001.
(Added by renumbering Section 5777.5 by Stats. 2012, Ch. 34, Sec. 176. Effective June 27, 2012. Operative July 1, 2012, by Sec. 254 of Ch. 34. Conditionally inoperative as provided in Section 14721.)
(2) An arrangement between local mental health plans for reimbursement for services provided by a mental health plan other than the mental health plan in the county of adjudication and designation of an entity to provide additional information needed for approval or reimbursement. This arrangement shall not require providers who are already credentialed or certified by the mental health plan in the beneficiary?s county of residence to be credentialed or certified by, or to contract with, the mental health plan in the county of adjudication.
(3) Arrangements between the mental health plan in the county of adjudication and mental health providers in the beneficiary?s county of residence for authorization of, and reimbursement
for, services. This arrangement shall not require providers credentialed or certified by, and in good standing with, the mental health plan in the beneficiary?s county of residence to be credentialed or certified by the mental health plan in the county of adjudication.
(Added by renumbering Section 5777.6 by Stats. 2012, Ch. 34, Sec. 177. Effective June 27, 2012. Operative July 1, 2012, by Sec. 254 of Ch. 34. Conditionally inoperative as provided in Section 14721.)
(1) On or before July 1, 2008, create all of the following items, in
consultation with stakeholders, including, but not limited to, the California Institute for Mental Health, the Child and Family Policy Institute, the California Mental Health Directors Association, and the California Alliance of Child and Family Services:
(A) A standardized contract for the purchase of medically necessary specialty mental health services from organizational providers, when a contract is required.
(2) On or
before January 1, 2009, use the standardized items as described in paragraph (1) to provide medically necessary specialty mental health services to a foster child who is placed outside his or her county of original jurisdiction, so that organizational providers who are already certified by a mental health plan are not required to be additionally certified by the mental health plan in the county of original jurisdiction.
(B) Authorize a county mental health plan to be exempt from
subparagraph (A) and have an addendum to a contract, authorization procedure, or set of documentation standards and forms, if the county mental health plan has an externally placed requirement, such as a requirement from a federal integrity agreement, that would affect one of these documents.
(4) Following consultation with stakeholders, including, but not limited to, the California Institute for Mental Health, the Child and Family Policy Institute, the California Mental Health Directors Association, the California State Association of Counties, and the California Alliance of Child and Family Services, require the use of the standardized contracts, authorization procedures, and documentation standards and forms as specified in paragraph (1) in the 2008?09 state-county mental health plan contract and each state-county mental health plan contract thereafter.
(5) The mental health
plan shall complete a standardized contract, as provided in paragraph (1), if a contract is required, or another mechanism of payment if a contract is not required, with a provider or providers of the county?s choice, to deliver approved specialty mental health services for a specified foster child, within 30 days of an approved treatment authorization request.
(3) On or before July 1, 2008, establish the following, in consultation with stakeholders, including, but not limited to, the California Mental Health Directors Association, the California Alliance of Child and Family Services, and the County Welfare Directors Association of California:
(A) Informational materials that explain to foster care providers how to arrange for specialty
mental health services on behalf of the beneficiary in their care.
(B) Informational materials that county child welfare agencies can access relevant to the provision of services to children in their care from the out-of-county local mental health plan that is responsible for providing those services, including, but not limited to, receiving a copy of the child?s treatment plan within 60 days after requesting services.
(C) It is the intent of the Legislature to ensure that foster children who are adopted or placed permanently with relative guardians, and who move to a county outside their original county of residence, can access specialty mental health services in a timely manner. It is the intent of the Legislature to enact this section as a temporary
means of ensuring access to these services, while the appropriate stakeholders pursue a long-term solution in the form of a change to the Medi-Cal Eligibility Data System that will allow these children to receive specialty mental health services through their new county of residence.
(Added by renumbering Section 5777.7 by Stats. 2012, Ch. 34, Sec. 178. Effective June 27, 2012. Operative July 1, 2012, by Sec. 254 of Ch. 34. Conditionally inoperative as provided in Section 14721.)
(a) This section shall be limited to specialty mental health services reimbursed to a mental health plan that certifies public expenditures subject to cost settlement or specialty mental health services reimbursed through the department?s fiscal intermediary.
(b) The following provisions shall apply to matters related to specialty mental
health services provided under the
approved Medi-Cal state plan and the Specialty Mental Health Services Waiver, including, but not limited to, reimbursement and claiming procedures, reviews and oversight, and appeal processes for mental health plans (MHPs) and MHP subcontractors.
may offset the amount of any federal disallowance, audit exception, or overpayment against subsequent claims from the MHP. The department may offset the amount of any state disallowance, or audit exception or overpayment against subsequent claims from the mental health plan, through the 2010?11 fiscal year. This offset may be done at any time, after the department has invoiced
or otherwise notified the mental health plan about the audit exception,
disallowance, or overpayment. The department shall determine the amount that may be withheld from each payment to the mental health plan. The maximum withheld amount shall be 25 percent of each payment
as long as the department is able to comply with the federal requirements for repayment of federal financial participation pursuant to Section 1903(d)(2) of the federal Social Security Act (42 U.S.C. Sec. 1396b(d)(2)). The department may increase the maximum amount when necessary for compliance with federal laws and regulations.
(3) (A) Oversight by the department of the MHPs may include client record reviews of Early Periodic Screening Diagnosis and Treatment (EPSDT) specialty mental health services
rendered by MHPs and MHP subcontractors under the Medi-Cal specialty mental health services waiver in addition to other audits or reviews that are conducted.
(i) Require the entity awarded the contract to comply with all federal and state privacy laws, including, but not limited to, the federal Health Insurance Portability and Accountability Act (HIPAA; 42 U.S.C. Sec. 1320d et seq.) and its implementing regulations, the Confidentiality of Medical Information Act (Part 2.6 (commencing with Section 56) of
Division 1 of the Civil Code), and Section 1798.81.5 of the Civil Code. The entity shall be subject to existing penalties for violation of these laws.
(i) ?Client record? means a medical record, chart, or similar file, as well as other documents containing information regarding an individual recipient of services, including, but not limited to, clinical information, dates and times of services, and other information relevant to the individual and services provided and that evidences compliance with legal requirements for Medi-Cal reimbursement.
(ii) ?Client record review? means examination of the client record for a selected individual recipient for the purpose of confirming the existence of documents that verify compliance with legal requirements for claims submitted for Medi-Cal reimbursement.
(D) The department shall recover overpayments of federal financial participation from MHPs within the timeframes required by federal law and regulation
for repayment to the federal Centers for Medicare and Medicaid Services.
(4) (A)?The department, in consultation with mental health stakeholders, the California Mental Health Directors Association, and MHP subcontractor representatives, shall provide an appeals process that specifies a progressive process for resolution of disputes about claims or recoupments relating to specialty mental health services under the
Medi-Cal specialty mental health services waiver.
(B) The department shall provide MHPs and MHP subcontractors the opportunity to directly appeal findings in accordance with procedures that are similar to those described in Article 1.5 (commencing with Section 51016) of Chapter 3 of Subdivision 1 of Division 3 of Title 22 of the California Code of Regulations, until new regulations for a progressive appeals process are promulgated. When an MHP subcontractor initiates an appeal, it shall give notice to the MHP. The department shall propose a rulemaking package
consistent with the department?s appeals process that is in effect on July 1, 2012 by no later than the end of the 2013?14 fiscal year. The reference in this subparagraph to the procedures described in Article 1.5 (commencing with Section 51016) of Chapter 3 of Subdivision 1 of Division 3 of Title 22 of the California Code of Regulations, shall only apply to those appeals addressed in this subparagraph.
(C) The department shall develop regulations as necessary to implement this
(5) The department shall conduct oversight of utilization controls as specified in Section 14133. The MHP shall include a requirement in any subcontracts that all inpatient subcontractors maintain necessary licensing and certification. MHPs shall require that services delivered by licensed staff are within their scope of
practice. Nothing in this chapter
shall prohibit the MHPs from establishing standards that are in addition to the federal and state requirements, provided that these standards do not violate federal and state requirements and guidelines.
(6) (A) Subject to federal approval and consistent with state requirements, the MHP may negotiate rates with providers of specialty mental
(B) Any excess in the
distribution of funds over the expenditures for services by the mental health plan shall be spent for the provision of specialty mental health services and related administrative costs.
(7) Nothing in this chapter
shall limit the MHP from being reimbursed appropriate federal financial participation for any qualified services. To receive federal financial participation, the mental health plan shall certify its public expenditures for specialty mental health services to the department.
(8) Notwithstanding Section 14115, claims for
federal reimbursement for service pursuant to this chapter shall be submitted by MHPs within the timeframes required by federal Medicaid requirements and the approved Medicaid state plan and waivers.
(c) Counties may set aside funds for self-insurance, audit settlement, and statewide program risk pools. The counties shall assume all responsibility and liability for appropriate administration of the funds. Special consideration may be given to small counties with a population of less than 200,000. Nothing in the paragraph shall in any way make the state or department liable for mismanagement or loss of funds by the entity designated by counties under this subdivision.
(d) The department shall consult with the California Mental Health Directors Association in February and September of each year to
obtain data and methodology necessary to forecast future fiscal trends in the provision of specialty mental health services provided under the Medi-Cal specialty mental health services waiver, to estimate
yearly specialty mental health services related costs, and to estimate the annual amount of
federal funding participation to reimburse costs of specialty mental health services provided under the Medi-Cal specialty mental health services waiver. This shall include a separate presentation of the data and methodology necessary to forecast future fiscal trends in the provision of Early Periodic Screening, Diagnosis, and Treatment specialty mental health services provided under the Medi-Cal specialty mental health services waiver, to estimate annual EPSDT specialty mental health services related costs, and to estimate the annual amount of EPSDT specialty mental health services provided under the state Medi-Cal specialty mental health services waiver, including federal funding participation to reimburse costs of EPSDT.
(Added by renumbering Section 5778 (as added by Stats. 2011, Ch. 651, Sec. 8) by Stats. 2012, Ch. 34, Sec. 179. Effective June 27, 2012. Section operative July 1, 2012, by its own provisions. Conditionally inoperative as provided in Section 14721.)
Notwithstanding any other law, including subdivision (b) of Section 16310 of the Government Code, the Controller may use the moneys in the Mental Health Managed Care Deposit Fund for loans to the General Fund as provided in Sections 16310 and 16381 of the Government Code. Interest shall be paid on all moneys loaned to the General Fund from the Mental Health Managed Care Deposit Fund. Interest payable shall be computed at a rate determined by the Pooled Money Investment Board to be the current earning rate of the fund from which loaned. This subdivision does not authorize any transfer that will interfere with
the carrying out of the object for which the Mental Health Managed Care Deposit Fund was created.
(Added by renumbering Section 5778.3 by Stats. 2012, Ch. 34, Sec. 180. Effective June 27, 2012. Conditionally inoperative as provided in Section 14721.)
(a) This chapter shall only be implemented to the extent that the necessary federal waivers are obtained. The director shall execute a declaration, to be retained by the director, that a waiver necessary to implement any provision of this
(b) This chapter shall become inoperative on the date that, and only if, the director executes a declaration, to be retained by the director, that more than 10 percent of all counties fail to become mental health plan contractors, and acceptable alternative contractors are not available, or if more than 10 percent of all funds allocated for Medi-Cal mental health services must be administered by the department because
an acceptable plan is not available.
(Added by renumbering Section 5780 by Stats. 2012, Ch. 34, Sec. 182. Effective June 27, 2012. Operative July 1, 2012, by Sec. 254 of Ch. 34. Note: Termination clause applies to Chapter 8.9, comprising Sections 14700 to 14726.)
(a) Notwithstanding any other law, a mental health plan may enter into a contract for the provision of specialty mental health services for Medi-Cal beneficiaries with a hospital that provides for a per diem reimbursement rate for services that include room and board, routine hospital services, and all hospital-based ancillary services and that provides separately for the attending mental
health professional?s daily visit fee. The payment of these negotiated reimbursement rates to the hospital by the mental health plan shall be considered payment in full for each day of inpatient psychiatric and hospital care rendered to a Medi-Cal beneficiary, subject to third-party liability and patient share of costs, if any.
(c) For purposes of this section, ?hospital? means a hospital that submits reimbursement claims for Medi-Cal psychiatric inpatient hospital services through the Medi-Cal fiscal intermediary.
(Added by renumbering Section 5781 by Stats. 2012, Ch. 34, Sec. 183. Effective June 27, 2012. Operative July 1, 2012, by Sec. 254 of Ch. 34. Conditionally inoperative as provided in Section 14721.)
(b) A public agency shall be eligible for supplemental reimbursement only if it is a county, city, or city and county
and if, consistent with Section 14718 it provides as a mental health plan, or subcontracts for, specialty mental health services to Medi-Cal beneficiaries pursuant to the Medi-Cal Specialty Mental Health Consolidation Waiver (Number CA.17), as approved by the federal Centers for Medicare and Medicaid Services.
(c) (1) Subject to paragraph (2), an eligible public agency?s supplemental reimbursement pursuant to this section shall be equal to the amount of federal financial participation received as a result of the claims submitted pursuant to paragraph (2) of subdivision (f).
(2) Notwithstanding paragraph (1), in computing an eligible public agency?s reimbursement, in no instance shall the expenditures certified pursuant to paragraph (1) of subdivision (e), when combined with the amount received from other sources of payment and with reimbursement from the Medi-Cal program, including expenditures otherwise certified for purposes of claiming federal financial participation, exceed 100 percent of actual, allowable costs, as determined pursuant to California?s Medicaid State Plan, for the specialty mental health services to which the expenditure relates. Supplemental
payment may be made on an interim basis until the time when actual, allowable costs are finally determined.
(2) Expenditures submitted to the department
for purposes of claiming federal financial participation under this section shall have been paid only with funds from the public agencies described in subdivision (b) and certified to the state as provided in subdivision (e).
(4) Keep, maintain, and have readily retrievable, any records specified by the department
to fully disclose reimbursement amounts to which the eligible public agency is entitled, and any other records required by the federal Centers for Medicare and Medicaid Services.
(f) (1) The department shall promptly seek any necessary federal approvals for the implementation of this section. If necessary to obtain federal approval, the program shall be limited to those costs that the federal Centers for Medicare and Medicaid Services determines to be allowable expenditures under Title XIX of the federal Social Security Act (Subchapter 19 (commencing with Section 1396) of Chapter 7 of Title 42 of the United States Code). If federal approval is not obtained for implementation
of this section, this section shall not be implemented.
(3) The department shall, on an annual basis, submit any necessary materials to the federal Centers for Medicare and Medicaid Services to provide
assurances that claims for federal financial participation will include only those expenditures that are allowable under federal law.
(g) (1) The director may adopt regulations as are necessary to implement this section. The adoption, amendment, repeal, or readoption of a regulation authorized by this subdivision shall be deemed to be necessary for
the immediate preservation of the public peace, health and safety, or general welfare, for purposes of Sections 11346.1 and 11349.6 of the Government Code, and the department is hereby exempted from the requirement that it describe specific facts showing the need for immediate action.
(Added by renumbering Section 5783 by Stats. 2012, Ch. 34, Sec. 185. Effective June 27, 2012. Operative July 1, 2012, by Sec. 254 of Ch. 34. Conditionally inoperative as provided in Section 14721.)
(a) The State Department of Health Care Services shall develop a quality assurance program to govern the delivery of Medi-Cal specialty mental health services, in order to assure quality
patient care based on community standards of practice.
(b) The department shall issue standards and guidelines for local quality assurance activities. These standards and guidelines shall be reviewed and revised in consultation with the California Mental Health Directors Association as well as other stakeholders from the mental health community, including, but not limited to, individuals who receive services, family members, providers, mental health advocacy groups, and other interested parties. The standards and guidelines shall be based on federal
(Added by renumbering Section 4070 by Stats. 2012, Ch. 34, Sec. 57. Effective June 27, 2012. Operative July 1, 2012, by Sec. 254 of Ch. 34. Conditionally inoperative as provided in Section 14721.)
The department shall approve each local program?s initial quality assurance plan, and shall thereafter review and approve each program?s Medi-Cal specialty mental health services quality assurance plan whenever the plan is amended or changed.
(Added by renumbering Section 4071 by Stats. 2012, Ch. 34, Sec. 58. Effective June 27, 2012. Operative July 1, 2012, by Sec. 254 of Ch. 34. Conditionally inoperative as provided in Section 14721.)
2015 Welfare And Institutions Code, Division 9. Public Social Services , Article 5. Mental Health Managed Care
2015 Welfare And Institutions Code, Division 9. Public Social Services , Article 3. Administration
2015 Welfare And Institutions Code, Division 9. Public Social Services , Article 5.4. Health Care Coordination, Improvement, And Long-Term Cost Containment Waiver Or Demonstration Project
2015 Welfare And Institutions Code, Division 9. Public Social Services , Article 1. General Provisions
2015 Welfare And Institutions Code, Division 9. Public Social Services , Article 4. The Medi-Cal Benefits Program
2015 Welfare And Institutions Code, Division 9. Public Social Services , Article 5.227. Hospital Quality Assurance Fee Act Of 2011
2015 Welfare And Institutions Code, Division 9. Public Social Services , Article 5.228. Medi-Cal Hospital Provider Rate Improvement Act Of 2011
2015 Welfare And Institutions Code, Division 9. Public Social Services , Article 5.7. Long-Term Services And Supports Integration
2015 Welfare And Institutions Code, Division 9. Public Social Services , Article 2. Definitions
2015 Welfare And Institutions Code, Division 9. Public Social Services , Article 5. Standards For Prepaid Health Plans