Overview of Medi-Cal for Child Welfare Agencies
Medi-Cal
All children who are in foster care are eligible to receive Medi-Cal that is either Fee-For-Service (FFS) or a Managed Care Plan (MCP). Access to Medi-Cal health plans depends on the California county in which the foster youth resides. Medi-Cal provides a core set of health benefits that can be viewed here: Medi-Cal Health & Dental Benefits.
The Department of Health Care Services (DHCS) added dyadic services and Doula services as as benefits effective January 1, 2023 for both MCP and FFS plans. Dyadic Services are a family and caregiver focused model of care intended to address developmental and behavioral health conditions of children and includes services provided to parent(s)/caregiver(s) (known as a “dyad”). Doula Services are supports provided for individuals and families throughout pregnancy and one year postpartum. This includes emotional and physical support provided during pregnancy, labor, birth, and the postpartum period, as well as support for and after miscarriage and abortion.
Fee-for-Service Plans (Straight Medi-Cal)
The FFS model, often referred to as Straight Medi-Cal, is a payment model where healthcare providers are reimbursed by the state of California for each individual service, they provide to Medi-Cal members (doctor visits, x-rays, etc.). With FFS plans, members can visit any provider who accepts Medi-Cal, obtain the needed service, then a claim would be submitted for payment that is determined, processed and paid (or denied) by the Medi-Cal program’s fiscal intermediary.
Profile of Enrolled Medi-Cal Fee-for-Service (FFS) Providers – Dataset – California Health and Human Services Open Data Portal.
Managed Care Plans
The MCPs receive a fixed per-member, per-month fee regardless of the services provided. The state contracts with MCPs to deliver a wide array of health care services to members, including primary care, specialty care, hospital services, prescription drugs. and preventative services. Once a Medi-Cal MCP is selected, members will select their primary care physician (PCP) within the MCP network. The PCP is the main contact point for coordinating member's healthcare needs.
The MCP Health Plan Directory breaks down the available MCP services by county. MCPs are available in 37 counties so a member must decide which MCP best serves their needs (if there is more than one option). There are 21 counties that provide the option between MCP and FFF so members must decide which best fits their needs. Child Welfare Agencies can support foster youth and their parents/caregivers by providing education and helping them compare the quality of providers and ensuring the key providers they need are within their health care plan.
Medi-Cal Behavioral Health Services
Delivery of Medi-Cal behavioral health services is split between counties, and Medi-Cal managed care plans (MCPs), and Fee-For-Service plans (FFS).
Pursuant to Welfare and Institutions Code (WIC) sections 14184.402(d) and (f)(1)(A), a mental health diagnosis is no longer a prerequisite for foster youth to access SMHS, as trauma due to involvement in child welfare or juvenile justice makes children and youth under age 21 eligible for SMHS. Behavioral Health Information Notice (BHIN) 21-073, ended the requirement for child welfare agencies and juvenile probation departments to conduct a mental health screening for the purpose of determining eligibility for specialty mental health services. ACL 24-35, requires all children in child welfare and juvenile justice should have a referral sent to the county mental health plan for a full comprehensive mental health assessment. The local level will determine what information is needed to be included in the referrals for mental health assessments.
Non-Specialty Mental Health Services (NSMHS)
- MCPs and FFS plans are responsible for outpatient services for lower-acuity patients; known as non-specialty mental health services (NSMHS)
What are NSMHS?
- Mental health evaluation and treatment, including individual, group, and family psychotherapy
- Psychological and neuropsychological testing, when clinically indicated to evaluate a mental health condition
- Outpatient services for the purposes of monitoring drug therapy
- Psychiatric consultation
- Outpatient laboratory, drugs, supplies, and supplements
NSMHS also include some new and expanded services such as dyadic services for families, which are available to Medi-Cal members in fee-for-service (FFS) and through managed care plans (MCPs) as of January 1, 2023.
Specialty Mental Health Services (SMHS)
- County Departments are responsible for specialty mental health and substance use disorder services
The Department of Health Care Services (DHCS) administers California’s Medicaid program (Medi-Cal). DHCS is responsible for administering and overseeing the Medi-Cal SMHS Waiver Program, which provides SMHS to Medi-Cal beneficiaries through county mental health plans (MHPs). MHPs are required to provide or arrange for the provision of outpatient and inpatient SMHS to beneficiaries in their counties who meet SMHS medical necessity criteria, consistent with the beneficiaries’ mental health treatment needs and goals, as documented in their client plans.
What are SMHS?
- Intensive Care Coordination (ICC): ICC is a targeted case management service that facilitates assessment of care planning for, and coordination of services to beneficiaries under age 21 who are eligible for the full scope of Medi-Cal services and who meet medical necessity criteria for this service.
- Intensive Home-Based Services (IHBS): IHBS are individualized, strength-based interventions designed to correct or ameliorate mental health conditions that interfere with a child or youth’s functioning and are aimed at helping the child or youth build skills necessary for successful functioning in the home and community, and improving the child or youth’s family’s ability to help the child or youth successfully function in the home and community.
- Therapeutic Foster Care (TFC): The TFC service model allows for the provision of short-term, intensive, trauma-informed, and individualized specialty mental health services (SMHS) for children up to age 21 who have complex emotional and behavioral needs. Services include plan development, rehabilitation, and collateral. In TFC, children are placed with trained, intensely supervised, and supported TFC parents.
- Therapeutic Behavioral Services (TBS): TBS are intensive, individualized, short-term outpatient treatment interventions for beneficiaries up to age 21 with full scope Medi-Cal. Individuals receiving these services have serious emotional disturbances, are experiencing stressful transitions or life crises, and need additional short-term, specific support services to achieve outcomes specified in their client plans.
To learn more about these SMHS services please refer to Medi-Cal Manual Third Edition and click here for more information.