This is the first article in a series that addresses key changes in the California healthcare market, focusing on changes to California’s behavioral health delivery systems. The next articles in the series will cover other California initiatives, including new tools to provide whole person care and address the social determinants of health., and new efforts to contain healthcare costs.
The State of California has announced major new initiatives that will significantly alter the California healthcare market and legal landscape for patients, payers, providers and other stakeholders. This article addresses some of the expansive new behavioral health initiatives available to Californians, which include new options for receiving both mental health services and treatment for substance use disorders.
The state’s focus on behavioral health has multiple goals. Like other states and health care payers, California aims to slow the growth in the cost of health care and has linked the effective and timely delivery of behavioral health services as part of its strategy to reduce long-term health care costs. California has also identified a significant increase in the need for behavioral health services following the COVID-19 pandemic. The expansion of behavioral health services is also an important component of the state’s response to the homelessness crisis.
New mandatory coverage of behavioral health services in schools
Through a new Children and Youth Behavioral Health Initiative (CYBHI), California aims to improve and redesign behavioral services for children and young people. A central component of the initiative is the expansion of behavioral health services accessible through schools, which could impact existing supplier networks and delivery systems.
California law, AB 133 (2021), requires the State Department of Health Services (DHCS) to develop a new statewide minimum fee for outpatient mental health services or “school-related” substance use disorder for students. aged 25 or younger. DHCS intends to use this statewide minimum fee to create a sustainable funding source for school-related behavioral health services, regardless of the payer.
Under AB 133, each California state-regulated health plan (including Medicaid plans, Knox-Keene plans, and disability insurance policies) must reimburse school-related behavioral health care providers at least the amount rate plan minimum, regardless of whether the provider has a contract with the plan. DHCS is intended to “develop and maintain” the network of eligible providers of these school services, but reimbursement will come from payers according to their terms of coverage.
New opportunities for virtual behavioral health care for children and young people
Also as part of CYBHI, and potentially in connection with the school services described above, DHCS will convene stakeholders to develop and select evidence-based interventions and “promising practices” to improve outcomes for children and young people with or at high risk. of conducting health conditions and will provide grants and incentive payments to stimulate investment in these areas.
DHCS will also procure a provider to establish and maintain a behavioral health service and support a virtual platform. Once deployed, this virtual platform will expand access to telecommunication health services available to millions of children and young people in California aged 25 and under, regardless of payer.
Implementation of new CARE courts
Under a controversial new law, SB 1338, seven of California’s counties (San Francisco, San Diego, Orange, Riverside, Stanislaus, Tuolumne and Glenn) will have to establish new community assistance, rehabilitation and empowerment (CARE) courts specifically for address the needs of people with severe untreated mental illness by October 1, 2023. The remaining 51 counties in California will follow by December 1, 2024. Once established, people (including family members, friends, hospital directors, rescuers and caregivers) Behavioral Health Care) may appeal to CARE courts on behalf of an individual to prove that they qualify for support. To qualify, an individual must have a severe mental illness, may not be clinically stabilized or be on voluntary care, and must meet other requirements.
CARE courts have the power to order an individual’s clinical evaluation and develop a CARE plan that can include medication and treatment, social services, housing resources, and general care. SB 1338 provides some additional funding to counties to help administer CARE courts. It also requires California health plans (including Knox-Keene plans and insurance policies) to cover health assessments and services required or recommended under a CARE plan, whether they are networked or offline provided or received. ‘prior authorization.
Clarifications and changes to the Fragmented Medi-Cal Behavioral Health Delivery System
California operates two separate managed behavioral health delivery systems for its Medicaid beneficiaries. Consistent with their historic mission to serve local destitute populations, California counties operate and contract with behavioral health service providers for individuals with severe mental health and / or substance use disorders. Additionally, as a result of recent expansions within the Medi-Cal program, California’s Medi-Cal Managed Health Care Plans cover “mild to moderate” behavioral health services as well as primary care services. Individuals can be enrolled in both plans at the same time.
As part of its broader California Advancing and Innovating Medi-Cal (CalAIM) initiative, the state is required to develop new standardized screening tools for referrals to county behavioral health systems. In addition, the state has introduced a “no wrong door” policy that, effective July 1, 2022, allows providers to bill both counties and Medi-Cal health care plans for services rendered during an evaluation period or before determining a diagnosis. These changes offer new flexibility for providers when seeking reimbursement for mental health services and are intended to help ensure that beneficiaries can maintain treatment relationships with providers until an appropriate referral can be made.
Finally, the state is undertaking a redesign of how counties are reimbursed for Medi-Cal behavioral health services delivered through their networks. Under the Behavioral Health Payment Reform, counties will no longer be restricted to cost-based reimbursement and will no longer be required to submit burdensome cost reports. These changes have the potential to affect how counties negotiate their contracts with Medi-Cal Behavioral Health Networking Providers, and counties will be encouraged to emphasize value-based components for reimbursement.
Foley is here to help you address the short- and long-term legal impacts of disasters on your facility. We have the resources to help you navigate important legal considerations related to business operations and industry-specific issues. For any questions, contact the authors, your Foley relationship partner, or our healthcare practice group.