Medi-Cal Manual Third Edition ADA
MEDI-CAL MANUALFor Intensive Care Coordination (ICC), Intensive Home BasedServices (IHBS), and Therapeutic Foster Care (TFC) Services forMedi-Cal BeneficiariesThird EditionJanuary 2018
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TABLE OF CONTENTSTABLE OF CONTENTS .3CHAPTER 1: Purpose and Background . 6Purpose.6Background.7Specialty Mental Health Services (SMHS) .7Katie A. v. Bontá Settlement .7Chapter 2: Target Population .9ICC and IHBS.9TFC .11Chapter 3: Principles of the Integrated Core Practice Model . 13ICPM Description .13ICPM Values and Principles .13Chapter 4: The Child and Family Team . 15CFT Overview .15Composition of Child and Family Teams .16Confidentiality .18CFT Meeting .18When to Convene a CFT Meeting .19CFT Meeting Frequency, Location, and Logistics .20CFT Meeting Preparation .20CFT Meeting Facilitation .21Claiming and Reimbursement .21CHAPTER 5: ICC, IHBS, and TFC . 23Planning for ICC, IHBS, and TFC .23INTENSIVE CARE COORDINATION (ICC) .23ICC General Description .23ICC Service Components and Activities .25Medi-Cal Documentation Requirements of ICC Service Components and Activities . 28ICC Provider Qualifications.28ICC Service Authorization .28Coordination of ICC with Other Speciality Mental Health Services .29ICC Service Settings / Limitations / Lockouts.29ICC Claiming and Reimbursement .30INTENSIVE HOME BASED SERVICES (IHBS) .30IHBS General Description .30IHBS Service Components and Activities .31Medi-Cal Documentation of IHBS Service Components and Activities .32IHBS Provider Qualifications .32IHBS Service Authorization.32
Coordination of IHBS with Other SMHS .32IHBS Service Settings .33IHBS Service Limitations and Lockouts.33IHBS Claiming and Reimbursement.33THERAPEUTIC FOSTER CARE (TFC) .34TFC General Description.34Role of the TFC Agency .34Role of the TFC Parent .36TFC Parent Required Qualifications .37TFC Components and Activities .40Documentation of TFC Components and Activities .46TFC Service Authorization .46Coordination of TFC with Other SMHS .47TFC Settings / Limitations / Lockouts.47TFC Claiming and Reimbursement .48APPENDIX A. 49Glossary .49APPENDIX B . 57Sample ICC and IHBS Progress Notes .57Sample 1: ICC Progress Note .58Sample 2: IHBS Progress Note .60APPENDIX C . 61Sample TFC Progress Notes .61Sample 1: TFC Progress Note.62Sample 2: TFC Progress Note.64Sample 3: TFC Progress Note.66Instructions for TFC Progress Note .68APPENDIX D. 70Non-Reimbursible Activities .70ACKNOWLEDGMENTS. 72
If you have questions regarding obtaining ICC, IHBS, or TFC for an eligiblechild or youth, please contact your County Mental Health Plan (MHP). A list ofCounty MHP’s toll free numbers can be located tactList.aspxYou also may contact the Mental Health Services Division, at the Departmentof Health Care Services (DHCS), at (916) 322-7445, or email your questionsto DHCS at: KatieA@dhcs.ca.gov.In addition, you may email your questions to the California Department ofSocial Services (CDSS) at: CWSCoordination@dss.ca.gov.
CHAPTER 1: PURPOSE AND BACKGROUNDPURPOSEThe purpose of this manual is to provideMental Health Plans (MHPs), Medi-Calproviders, children and youth, families,county representatives, and otherstakeholders with information regardingIntensive Care Coordination (ICC),Intensive Home Based Services (IHBS),and Specialty Mental HealthServices (SMHS) service activitiesprovided through the Therapeutic FosterCare service model (referred to as“TFC” hereinafter). These services areavailable, when medically necessary, tocorrect or ameliorate defects and mentalillnesses or conditions through the Earlyand Periodic Screening, Diagnosis, andTreatment (EPSDT) benefit.This benefit is available to beneficiaries,up to age of 21, who are eligible for fullscope Medi-Cal (42 U.S.C. § 1396a (a)(43) and 42 U.S.C. § 1396d (r)).This manual provides information andguidelines for the delivery and billing ofICC, IHBS, and TFC. Please note thatMHPs and providers should continue toprovide other existing SMHS to childrenand youth, when medically necessary.In addition to this manual, other federaland state documents related to thedelivery of SMHS in the State ofCalifornia should be consulted to obtainmore information on SMHS. Thesedocuments include, but are notlimited to: Federal Medicaid laws andregulations California Code of Regulations(CCR), Title 9, Division 1,Chapter 11, California Medicaid State Plan, DHCS contract with MHPs, DHCS/CDSS Core Practice Model(CPM) Guide 1;DHCS Mental Health Substance UseDisorder Services (MHSUDS)Information Notices, as well as formerDepartment of Mental Health PolicyLetters and Department of MentalHealth Information Notices.This manual will be maintained byDHCS and reviewed and updated, asneeded. The most recent version of thismanual can be found on the DHCSKatie A. webpage. Any questionsconcerning the information contained inthis manual should be directed to:KatieA@dhcs.ca.gov.1As of January 2018, a draft of the ICPM isbeing finalized.Page 6 of 72
BACKGROUNDKATIE A. V. BONTÁSETTLEMENTSPECIALTY MENTALHEALTH SERVICES (SMHS)California administers aSection 1915 (b) Freedom of ChoiceWaiver for SMHS, using a managedcare model of service delivery. DHCSoperates and oversees this waiver, andcontracts with county MHPs for theprovision of SMHS. Each MHPprovides, or arranges for, SMHS forMedi-Cal beneficiaries (children, youth,and adults) who meet medicalnecessity criteria.The following is a list of available SMHS(see the glossary for descriptions): 2Mental Health Services,Crisis Intervention Services,Crisis Stabilization Services,Day Treatment Intensive Services,Day Rehabilitation Services,Adult Residential Services,Crisis Residential Services,Medication Support Services,Psychiatric Health Facility Services,Psychiatric Inpatient HospitalServices,Targeted Case ManagementServices,Therapeutic Behavioral Services,Intensive Care Coordination,Intensive Home Based Services, andTherapeutic Foster Care.As defined in the Settlement Agreement.As a result of the Settlement Agreementin Katie A. v. Bontá, the State ofCalifornia agreed to take a series ofactions that transformed the wayCalifornia children and youth who are infoster care, or who are at imminent riskof foster care placement, 2 receiveaccess to mental health services. Thesettlement specifically changed the waya defined group of children and youthwith the most intensive needs, referredto as “Katie A. subclass members”, areassessed for mental health services.Pursuant to the settlement, subclassmembers were required to be providedan array of services, and specificallymedically necessary ICC, IHBS, andTFC, consistent with the Core PracticeModel (CPM). 3The Settlement Agreement had thefollowing objectives: Facilitate the provision of an array ofservices delivered in a coordinated,comprehensive, community-basedfashion that combines serviceaccess, planning, delivery, andtransition into a coherent and allinclusive approach; Support the development anddelivery of a service structure and afiscal system that supports a corepractices and services model, asdescribed in the previous bullet;3Now referred to as the “Integrated CorePractice Model"Page 7 of 72
Support an effective and sustainablesolution, that will involve standardsand methods to achieve qualitybased oversight, along with trainingand education that support thepractice and fiscal models; Address the need for certain classmembers with more intensive needs(hereinafter referred to as “Katie A.subclass members”) to receivemedically necessary mental healthservices in the child’s or youth’s ownhome, a family setting, or the mosthomelike setting appropriate to thechild’s or youth’s needs, in order tofacilitate reunification, and to meetthe child’s or youth’s needs forsafety, permanence, and well-being; Utilize the CPM principles andcomponents, including: Reduce timelines to permanencyand lengths of stay within the childwelfare system; and Reduce reliance on congregate care.While the Katie A. Settlement onlyconcerned children and youth in fostercare, or at imminent risk of placement infoster care, membership in theKatie A. class or subclass is nolonger a requirement for receivingmedically necessary ICC, IHBS, andTFC. Therefore, a child or youth neednot have an open child welfare servicescase to be considered for receipt of ICC,IHBS, or TFC. 4o A strong engagement with, andparticipation of, the child/youthand the family;o Focus on the identification ofchild/youth and family needs andstrengths when assessing andplanning services;o Teaming across formal andinformal support systems; ando Use of Child and Family Teams(CFTs) to identify strengths andneeds, make plans and trackprogress, and provide intensivehome-based services; 4Assist, support, and encourage eacheligible child/youth to achieve andmaintain the highest possible level ofhealth, well-being, andself-sufficiency;See MHSUDS Information Notice 16-004.Page 8 of 72
CHAPTER 2: TARGET POPULATIONICC AND IHBSICC and IHBS are provided through theEPSDT benefit to all children and youthwho: Are under the age of 21;Are eligible for the full scope ofMedi-Cal services; andMeet medical necessity criteria forSMHS. 5MHPs have an affirmative responsibilityto determine if children and youth whomeet medical necessity criteria needICC and IHBS.ICC and IHBS must be provided to allchildren and youth who meet medicalnecessity criteria for those services.Membership in the Katie A. subclass isnot a prerequisite to receiving ICC andIHBS. (DHCS MHSUDS InformationNotice No: 16-004.). 6MHPs must make individualizeddeterminations of each child’s/’youth’sneed for ICC and IHBS, based on thechild’s/youth’s strengths and needs. Asdiscussed below, these services areappropriate for children and youth withmore intensive needs who are in, or atrisk of, placement in residential orhospital settings, but could be effectivelyserved in the home and community.Child welfare departments have anaffirmative responsibility to screen andrefer children and youth who are in thechild welfare system, and may be inneed of ICC and IHBS.5Other entities, such as juvenileprobation, have an affirmativeresponsibility to screen and referchildren and youth who may be in needof ICC and IHBS.To receive SMHS, Medi-Cal children and youthmust have a covered diagnosis and meet thefollowing criteria: 1. have a condition that wouldnot be responsive to physical health care basedtreatment; and 2. the services are necessary tocorrect or ameliorate a mental illness andcondition discovered by a screening.The following criteria should beconsidered as indicators of need for ICCand IHBS, and are intended to be usedto identify children and youth whoshould be assessed for whether ICCand/or IHBS are medically necessary.Thus, ICC and IHBS are very likely to bemedically necessary for children andyouth who meet the following criteria.These criteria are not requirements orconditions, but are provided asguidance, in order to assist counties inidentifying children and youth who are inneed of ICC and IHBS.ICC and IHBS are very likely to bemedically necessary for children andyouth who: Are receiving, or being consideredfor, Wraparound; Are receiving, or being consideredfor, a specialized care rate due tobehavioral health needs;6This clarification is not intended to decreasethe utilization of ICC and IHBS amongst Katie A.subclass members. The State and countieshave made significant strides in providing theseservices to Katie A. subclass members overmany years. It is expected that Katie A.subclass members will continue to receiveICC, and IHBS when medically necessary.Page 9 of 72
Are being considered for otherintensive SMHS, including, but notlimited to, TBS, or are receivingcrisis stabilization/interventionservices; Are currently in, or being consideredfor, high-level-care institutionalsettings, such as group homes orShort-Term Residential TherapeuticPrograms (STRTPs); Have been discharged within 90days from, or currently reside in, orare being considered for placementin, a psychiatric hospital or 24-hourmental health treatment facility[e.g. psychiatric inpatient hospital,psychiatric health facility (PHF),community treatment facility, etc.]; Have experienced two or moremental health hospitalizations in thelast 12 months;Have experienced two or moreplacement changes, within 24months, due to behavioralhealth needs;Have been treated with two or moreantipsychotic medications, at thesame time, over a three-monthperiod [Healthcare EffectivenessData Information Set (HEDIS)Specification for Antipsychotics inChildren and Adolescents (APC)];If the child is zero through five yearsold and has more than onepsychotropic medication, the child is7Medi-Calcoverage of services for juveniles, under age 21, while the Medi-CalThis criterion does not alter the suspension ofMedi-Cal coverage of services for juveniles,federal law. However, youths who are physically in juvenile hall, not due to criminalunder age 21, while the Medi-Cal beneficiary isactivity, and who are awaiting placement, or are there temporarily under a specific planan “inmate of a public institution,” w
p c M H P ( A o M t f n c b l. c t D t H Ca Se ( at If you have questions regarding obtaining ICC, IHBS, or TFC for an eligible child or youth, lease ontact your County ental ealth lan MHP).
55 11-13 Crisis Referral Not Medi-Cal Eligible 55 14-16 MHS Contract Admin. Not Medi-Cal Eligible 55 17-19 Discounted MH Outreach Not Medi-Cal Eligible 55 21-23 SPMP Case Management Not Medi-Cal Eligible 55 24-26 SPMP Program Planning Not Medi-Cal Eligible 55
Directorio de Proveedores y Servicios Medi-Cal Network 661.716.7270 Toll Free: 800.918.7302 Contracted with Health Net Medi-Cal Plan Contratado con el Plan de Health Net Medi-Cal . Aceptando pacientes mayores de 5 Ned Devasia, MD (m) 661.327.3747 5801 Truxtun Ave Bakersfield, CA 93309 BC: Internal Medicine LS: Spanish. 4 Medi-Cal Jae Kim, MD .
Medi-Cal Telecommunications Provider and Biller Application/Agreement (DHCS 6153) Medi-Cal Point of Service (POS) Network/Internet Agreement Note: These forms can be downloaded from the Forms page on the Medi-Cal Provider website (www.medi-cal.ca.gov). When the provider or submitter has approval for electronic submission, then a .
Medi-Cal Dental Action Reason for Action Code(s) (see enclosed for explanation) You can discuss different treatment plans with your dentist to obtain the best care allowable under the Medi-Cal Dental program. If. have a question regarding this action, please contact your dentist or Medi-Cal Dental at 1-800-322-6384 for a more detailed .
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