First 5 Center PSP Webinar Series - PowerPoint Presentation

1. First 5 Center PSP Webinar SeriesPreventive Pediatric Mental Health Services in Medi-CalMonday, November 9th, 12:30 – 2:00 PM PTAlex BriscoePrincipalCalifornia Children’s Trustalex@cachildrenstrust.orgDr. Sam SingerPediatricianHighland Hospitalssinger@alamedahealthsystem.orgAlice LamManaging DirectorManatt Healthalam@manatt.com

2. AgendaWelcomeRefresh of Behavioral Health Pediatric Services in Medi-CalImportance of Preventive Mental Health Services for Young ChildrenSpotlighting Dyadic Models: DULCE & HealthyStepsQuestions & DiscussionNovember 9, 2020 | Center for the Study of Social Policy | Manatt Health Strategies

3. Pediatrics Supporting Parents (PSP) California OverviewThe PSP CA initiative will feature a Medi-Cal options paper spotlighting recommended strategies and implementation approaches to improve the well-being of young children in California and better support their families.PSP CA is supported by three funders to leverage Medi-Cal and pediatric primary care to better support the healthy social and emotional development of young children in California.

4. Zoom Poll: Refresh of Behavioral Health Pediatric Services in Medi-CalNovember 9, 2020 | Center for the Study of Social Policy | Manatt Health Strategies

5. Refresh of Behavioral Health Pediatric Services in Medi-CalNovember 9, 2020 | Center for the Study of Social Policy | Manatt Health Strategies

6. Medicaid’s Commitment to Children: Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Federal law requires the delivery of comprehensive pediatric healthcare services to all enrolled children and youth under 21 through the EPSDT benefit. Medi-Cal covers the Children’s Health Insurance Program (CHIP), resulting in all enrolled children receiving the full EPSDT benefit. Early and Periodic ScreeningsDiagnostic Services Treatment Services Regularly scheduled comprehensive health and developmental screeningsComprehensive unclothed physical examsAppropriate vision and hearing tests, immunizations, and laboratory testsDental screenings and referralsHealth educationMedically necessary diagnostic services when a risk is identified, including follow-up testing, evaluation, and referrals Timely treatment services as discovered by child health screenings (which includes treatment services medically necessary to correct or ameliorate defects and address physical and behavioral health conditions)If a service or device is medically necessary to correct or ameliorate a condition and could be covered under Medicaid, then it must be provided, even if that service or device is not identified in the Medicaid State Plan. Notably, California and managed care plans (MCPs) may not impose hard or fixed limits on specific services related to EPSDT.Sources: SSA § 1905(r); 42 CFR § 441.56; CMS EPSDT Guide for States: Coverage in the Medicaid Benefit for Children and Adolescents.

7. 2011 Realignment in CaliforniaSince 1991, there have been a number of realignments in California impacting Medi-Cal spending and county responsibilities with the State legislature shifting fiscal and programmatic responsibility for many Medi-Cal services from the State to the counties.Sources: CA LAO: Assessing the Governor’s 1991 Realignment Proposals, March 2019; California State Association of Counties: Chapter 6, Health Services, February 2019; California State Association of Counties: Chapter 11, Human Services, February 2019. Merged county behavioral health departments with previous Department of Health Care Services (DHCS) operated behavioral health programCreated 58 different county-administered behavioral health programs for enrollees with specialty mental health services – known as specialty mental health programs (SMHPs)Effectively “carved out” DHCS managed care responsibility of behavioral health and delegated it to local SMHP managed care programsThe 2011 Realignment’s Impact on Medi-Cal Behavioral Health SystemsUnclear guidance, missed diagnoses, and ambiguity amongst providers creates a lack of clarity on when a child’s social and emotional health concern qualifies as mild-to-moderate versus a specialized mental health service, making it difficult for families to identify how to secure behavioral healthcare for their children

8. Medi-Cal Bifurcated Managed Care Behavioral Health SystemMedi-Cal MCPOther Providers (i.e., First 5s)Medi-Cal BeneficiariesPrimary Care & SpecialistsClinics & HospitalsDelivery of Care & ServicesCounty SMHPContracts, Capitated Payments Contracts, Provider PaymentsBeneficiaries SMI/SED in need of more specialized treatment, such as inpatient care, are treated through their county SMHPBeneficiaries with mild-to-moderate behavioral health needs, such as outpatient therapy and medication, receive care through their MCPFinancially, counties are responsible for the non-federal share of the SMHPs’ costs, effectively creating a cap on behavioral services for enrollees with SMI/SEDEach California county has a specialty mental health plan (SMHP) – a Medi-Cal behavioral health services managed care program for adults with serious mental illness (SMI) and children with serious emotional disturbance (SED). Sources: California Counties: Chapter Six, Health Services; DHCS: All Plan Letter 18-015: Memorandum of Understanding Requirements for Medi-Cal Managed Care Plans & Attachment 2; California Health Care Foundation: The Circle Expands – Understanding Medi-Cal Coverage of Mild-to-Moderate Mental Health Conditions.

9. Importance of Preventive Mental Health Services for Young ChildrenNovember 9, 2020 | Center for the Study of Social Policy | Manatt Health Strategies

10. California’s Pediatric Behavioral Health CrisisNovember 9, 2020 | Center for the Study of Social Policy | Manatt Health StrategiesCalifornia ranks 43rd nationwide in providing pediatric behavioral, social, and developmental screenings 62% of California adults has at least one adverse childhood experience (ACE); Children with ACEs commonly report:Emotional/verbal abuse (35%)Parental separation/divorce (27%)Substance abuse in the household (26%)Physical abuse (20%)Witnessing domestic violence (18%)63% of children and youth with a major depressive episode do not receive mental health servicesPreventing, identifying, and treating pediatric mental health needs is critical to supporting children and their families. Children with untreated behavioral health needs are more likely to experience negative health, education, and lifelong outcomes. Children Now’s 2020 grade for California’s behavioral healthcare services, driven by a lack of preventive care1 in 7, or 14%, of children hospitalized for mental diseases or disordersSources: California Children’s Trust, Reimagining Our Mental Health System to Achieve Equity and Healing for Children and Families, February 2020; Mental Health America, The State of Mental Health in America 2020; Children Now, California Children’s Report Card 2020.D

11. Dyadic Care ModelsNovember 9, 2020 | Center for the Study of Social Policy | Manatt Health StrategiesDyadic therapy includes the child and parent/caregiver receiving healthcare services together to support the child’s development May be delivered in the pediatric primary care setting to promote the child and families’ well-being and healthFor Medi-Cal provider payment, at least one of the two individuals must be enrolled in Medi-CalWhat is Dyadic Therapy?Dyad includes two people – often the child + family member, such as a parent, sibling, grandparent, or other caregiver. There are many dyadic therapy models for young children and their families.

12. Caregivers’ Coverage Opportunities & Dyadic TreatmentThe behavioral health status of a child’s parent/caregiver have a profound impact on a child’s health and well-being, making it critical to ensure parents have health insurance coverage and access to preventive care and treatment.Family TherapyCoverage for dyadic treatment for children enrolled in Medi-CalNo mental health diagnosis required, so long as at least one broadly defined risk factorNo cap on the number of visitsRequires prenatal providers (e.g., OB/GYN) to offer screeningAllows maternal depression screening in the pediatric setting For pregnant and postpartum women between 213 – 322% of the federal poverty level who screen positive, treatment must be covered, regardless citizenship status Maternal Depression Screening & TreatmentDHCS has clarified two critical opportunities for children’s parent(s) and/or caregivers to access behavioral health services:Sources: DHCS: Medi-Cal Rates, October 2020; DHCS: Psychological Services Manual, September 2020; DHCS: Psychological Services Manual, Pregnancy Early Care and Diagnostic Services, August 2020; AB 2913: Maternal Mental Health; National Academy for State Health Policy: Medicaid Policies for Maternal Depression Screening During Well-Child Visits, March 2020; 2020 Mom: California’s Medicaid Program Now Reimburses Screening and Treatment to Prevent Maternal Depression, August 2019; California Health & Wellness: AB 2913 Requires Maternal Mental Health Screening; First 5 Center: New Program Extends Medi-Cal Coverage to Individuals Diagnosed with a Maternal Mental Health Condition. See Appendix for (1) New Resource: Crosswalk of Medi-Cal Family Therapy Guidance & Dyadic Integrated Care Models Currently Implemented in California; and (2) details the benefits’ eligibility requirements, provider requirements, frequency of benefit, and provider reimbursement rates.

13. Zoom Poll: HealthySteps & DULCENovember 9, 2020 | Center for the Study of Social Policy | Manatt Health Strategies

14. Spotlighting Dyadic Care Models: HealthySteps & DULCETwo young children models available in California – HealthySteps and DULCE* – integrate a licensed behavioral health provider (e.g., psychologist, psychiatrist) and a family specialist into the pediatric clinical team to extend the reach of the pediatric primary care office.Screenings for developmental delays, maternal depression, social determinants of health, and ACEs/toxic stress Address parenting concerns and questions, including feeding, behavior, and sleep attachmentNavigating health care system and community supportsAssistance connecting to services and resourcesOngoing assistance during and between well-child visitsDeveloped by ZERO TO THREEDeveloped by the Center for the Study of Social Policy (CSSP)* DULCE = Developmental Understanding and Legal Collaboration for EveryoneHealthySteps Specialists and DULCE Family Specialists provide:See Appendix for new CSSP resource: Fostering Social and Emotional through Pediatric Primary Care: Common Threads to Transform Everyday Practice and Systems.

15. California HealthySteps & DULCE SitesHealthySteps & DULCE California Sites*IMPERIALSAN DIEGORIVERSIDESAN BERNADINOLOS ANGELESVENTURASANTABARBARAKERNSAN LUISOBISPOINYOTULAREKINGSMONTEREYFRESNOSANTACRUZSANMATEOSANFRANCISCONAPASONOMALASSENSHASTATRINITYHUMBOLDTMODOCSISKIYOUDELNORTEALAMEDAORANGEEL DORADOLAKEYUBAPLACERNEVADASIERRABUTTEGLENNMENDOCINOPLUMASTEHAMACOLUSASUTTERYOLOMONOTUOLUMNEALPINECALAVERASAMADORSACRA-MENTOSOLANOSANBENITOMADERAMARIPOSAMERCEDSANTACLARASTANISLAUSCONTRACOSTASANJOAQUINMARIN* Multiple counties have more than one clinic site; nothing precludes a county from operating both HealthySteps and DULCEDULCEServes 1,000 families with direct supports from a Family Specialist annually in California7 California sites in 3 countiesAlso in FL, VTNearly all of children enrolled in DULCE have Medi-Cal coverageNovember 9, 2020 | Center for the Study of Social Policy | Manatt Health StrategiesHealthyStepsServes 30,000 children annually in California15 California sites in 5 countiesAlso in AL, AZ, CO, CT, DC, FL, IL, IN, MA, MD, MN, MO, MS, NC, NY, OH, OK, OR, PA, SC, TX, WA More than half of children enrolled in HealthySteps have Medi-Cal coverage

16. Dyadic Care Model SpeakersNovember 9, 2020 | Center for the Study of Social Policy | Manatt Health StrategiesDr. Sam SingerHighland HospitalPediatricianssinger@alamedahealthsystem.orgAlex BriscoeCalifornia Children’s TrustPrincipalalex@cachildrenstrust.org

17. Scaling and sustaining dyadic models of care in pediatric primary care:UCSF/CHC Dyadic therapy pilot and DHCS family therapy guidanceFirst 5 Webinar11/9, 202017

18. AGENDAThe Well Child Visit and Context for Dyadic CareThe Children’s Health Center and Healthy StepsThe Journey Toward Sustainability: Mapping Medicaid.Babies Don’t Go To The Doctor By Themselves ProposalDHCS and The Family Therapy BenefitWhat’s Next18

19. ACKNOWLEDGMENTS6MBHT Kathy Stanton, Amanda Wagstaff, Katie Mason, Nelly Pino, Liliana Ramos, Cesia Zelaya, Blanca DiDonato, Kathryn Hallinan, Kate Dube, Amanda Wallin, Ana Galdamez, Anna Harrison, John Fernandez, Sharece Francis, ICAP MCTP InternsUCSF @ ZSFG Peds Amy Whittle, Shon Jain, Ellen Laves, Christine Mayor, Susan Fisher-Owens, Maggie Gilbreth, Pallavi Sheth, Eleanor Chung, Raul Gutierrez, Dave GordonUCSF @ ZSFG Psychiatry/Infant, Child & Adolescent Psychiatry Marina Tolou-Shams, Lisa Fortuna, Chris Weyer-JamoraSolid Start Melanie Thomas, Kate DubeCenter for Child and Community Health Anda Kuo, Baylee DeCastro, Dayna Long, Adam DavisSFDPH  SDOH Working Group Ben Lui, Matt PantellUCSF SIREN Laura Gottlieb Health Advocates Phil Herrera, Laura Gottlieb, Laurie Rothstein, Anais AmayaFirst Five Theresa Vergara, Nadia Thind, Sarah Crowe, Christina AltameyerSFGH Foundation & Funders Solid Start, Stupski, John and Lisa Pritzker, Clinton Foundation, KaiserZero to Three & Healthy Steps National OfficeSFHP Medical Director and Executive Leadership, Jim Glauber MDAnthem Blue Cross Dennis Mcintyre MDPhilanthropic Funders including Heising Simmons, Kaiser, Susie Sarlo Genentech, Packard, Zellerbach, WBT, MHSA OACCalifornia Children’s Trust staff and partnersProject CLIMB Team/Children’s Hospital Colorado HealthySteps,, Ayelet Talmi, PhD & Melissa Buchholz, PsyDCalifornia DHCS Lisa Baumeister, MD & Kelly Pfeifer, MD

20. WHAT DRIVES THIS WORK?20Zuckerberg San Francisco General

21. PEDIATRIC SECTOR: CHILD ONLY FOCUSEDEDUCATION SECTOR: CHILD ONLY FOCUSEDEarly Pre-k Opportunities Limited; Voluntary Pre-k Opportunities Growing; Voluntary Entry Into K-12 Compulsory Education SystemEarly Pre-k Opportunities Limited; Voluntary 7 Well Visits Per Year4Well Visits Per Year1Well Visits Per Year2 Well Visits Per Year1 Well Visits Per Year1Well Visits Per YearFAMILY-FOCUSED SYSTEMS: PUSH IN, RUN PARALLELEARLY INTERVENTION SYSTEMS: CURRENT STATEAGES0-1AGES1-2AGES2-3AGES3-4AGES4-5AGES5+Source: Albany Promise Cradle to Career Partnership adapted by First 5 San Francisco 21

22. “An evidence-based, interdisciplinary pediatric primary care program that promotes positive parenting and healthy development for babies and toddlers, with an emphasis on families living in low-income communities.”

23. THE FEDERAL MATCH IS GUARANTEED:23Certified Public Expenditure (CPE) = A state’s use of public funds spent by other government entities (state or county) to claim federal reimbursement for Medicaid services.Federal Financial Participation (FFP) = The Federal share of Medicaid dollars – GUARANTEED match without limit or cap.a Medicaid Expenditure$$=CPEFFPCONTEXTSCHOOLS AS ESSENTIAL ACTORSHOW MEDICAID WORKS5 EMERGING MODELSHOW CAN PHILANTHROPY ENGAGESYSTEMS CHANGE

24. FOLLOW MEDICAID DOLLARS TO FIND MONEY LEFT ON THE TABLE24Federal GovernmentState of CADistributed through Federal departments with funding authorized by Congress (FFP/Match)Acting as pass-through, enhancer, or reconciler of funding—sometimes providing it, sometimes certifying (CPE)Health Plans (MCO)CAPITATIONCounty Mental Health Depts (MHP)CPEDept. of Heath (LGA)CPESchool Districts (LEAs/SELPAs)CPECommunity Health Centers FQHCPPSHospital UC/PHIGTRegional CenterCPE$CONTEXTSCHOOLS AS ESSENTIAL ACTORSHOW MEDICAID WORKS5 EMERGING MODELSHOW CAN PHILANTHROPY ENGAGESYSTEMS CHANGE

25. Pilot Proposal to SF Health Plan & Anthem25

26. 26STRATEGY 1: USE THE WELL CHILD VISIT AS PRIMARY REPLICATE SFHP PRACTICECredentialed non-specialty behavioral health providers may submit as a billable primary diagnosis, the Z-code for a well-child visit, as the primary ICD-10 code attached to any allowable CPT code under the mild to moderate benefit. (Approved Z-codes include, Z00.11, Z00.12).

27. 27Any appropriate BH CPT code for level of serviceWell Child Visit Z-codeIndicate BH Dyadic visit occurring same day as WCVNon-specialty Mental Health Encounter Form

28. 28STRATEGY 2: LEVERAGE THE NEW FAMILY THERAPY BENEFITLeverage new Family Therapy Benefit that opens Z codes and redefines Medical Necessity criteria.There is no cap on the number of family therapy visits billed with ICD-10 code Z65.9 in place of a mental health diagnosis ICD-10 code.   However, for children without a specified risk factor who are suspected of having a mental health disorder, no diagnosis is required until after the 5th visit.Benefit still on accessible by credentialled providers (license eligible)We want DHCS to Add Z13.39 “Encounter for Screening Examination for Other Mental and Behavioral Disorders” to the family therapy benefit as an ICD-10 code accepted in addition to Z65.9.

29. 29A DEEPER DIVE: DHCS FAMILY THERAPY BENEFITYou can find the Medi-Cal Bulletin article here:https://filessysdev.medi-cal.ca.gov/pubsdoco/bulletins/artfull/gm202006.aspx#a11 The full policy, found on pages 4-6 of the Psychological Services section of the provider manual is can be accessed via this link: https://filessysdev.medi-cal.ca.gov/pubsdoco/publications/masters-mtp/part2/psychol_a07.doc.  The reimbursement rates can be found in the Psychological Services: Billing Codes and Reimbursement Rates section of our provider manual via this link: https://filessysdev.medi-cal.ca.gov/pubsdoco/publications/masters-mtp/part2/psycholcd_a07.doc 123

30. 30STRATEGY 3: CREATE A NEW BENEFITSeek parity for preventative behavioral health services by….Open code H0025 (Behavioral health prevention education service) to be accessible for behavioral health prevention to all infants and young children ages birth to 5 similar to how routine encounters for wellness exams are available to all children in physical health. Pair H0025 with the diagnosis: Z13.39 “Encounter for Screening Examination for other Mental and Behavioral Disorders” or a similar Z code that does not specify criteria for medical necessity.

31. DHCS Dyadic Behavioral Health Proposal31Open Health & Behavior CodesExpand caregiver mental health screening Expand family therapy guidance with prevention Z-codesAllow preventive Z-Codes on BH services (existing/new CPT codes)Postpartum Extension to include maternal mental health conditionCreate New Benefits:Behavioral Health Well Child VisitsCare ManagementCouples Therapy

32. What does success look like?Short Term:Dyadic service model meets fidelity & is scalableCHC reports on HS cost savings metrics & plan QI metricsMeet enrollment goals for T2 & T3Solid partnership with plans: innovation & data feedbackClaims data, total cost of care per familyLong Term:Movement towards DHCS adoption of pilot strategiesPlans’ pilot exenditures considered in look-back period for future rate settingHealthcare reform  payment of primary care based dyadic BH models in early childhoodBH/Development Well Child Visits = Parity with Physical Health32

33. Next Steps for First 5 Agencies to Support Dyadic CareNovember 9, 2020 | Center for the Study of Social Policy | Manatt Health StrategiesEstablish partnerships with family-centered organizations to share the importance of dyadic therapy and learn about what’s happening in your communityShare information about the value of dyadic therapy, how to determine eligibility, billing codes, and reimbursement protocols FamiliesProvidersHealth plansSupport funding and provide technical assistance for training, implementation, and quality improvements to models providing dyadic therapy First 5 Agencies’ Next StepsSee Appendix for new resource: Crosswalk of Medi-Cal Family Therapy Guidance & Dyadic Integrated Care Models Currently Implemented in California.

34. Questions & DiscussionNovember 9, 2020 | Center for the Study of Social Policy | Manatt Health Strategies

35. Save the Date for our Final First 5 Center PSP CA Webinar!Early Identification & Intervention in Medi-Cal Wednesday, December 9th10:45 – 12:00 PM PT November 9, 2020 | Center for the Study of Social Policy | Manatt Health Strategies

36. Thanks & Be Well! November 9, 2020 | Center for the Study of Social Policy | Manatt Health Strategies

37. AppendixNovember 9, 2020 | Center for the Study of Social Policy | Manatt Health Strategies

38. Caregivers’ Coverage Opportunities: Family TherapyFamily TherapyEligibilityMedi-Cal enrolled children under age 21To qualify for family therapy:Child has a diagnosis of a mental health condition (defined by DSM or DC: 0-5)OR Child has at least one risk factor (e.g., food insecurity, housing instability, separation from a parent/caregiver, experience of discrimination)*Or child has a parent/caregiver with at least one risk factor (e.g., substance use disorder, depression, mood disorder, history of incarceration)*Or the provider suspects a mental health disorder*ProviderPsychologistLicensed Clinical Social WorkerLicensed Professional Clinical Counselor Marriage and Family TherapistFrequencyUnlimited for children with at least one risk factorFive sessions for any child, without at least one risk factor, before a diagnosis is required Reimbursement Rate$51.00 – $112.41* Denotes expanded eligibility criteria Sources: DHCS: Medi-Cal Rates, October 2020; DHCS: Psychological Services Manual, September 2020. November 9, 2020 | Center for the Study of Social Policy | Manatt Health Strategies

39. Caregivers’ Coverage Opportunities: Maternal Depression Screening & TreatmentMaternal DepressionScreeningTreatmentEligibilityPregnant woman enrolled in Medi-CalPostpartum woman (60 days after delivery) enrolled in Medi-CalWoman with a child up to age one enrolled in Medi-CalPregnant or postpartum (up to 12 months after birth) women with at least one risk factor (e.g., history of depression, depressive symptoms that do not have to reach a diagnostic threshold, history of significant negative life events or socioeconomic risk factors)ProviderAny healthcare provider providing prenatal or postpartum care must offer to screenPediatric provider during a well-child visitAny healthcare provider providing prenatal or postpartum careFrequencyFour times in child’s first year in a well-child visitTwice by prenatal provider – once prenatal and once postpartumTwenty individual or group counseling sessions delivered in the perinatal or postpartum periodReimbursement Rate$10.70 negative screen$29.68 positive screen$64.47 - $119.54 individual counseling $14.48 group counselingSources: DHCS: Medi-Cal Rates, October 2020; DHCS: Psychological Services Manual, September 2020; DHCS: Psychological Services Manual, Pregnancy Early Care and Diagnostic Services, August 2020; AB 2913: Maternal Mental Health; National Academy for State Health Policy: Medicaid Policies for Maternal Depression Screening During Well-Child Visits, March 2020; 2020 Mom: California’s Medicaid Program Now Reimburses Screening and Treatment to Prevent Maternal Depression, August 2019; California Health & Wellness: AB 2913 Requires Maternal Mental Health Screening; First 5 Center: New Program Extends Medi-Cal Coverage to Individuals Diagnosed with a Maternal Mental Health Condition. November 9, 2020 | Center for the Study of Social Policy | Manatt Health Strategies

40. HealthySteps & DULCE Key FeaturesEligibility*Birth to age twoBirth to six months; site discretion to continue up to 18 monthsServicesScreen for age-appropriate child concerns and family needsProvide child development and behavior consultations Share positive parenting guidance and early learning resourcesCoordinate care and systems navigationMaintain a child development support line (e.g., phone, text, email, online portal)Screen for age-appropriate child concerns and family needsAttention to health-related social needs requirements (e.g., food, housing, employment, violence)Address parent-identified needs and community supports Coordinate care and systems navigationProvide legal services and assistance ProviderHealthySteps Specialists are often social workers with mental health training, psychologists, early childhood educators, and/or nurses with experience in early childhood developmentDULCE Behavioral Health Providers are mostly Marriage and Family Therapists and Licensed Clinical Social Workers and provide clinical oversight and supervise Family SpecialistsClinicPediatric care clinicsHospital outpatient clinicsFederally qualified health centersSome sites work with infants in the newborn intensive care unit (NICU)Pediatric care clinicsHospital outpatient clinicsFederally qualified health centersSome sites work infants in the NICUBillingChild most likely covered by Medi-CalUnder some circumstances (e.g., NICU), the adult’s Medi-Cal ID may be billedChild most likely covered by Medi-CalUnder some circumstances (e.g., NICU), the adult’s Medi-Cal ID may be billed* Children receive services from both HealthySteps and DULCE if they are seen in the clinics in which the models operate, not based on risk factors

41. MCP & SMHP Memorandums of Understanding (MOUs)California Code Title 9 RequirementsReferral protocols between Medi-Cal MCPs and county SMHPs (e.g., physical care services, SMHP services);Clinical consultations;Care management and data exchange;Benefits for behavioral health concerns covered by the SMHP and Medi-Cal MCP (e.g., prescription drugs, emergency care, hospital transfers between psychiatric and inpatient care); and Dispute resolution and processes. Every Medi-Cal MCP in each of California’s 58 counties is required to establish an MOU with the county’s SMHP to ensure members have access to mental health services across the bifurcated Medi-Cal behavioral health system. Through a combination of California Code Title 9 requirements and DHCS All Plan Letters, the MOUs must address all of the following considerations:DHCS All Plan Letter 18-015Basic requirements (e.g., screening assessment and referrals, medical necessity determination, care coordination, data exchange);Covered services and populations;Oversight responsibilities of the Medi-Cal MCP and SMHP (e.g., mental health management, quality improvement); Screening, assessment, and referral (e.g., screening tools, referral processes);Care coordination (e.g., inpatient treatment notification processes, transition of care); Information exchange in timely manner;Reporting and quality improvement requirements (e.g., track cross-system referrals, regular meetings); Dispute resolution in timely manner;After-hours/non-business hours policies and procedures; andMember and provider education jointly developed by the Medi-Cal MCP and SMHP.At the discretion of county SMHPs and/or Medi-Cal MCPs, MOUs can be expanded to include specific language aimed at addressing and preventing young children and their parent/caregivers’ behavioral health conditions. Sources: Title 9 California Code of Regulations § 1810.370; DHCS: All Plan Letter 18-015, September 2018 – MOU Requirements for Medi-Cal MCPs & Attachment 2; California Health Care Foundation: The Circle Expands, Understanding Medi-Cal Coverage of Mid-to-Moderate Mental Health Conditions, July 2016.

42. Recent DHCS Developments for Pediatric Primary Care: Supplemental Screening PaymentsSources: DHCS: Proposition 56, Developmental Screenings; DHCS: Trauma Screenings and Trauma-Informed Care Provider Trainings; ACEs Aware: Certification & Payment; California State Auditor: DHCS – Millions of Children are Not Receiving Preventive Health Services.Payments for DevelopmentalScreeningPayments for Adverse Childhood Experiences ScreeningEligibilityChildren with Medi-Cal coverage up to age 30 monthsMedi-Cal enrollees under age 65ProviderAllAll that have completed a two-hour online training FrequencyAt least two times per yearChildren: Once per year, per provider (per MCP)Adult: Once per adult lifetime, per provider (per MCP)Reimbursement Rate$59.90$29.00A March 2019 audit conducted by the California State Auditor documented that 2.5 million children enrolled in Medi-Cal are not receiving federally-required preventive healthcare screenings and services through the EPSDT benefit.November 9, 2020 | Center for the Study of Social Policy | Manatt Health Strategies

43. Dyadic Care Resources for First 5 CommissionsZERO TO THREE HealthyStepsResource PageWhat is HealthySteps?Embracing Growth: 2019 Annual ReportClinic LocationsZERO TO THREE’S State of Babies Yearbook 2020CSSP DULCECSSP Resource PageProject DULCE National Resource PageWhat is DULCE: AnimationsEnglish and SpanishThe Unique Relationship Between the Family Specialist and Medical ProviderDULCE’s Secret Ingredient: The Interdisciplinary TeamFirst 5 LA: Project DULCEDyadic Care ResourcesPSP Analysis – New Medi-Cal Family Therapy Guidance and Dyadic Integrated Care Models Currently Implemented in CaliforniaCSSP – Analysis Fostering Social and Emotional through Pediatric Primary Care: Common Threads to Transform Everyday Practice and SystemsBabies Don’t Go to the Doctor By Themselves: Innovating a Dyadic Behavioral Health Payment Model to Serve the Youngest Primary Care Patients and their FamiliesNovember 9, 2020 | Center for the Study of Social Policy | Manatt Health Strategies

44. Medicaid Federal Requirements & OptionsFeatureMandatory RequirementsOptionsCovered Populations & Eligibility LevelsChildren up to 133% FPL Pregnant women & postpartum women for 60 days up to 133% FPLParents and caregivers* Children in foster careFormer foster care children up to age 26Children and adults receiving supplemental security income (SSI)*Elderly individuals receiving SSIRefugees and asyleesLow-income children above 133% FPL* Low-income pregnant women up to 185% FPL*Low-income postpartum women for more than 60 days*Non-disabled, non-pregnant adults ages 19-65 up to 138% FPL*Medically needy individuals up to 133% FPLSpecific diagnoses (e.g., Breast or cervical cancer, tuberculosis)*Family planning services for non-pregnant women*Covered ServicesEPSDT benefitInpatient and outpatient hospital servicesLaboratory and x-raysPhysician servicesHome health servicesPediatric or family nurse practitioner servicesNurse midwife servicesFamily planning services and suppliesTobacco cessation for pregnant women Federally qualified health centers, rural health clinic centers, free standing birth centersNon-emergency medical transportation Nursing facility services (ages 21 and older)Included, but not limited to:Pharmaceutical coverage (all states opt to cover drugs)Dental services for adultsSubstance abuse rehabilitationEyeglasses and optometry services Speech, hearing, and language disorder services Targeted case management Delivery ModelStates must pick at least one delivery system. Medicaid Managed Care, Fee-For-Service, or bothFinancing & PaymentMedicaid services’ State share between 50 – 83%, with at least 40% coming from State; remainder can come from local governments General Medicaid administrative activities’ State-share 50%Other Medicaid administrative activities (i.e., translation services, MMIS operations) have higher match up to 100%As of January 2020, California has expanded eligibility to all children and young adults regardless of immigration status, through age 25. California leverages these generous eligibility standards using State-only dollars to fund this expansion.* Income eligibility limits vary by stateSources: Medicaid & CHIP Payment & Access Commission (MACPAC): Eligibility; Federal Requirements & State Options for Eligibility; Mandatory & Optional Benefits; Provider Payment & Delivery Systems; Financing.

45. Medicaid Authorities & State Program AdministrationMedicaid AuthorityAuthority DetailsFederal StatuteSocial Security Act Title XIX. Authorizes Medicaid and the federal-state matching. Social Security Act Title XXI. Authorizes states’ CHIP programs and federal-state matching.Social Security Act § 1115. Permits states to seek permission from HHS Secretary to waive certain federal requirements and implement demonstration projects to promote the goals of Medicaid. Federal RegulationsCode of Federal Regulations Title 42: Public Health. The set of rules and regulations issued by federal agencies regarding public health. Chapter IV specifically contains regulations issued by CMS for Medicaid and CHIP. Federal GuidanceState Medicaid Director Letter (SMDLs). Clarify Medicaid statutory and regulatory issues, and communicate policies in federal regulations.State Health Official Letters (SHOLs). Similar to SMDLs, but apply to Medicaid and CHIP.Medicaid & CHIP Informational Bulletins (CIBs). Address operational and technical issues; does not issue new guidance.Frequently Asked Questions (FAQs). Clarify regulatory issues and address operational concerns.State Program AdministrationMedicaid & CHIP State Plan. Describes how California administers its programs (i.e., populations covered, services covered, provider reimbursement)State Plan Amendment (SPA). Amends the agreed up on State Plan for policies and operational changes, corrections, or updatesMedicaid Managed Care Contract. Contract between DHCS and MCPs on roles and responsibilities for MCPs.Requires Federal ApprovalNovember 9, 2020 | Center for the Study of Social Policy | Manatt Health Strategies

46. Medi-Cal Managed Care Policy ToolsMedi-Cal MCP ContractDHCS has broad flexibility to require or incentivize MCPs to implement initiatives aimed at pediatric populations, including:Focusing on targeted populationsPartnering with community organizations to support families with young children Meeting higher quality performance metrics (e.g., HEDIS, CMS Core Set Measures)DHCS All Plan Letter (APL)DHCS issues APLs to provide instructions and policy updates to Medi-Cal MCPs, with recent APLs including:Directed payments for developmental and adverse childhood experiences screeningEPSDT requirementsTelehealth services policy (pre- and post-COVID-19)Behavioral health treatment coverage for childrenDHCS Policy and Procedure Letter (PPL)DHCS issues PPLs to notify Medi-Cal MCPs of important details, including:Enhanced FMAP during COVID-19 Resubmission of updated Medi-Cal MCP/SMHP MOURevised Medicaid Administrative Activities (MAA) templateReplacement of CPT codes Sources: DHCS: APLs 1998 – 2020; DHCS: Administrative Claiming PPLs 1996 – 2020; DHCS: Medi-Cal Managed Care RFP Schedule by Model Type; DHCS: RFI #20-001. In September 2020, the agency accepted responses to a Request for Information (RFI) to inform the development of the draft Request for Proposal (RFP) expected in January 2021. Childhood advocates – including the First 5 Center for Children’s Policy – requested initiatives be included in the next Medi-Cal MCP contract to improve young children’s health and well-being. MCPs will submit responses to the RFP in 2021 with contracts effective in January 2024.DHCS Competitive Reprocurement of Medi-Cal MCPs

47. Resources for First 5 CommissionsFederal AuthoritiesFederal StatuteSSA Title XIX: Grants to States for Medical Assistance ProgramsSSA Title XXI: State Children’s Health Insurance ProgramSSA Section 1115Federal Regulation42 CFR Chapter IVSub-Regulatory GuidanceCMS: Federal Policy Guidance (FAQs, CIBs, SHOL, SMDL)California-Specific MaterialsSection 1115 WaiversCMS: Medi-Cal 2020 1115 Waiver (December 2015 – December 2020)CMS: Medi-Cal 2020 1115 Waiver Extension Application (December 2020 – December 2021)DHCS: CalAIM 1115 Waiver Proposal (tentatively December 2021 – December 2026)CMS: California Waivers (1115, 1915(b4), 1915(c))Medicaid & CHIP State Plan MaterialsDHCS: California Medicaid State PlanDHCS: California CHIP State PlanCMS: California Medicaid & CHIP SPAsDHCS: Resource Page on Medicaid State Plan & SPAsDHCS: Resource Page on CHIP State Plan & SPAsMedi-Cal MCP Reprocurement MaterialsRequest for Information #20-001Reprocurement Schedule (as of February 2020)DHCS: Resource Page on Reprocurement

48. Resources for First 5 Commissions (Cont’d)Medicaid 101: MACPACMedicaid 101 Resource PageEligibility OverviewFederal Requirements and State Options: EligibilityMandatory and Optional Benefits Provider Payment and Delivery SystemsFinancing OverviewNon-Federal FinancingMatching RatesFederal Match Rates for Medicaid Administrative ActivitiesMCPs’ Performance Quality Metrics & SurveysBy County & MCPDHCS: Medi-Cal Managed Care Accountability SetDHCS: Medi-Cal Managed Care External Quality Review Technical Report, Volume 1 of 3 and Volume 2 of 3DHCS: Medicaid Managed Care Survey, Consumer Assessment of Healthcare Providers and Systems (CAHPS)National Committee for Quality Assurance: health Insurance Plan Ratings, MedicaidBy StateCMS: Child Core Set MeasuresAnalysis on MCPs’ Performance in Pediatric Care, by County & MCPChildren Now: Children’s Medi-Cal Managed Care in California CountiesNovember 9, 2020 | Center for the Study of Social Policy | Manatt Health Strategies