In the duals demonstration, participating health plans will be responsible for providing enrollees access to all medically necessary behavioral health services (mental health and substance use disorder treatment) currently covered by Medicare and Medi-Cal. While all Medicare-covered behavioral health services will be the responsibility of the health plans under the demonstration and included in their capitation payment, Medi-Cal specialty mental health services not covered by Medicare and Drug Medi-Cal benefits will not be included in the capitation payment made to the participating health plans (i.e. they will be “carved out). Demonstration plans will coordinate with county agencies to ensure enrollees have seamless access to these services.
DHCS requires participating health plans execute Memoranda of Understanding (MOUs) with their local county Mental Health Plan (MHP) and the county department responsible for alcohol and drug services (if the entities are separate) for the demonstration enrollees who meet the medical necessity criteria for Medi‐Cal Specialty Mental Health or Drug Medi-Cal Services. The MOU template below includes optional language that duals demonstration health plans and county MHPs and the county department responsible for alcohol and drug services may use to update their existing MOUs (or create one in the case one does not exist).
Additionally, DHCS has created care coordination standards that work in conjunction with the MOUs to ensure beneficiaries have seamless access to needed behavioral health services. The standards below are intended to be view in conjunction with the companion Care Coordination Standards. They are part of the requirements that the Centers for Medicare/Medicaid (CMS) and the California Department of Health Care Services (DHCS) will use to assess health plan readiness for the duals demonstration. These standards are specific to the coordination of the behavioral health services carved out of the duals demonstration – Medi-Cal specialty mental health and Drug Medi-Cal services. These standards will be incorporated into the contract requirements for health plans, the health plan readiness assessment checklist, and used for ongoing monitoring of participating health plans.
Revised Documents
- Revised local Behavioral Health MOU template (2/20/13)
- Revised Behavioral Health Coordination Standards (2/20/13)
- Fact Sheet: Inpatient and IMD coverage (3/4/13)
- List of Behavioral Health Quality Measures (3/28/13)
- Revised Benefit Coverage Matrix (Appendix A) (January 2020)
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