A Psychotherapist's Basic Guide to Medi-Cal and Resources for Navigating the System

By Sara Jasper, JD
Staff Attorney
The Therapist
January/February 2020

---

More than 13 million Californians, or roughly one out of three Californians, are covered by Medi-Cal. Medi-Cal is California’s version of Medicaid, which is a national health program that provides health care coverage for low-income adults, children, pregnant women, elderly adults and people with disabilities.¹ The Medi-Cal program has been in place since 1966 and was expanded under the Affordable Care Act (ACA) in 2014. Since Medi-Cal serves as a major method of delivery for behavioral health services in the state, psychotherapists may benefit from having a basic understanding of how the system operates as well as the resources available to assist providers who work within it.

This article explains Medi-Cal’s behavioral health care system, recent changes to the provider enrollment process, the California Advancing and Innovating Medi-Cal (CalAIM) initiative, and offers information about resources for Medi-Cal providers.

An Overview of Medi-Cal’s Behavioral Health System The Department of Health Care Services (DHCS) is the state agency responsible for implementing and overseeing the Medi-Cal services delivery system. The Medi-Cal system has three pathways to services for eligible Medi-Cal beneficiaries who have behavioral healthcare needs. These pathways include: 1) County Mental Health Plans (MHPs) which are responsible for providing services to Medi-Cal enrollees with severe behavioral health needs; 2) Medi-Cal Managed Care Plans (MCPs) which are responsible for providing services to beneficiaries with mild to moderate behavioral health issues, and 3) the State’s Fee-For-Service (FFS) providers who serve beneficiaries with mild to moderate impairment of mental, emotional or behavioral functioning.

As a result of CAMFT’s advocacy efforts, State Plan Amendment (SPA) 14-012 was approved by the Centers for Medicare and Medicaid Services on May 2, 2014. Per the SPA, LMFTS and Registered Associate MFTs (AMFTs) were added to the list of eligible Medi-Cal providers. This change to the state plan means that LMFTs may enroll as FFS providers directly with the State’s MediCal System. Prior to the SPA, LMFTs were limited to working with clients as a result of employment or volunteer relationships with the County Mental Health Plans or by contracting with Medi-Cal managed care plans. The SPA also made it possible for AMFTs who are being properly supervised by a qualified supervisor, to treat Medi-Cal clients through any of the three pathways. Under the SPA, the County Mental Health Plans and the MediCal Managed Care Plans do, however, have discretion as to whether to accept AMFTs as rendering providers. For this reason, CAMFT urges supervisors and employers to check with a plan’s provider relations department to determine the plan’s eligibility and reimbursement policies for AMFTs who wish to serve as rendering providers.

For more information about how LMFTs and AMFTs fit into the Medi-Cal system, see “Pathways to Becoming a Medi-Cal Provider” on page 48 of this issue.

Recent Changes to Medi-Cal On June 12, 2019, DHCS sent out All Plan Letter (APL)2 19-004 to all MCPs regarding provider credentialing/re-credentialing and provider screening and enrollment. As a result of changes to federal regulations, licensed providers who are already in-network with MCPs, and prospective network providers, are required to enroll in the Medi-Cal program.³ Per the APL, MCPs may either develop a screening and enrollment process and make determinations about providers within 120 days of receipt of an application⁴ or providers may enroll by applying through DHCS’s FFS system. Providers should note that DHCS may take up to 180 days to review FFS applications.⁵

Although MCP network providers who are screened and enrolled through DHCS’s FFS system may have to wait up to six months for word about their applications, there is an advantage to being screened and enrolled through the state. Providers who are vetted by DHCS have the option of offering services not only through their contracts with the MCPs but also through the FFS system as FFS providers. MCP network providers who enroll through DHCS’s FFS process are not, however, required to take clients through the FFS system. Providers who go through an MCP’s screening and enrollment process are limited to working only with the MCP’s Medi-Cal clients. Occasionally, plans may work with providers on the basis of temporary letters of agreement, continuity of care agreements or based on an urgent/emergency basis. DHCS is not requiring MCPs to screen and enroll providers in those situations.

Once a provider has been screened and enrolled by either the state or an MCP, plans can rely on the results of either process. Information about providers who enrolled through DHCS’s FFS system can be accessed via the California Health and Human Services Open Data Portal.⁶ MCPs must issue network providers who have been vetted through their system a “verification of enrollment” which providers can use to demonstrate to other plans they have already met the screening and enrollment requirements. In order to avoid duplicate enrollments, MCPs are free to share provider screening and enrollment results with one another.

AMFTs, their employers and supervisors should be aware that AMFTs are not required to undergo the same screening and enrollment process as licensees. According to DHCS, MCPs are expected to develop their own credentialing process for AMFTs. DHCS will not accept any applications from AMFTs.

Those who undergo the provider screening and enrollment process through DHCS will be working with DHCS’s Provider Enrollment Division (PED).⁷ As of 2019, DHCS stopped accepting paper applications from most provider types, including LMFTs. LMFT providers are now required to use the Provider Application and Validation for Enrollment (PAVE) portal to complete and submit enrollment applications. Providers must also use the PAVE portal to report changes to existing enrollments, and respond to PED requests for re-enrollment or revalidation.⁸

Future Changes to Medi-Cal In October of 2019, the Department of Health Care Services introduced its California Advancing and Innovating Medi-Cal (CalAIM) initiative. The CalAIM proposal is an ambitious project which is intended to bring about major reforms across the Medi-Cal system. DHCS will be implementing these proposal-driven changes in stages beginning in January of 2021. CalAIM’s overarching goals are to do the following:

• Identify and manage member risk and need through Whole Person Care approaches and by addressing the social determinants of health.
• Move Medi-Cal to a more consistent and seamless system by reducing complexity and increasing flexibility

• Improve quality outcomes and drive delivery system transformation through value-based initiatives, modernization of systems, and payment reform.

As a result of these goals, DHCS is proposing significant reforms to the behavioral health care payment and delivery systems. More specifically, the behavioral health care reform proposals within the CalAIM initiative relate to the following:

• Behavioral health payment reform
• Behavioral health integration
• Medical necessity
• Regional contracting
• Substance use disorder managed care program

DHCS began the work of the initiative by holding workgroup meetings that began in November of 2019 and will continue into late February 2020. CAMFT is attending the CalAIM Behavioral Health Workgroup meetings for stakeholders and members of the public to ensure that our members’ interests are represented. CAMFT will have numerous opportunities to comment on the proposal throughout the policy development process. CAMFT will keep members informed about the initiative process as it unfolds through updates in The Therapist, the e-newsletter, and the CAMFT website. For a copy of the CalAIM proposal and more information about the initiative visit https://www.dhcs.ca.gov/calaim.

Resources for Medi-Cal
Providers DHCS has developed a number of methods for training Medi-Cal providers about the MediCal system and assisting them with claim issues. The Department’s Outreach and Education team consists of Regional Representatives, the Small Provider Billing Unit and coordinators. Regional Representatives offer basic and advanced live training seminars and webinars. At the Seminars which are held throughout California, providers can receive billing assistance service at no cost in the Claims Assistance Room.

Providers can also set up appointments for one of the 22 Regional Representatives to come to their offices to conduct trainings or discuss billing issues. Coordinators also help with providers’ training needs and billing concerns.

DHCS’s Small Provider Billing Unit includes four specialists who provide individual billing assistance for one year. This service is only available to providers who submit fewer than 100 claim lines per month. For more information about the service, providers can call 916-636-127 or 1-800-541-5555.

Providers who want to contact a Regional Representative or sign up for a live seminar or webinar should register with DHCS’s MediCal Learning Portal (MLP). In addition to seminar and webinar schedules, the learning portal also has online tutorials and recorded webinars. The MLP can be accessed by going to http://www.medi-cal.ca.gov/education.asp. For more information about the MLP, providers may also call the Telephone Service Center at 1-800-541-5555.

Provider Enrollment Division (PED) contact information:
For questions concerning enrollment policy or enrollment forms or the status of an application, you may submit your questions via email to PEDCorr@dhcs.ca.gov. Mail questions to: Department of Health Care Services, Attn: Provider Enrollment Division, MS 4704, P. O. Box 997412, Sacramento, CA 95899-7412. Providers may also call the PED Message Center at (916) 323-1945. After reaching the welcome message, select option 4, then option 1 to speak with a live agent.

In an effort to provide further guidance on screening and enrollment requirements, DHCS created a “Medi-Cal Provider Enrollment Frequently Asked Questions” pdf that can be found at https://www. dhcs.ca.gov/formsandpubs/Documents/ MMCDAPLsandPolicyLetters/APL2017/ APL17-019FAQ.pdf

Provider Application and Validation for Enrollment (PAVE) contact information:
For technical assistance with the PAVE provider portal, contact the PAVE help desk at (866) 252-1949. The help desk is available Monday through Friday from 8 a.m. to 6 p.m. Pacific Time, excluding state holidays. Providers can also access live training webinars and pre-recorded training videos by going to https://www.dhcs.ca.gov/provgovpart/Pages/ PAVE.aspx.

Conclusion
Medi-Cal is a complex health care system that can be difficult for providers to understand and navigate. CAMFT continues to stay abreast of changes to the Medi-Cal system in order to assist and advocate for our members who work with Medi-Cal clients. Members should look for regular Medi-Cal updates in The Therapist, in e-newsletters, and on CAMFT’s website.

---

Sara Jasper, JD, CAE, is a staff attorney for CAMFT. Sara is available to answer member calls regarding legal, ethical, and licensure issues.

---

This article is not intended to serve as legal advice and is offered for educational purposes only. The information provided should not be used as a substitute for independent legal advice and it is not intended to address every situation that could potentially arise. Please be aware that laws, regulations and technical standards change over time. As a result, it is important to verify and update any reference or information that is provided in this article.

Endnotes

¹ Medicaid is administered by states in accordance with federal requirements and a state plan.A state plan is an agreement between a state and the federal government (i.e., the Centers for Medicare and Medicaid Services or CMS) which describes how a state will administer its Medicaid program. States submit State Plan Amendments or SPAs to CMS in order to request program changes, make corrections, or update their Medicaid plans with new information.

² All Plan Letters (APLs) are the means by which the Medi-Cal Managed Care arm of DHCS conveys information or interpretation of changes in policy or procedure at the federal or state levels, and provides instruction to contractors on how to implement those changes on an operational basis.

³ 42 CFR §438.602(b).

⁴ Within 120 days of receipt of a provider application, MCPs must complete the enrollment process and provide the applicant with a written determination. Under 42 CFR §438.602(b)(2), MCPs may allow providers to participate in their networks for up to 120 days, pending the outcome of the screening process.

⁵Cal. Wel. & Inst. Code §14043.26.

⁶ The CHHS Open Data Portal can be found at https://data.chhs. ca.gov/dataset/profile-of-enrolled-medi-cal-fee-for-service-ffsproviders-as-of-June-1-2017.

⁷ PED also updates and maintains provider information which is used in the claims payment process

⁸ For information about the PAVE portal and how to access live training webinars and pre-recorded training videos, visit https:// www.dhcs.ca.gov/provgovpart/Pages/PAVE.aspx.