Pipeline to Treatment for Foster Youth 

Background:

• Medicaid is public health insurance for low-income families and individuals with disabilities. The federal government splits the cost with states and in exchange federal rules must be followed. 
• Medi-Cal is California’s name for Medicaid. 
• Eligible members meet the income and disability qualifications and are in good standing. Children with slightly higher incomes are included in Medi-Cal (CHIP). Foster Youth and former foster youth are automatically qualified and enrolled in Medi-cal, regardless of income or resources.
• Medi-Cal must provide Preventative Services – to prevent future health problems – and also all medically necessary services for individuals under 21 through an expansive benefit called EPSDT (Early, Periodic Screening, Diagnostic, and Treatment).  Behavioral Health Treatment (BHT) is required under both these categories of service.
• “BHT services include applied behavioral analysis (ABA) and a variety of other behavioral interventions that have been identified as evidence-based approaches that prevent or minimize the adverse effects of behaviors that interfere with learning and social interaction.” (APL 23-010) 
• The Department of Healthcare Services (DHCS) is the Single State Agency administering Medi-Cal and ultimately responsible for ensuring all eligible Medi-Cal members receive services.
• Medi-Cal members can be enrolled in two types of Medi-Cal health plans: Managed Care Plans (MCP/MCO) or Fee For Service (FFS) plans. FY are predominantly enrolled in FFS.
• Medi-Cal must ensure BHT is accessible whether a member is enrolled in an MCO or FFS.
• Under EPSDT (under age 21), medical necessity is established when BHT or ABA is recommended as medically necessary by a licensed physician, surgeon, or psychologist. 
• “For the EPSDT population, state and federal law define a service as “Medically Necessary” if the service is necessary to correct or ameliorate defects and physical and/or mental illnesses and other conditions.” i.e., “sustain,” “support,” “maintain,” “prevent … from worsening,” “make more tolerable.” (APL 23-010) 
• There can be no other limitations put on medical necessity such as diagnostic requirements or limitations on settings, such as school.
• Unlike all other Medi-Cal services, in 2014, DHCS decided to provide the BHT/ABA benefit through the Department of Developmental Services (DDS) and the regional centers.

The Problem:

• A decade after the California State Plan was amended to include BHT services, there is still no clear mechanism for Medi-Cal FFS members to access medically necessary BHT services covered under the EPSDT benefit. As a result, FFS members, including the majority of children in foster care, are not being able to access life altering BHT services.
• In 2014 when implementing SPA 14-026, DHCS entered into a binding Interagency Agreement Memorandum of Understanding (IA MOU) with DDS to provide BHT services to FFS members. SNN’s analysis of the IA MOU identified a clear disconnect between the expectations set forth and their implementation due to the ambiguous use of the term “eligible” in the IA MOU. 
• Currently, DDS is only providing BHT to a subset of FFS members who are eligible for regional center (RC) services, a separate eligibility process that has nothing to do with Medi-Cal eligibility and limits access to BHT for hundreds of thousands of members. 
• As of July 2023, there were 5.75 million children ages 0-20 enrolled in California Medi-Cal Program, with 9.2% of total members enrolled in fee-for-service. We estimate more than 500,000 Medi-Cal FFS members being without access to BHT services. 
• Moreover, even RC eligible FFS members are having trouble accessing BHT and are not receiving them per Medi-Cal timely access standards and sometimes not at all.

Objective:

• Provide appropriate access to behavioral health treatment (BHT) services to all Medi-Cal beneficiaries under the age of 21 when it has been determined medically necessary and as recommended by a licensed physician and surgeon or a licensed psychologist.
• Ensure all EPSDT standards are met for FFS members accessing BHT services
• statewideness: services must be available statewide 
• comparability: services must be the same for all members (MCP/FFS)
• medical necessity standards: services have been recommended as medically necessary by a licensed clinician
• timely access standards: services are provided within 10 days of a request  
• network adequacy: reasonable access to sufficient providers to meet the need within the required time frames
• mental health parity standards: behavioral and mental services can’t have more restrictions or limitations than medical or surgical service