Mental Health
Provider Type
- Physicians
- Participating Physician Groups (PPG)
- Hospitals
- Ancillary
Health Net Medi-Cal members obtain the following mental health services through Health Net:
- Non-specialty mental health services (NSMHS):
- Mental health evaluation and treatment, including individual, group and family psychotherapy.
- Psychological and neuropsychological testing, when clinically indicated to evaluate a mental health condition.
- Outpatient services for purposes of monitoring drug therapy.
- Psychiatric consultation.
- Outpatient laboratory, drugs, supplies and supplements.
- Medications for Addiction Treatment (MAT), also known as medication-assisted treatment provided in primary care, inpatient hospital, emergency departments, and other contracted medical settings.
- Emergency services necessary to stabilize the member.
Members do not need to contact their primary care physician (PCP), participating physician group (PPG) or attending physician to request a referral for mental health care services. Health Net members may obtain these services directly through Health Net's extensive behavioral health network by calling the member services telephone number listed on their identification card (ID). Participating providers may also contact Behavioral Health Provider Services for assistance with mental health services referrals.
Prior authorization is not required for initial assessment for outpatient behavioral health services.
PCPs may refer members to marriage and family therapists, social workers, professional counselors, psychologists, and psychiatrists for services, as follows:
- Marriage and family therapists, social workers, professional counselors, and psychologists can:
- Diagnose, treat and consult for the management of mild to moderate emotional problems for which the PCP or member feels the need for consultation.
- Evaluate cases for which a member would benefit from psychotherapy in addition to psychotherapeutic medication.
- Conduct psychological testing for clarification of diagnosis to establish a treatment plan (psychologists).
- Psychiatrists can:
- Diagnose, treat and recommend a medication regimen in difficult or complex cases, including cases of depression that do not respond to a 60-day trial of selective serotonin re-uptake inhibitor (SSRI) medications or other antidepressants.
- Evaluate cases in which members report feeling suicidal or homicidal, severe anxiety states, clear somatoform disorders, schizophrenic disorders where Clozaril® or risperidone is being considered, and bipolar disorder where lithium, carbamazepine or valproic acid may be needed.
PCPs are responsible for coordinating referrals for members requiring specialty or inpatient mental health services to county mental health plans (CMHPs) in Fresno, Kern, Kings, Los Angeles, Madera, Sacramento, San Diego, San Joaquin, Stanislaus, Tulare. PCPs retain responsibility for coordination of ongoing care for co-existing medical and mental health needs and provision of medically necessary medications.
The Mental Health Services Division (MHSD) oversees CMHPs and each county is required to provide access to specialty mental health services for Medi-Cal members. Refer to the MHSD Medical Necessity Criteria document for additional information about criteria for specialty mental health services.
Excluded Psychotherapeutic Medications
Refer to the Medi-Cal Rx program for psychotherapeutic medications excluded. These medications are covered through the Medi-Cal fee-for-service (FFS) or Medi-Cal Rx program. Providers must bill the state directly for these medications.
Health Net Responsibilities
Health Net is responsible to:
- Monitor appropriate referral of members by primary care physicians (PCPs) through audits (specific services may be considered Early and Periodic Screening, Diagnosis and Treatment (EPSDT) supplemental services for members under age 21).
- Monitor the availability of coordination of care services when indicated and requested by the PCP or mental health care provider.
- Provide medically necessary emergency room (ER) professional services and medical transportation services for emergency medical conditions. This includes facility charges for ER visits that do not result in a psychiatric admission and all laboratory and radiology services necessary for the diagnosis, monitoring or treatment of a member's mental health condition.
- Transportation for non-emergency conditions is not covered unless prior authorized. ER services for non-emergency medical conditions, services after stabilization, or an emergency medical condition require authorization.
MHSD Medical Necessity Criteria
The following Mental Health Services Division (MHSD) medical necessity criteria for specialty mental health services are the responsibility of the county mental health plan (CMHP).
Diagnosis - The member must have one of the following DSM IV-included diagnoses, which indicates the focus of the intervention provided:
Included diagnosis | Excluded diagnosis* |
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*A beneficiary may receive services for an included diagnosis even if an excluded diagnosis is present.
**Early and Periodic Screening, Diagnosis and Treatment (EPSDT) beneficiaries with an included diagnosis and a substance-related disorder may receive specialty mental health services directed at the substance use component. The intervention must be consistent with, and necessary to the attainment of, the specialty mental health treatment goals.
Impairment - Member must have one of the following as a result of an included mental disorder:
- A significant impairment in an important area of life functioning
- A probability of significant deterioration in an important area of life functioning
Children also qualify if there is a probability the child will not progress developmentally as individually appropriate. Children covered under EPSDT qualify if they have a mental disorder that can be corrected or ameliorated.
Intervention related - All three of the following must apply:
- The focus of proposed intervention is to address the condition identified in the impairment criteria identified above.
- It is expected the beneficiary will benefit from the proposed intervention by significantly diminishing the impairment, or preventing significant deterioration in an important area of life functioning, or for children, it is probable the child will progress developmentally as individually appropriate (or if covered by EPSDT can be corrected or ameliorated).
- The condition would not be responsive to physical health care-based treatment.
PCP Responsibilities and Referrals to Behavioral Health Providers
Primary care physicians (PCPs) provide outpatient mental health services within the scope of their practice. The PCP is responsible for identifying and treating, or making a specialty medical referral for, the member's general medical conditions that cause or exacerbate psychological symptoms.
If members require mental health services for mild to moderate conditions, PCPs may refer members to Health Net for assessment and referral to a mental health provider. PCPs must continue to:
- Make available all necessary medical records and documentation relating to the diagnosis and care of the mental health condition that resulted in a referral.
- Ensure the appropriate documentation is included in the member's medical record.
- Respond to requests to coordinate non-specialty mental health conditions and services with specialists.
Examples of mental health services generally considered appropriate to be provided by the PCP are:
- Complete physical and mental status examinations and extended psychosocial and developmental histories when indicated by psychiatric or somatic presentations (fatigue, anorexia, overeating, headaches, pains, digestive problems, altered sleep problems, and acquired sexual problems).
- Diagnosis of physical disorders with behavioral manifestation.
- Maintenance medication management after stabilization by a psychiatrist or, if longer-term psychotherapy continues, with a non-physician therapist.
- Diagnosis and case management of child, elder and dependent adult abuse and domestic violence victims.
- Coordination of psychological assessments to rule out:
- General medical conditions as a cause of psychological symptoms.
- Mental or substance-related disorders caused by a general medical condition.
PPG Responsibilities
Participating physician groups (PPGs) are responsible for providing the initial health history and physical assessment of members admitted to the psychiatric ward of a general acute care hospital or to a freestanding licensed psychiatric inpatient hospital.
Problem Resolution
Health Net's public programs administrators resolve disputes that arise between the county mental health plan (CMHP) and Health Net or the primary care physician (PCP). During the dispute period, the Health Net Medi-Cal Health Services Department and the PCP or specialty provider continue to coordinate the care of the member until the matter is resolved.
Referral Process to Specialty Mental Health
The need for referral for specialty mental health services is determined by the primary care physician's (PCP's) evaluation of the member's medical history, psychosocial history, current state of health, and any request for such services from either the member or the member's family. Once the determination has been made to refer the member for specialty mental health services, PCPs may do one of the following based on the member's level of mental health impairment:
- For members with mild to moderate impairment, providers may contact Behavioral Health Provider Services for assistance.
- For Health Net members assigned to Molina with mild to moderate impairment, refer to the Molina Behavioral Health Services Line.
- For all Medi-Cal members with a severe level of impairment, refer to the county mental health plan (CMHP) for specialty mental health services (SMHS). Providers may also refer directly to the CMHP.
Refer to the Mental Health Services Division (MHSD) Medical Necessity Criteria in the section above for included and excluded diagnoses and information on when to refer to the CMHP.
Members may self-refer for behavioral health services by calling the member services phone number listed on their identification card (ID). Health Net members assigned to Molina may also self-refer by calling the member services phone number listed on their ID card.
Specialty Mental Health Services
Specialty mental health services covered by county mental health plans (CMHPs) include:
- Outpatient services
- Mental health services, including assessments, plan development, therapy and rehabilitation
- Medication support
- Day treatment services and day rehabilitation
- Crisis intervention and stabilization
- Targeted case management
- Therapeutic behavior services
- Residential services
- Adult residential treatment services
- Crisis residential treatment services
- Inpatient services
- Acute psychiatric inpatient hospital services
- Psychiatric inpatient hospital professional services
- Psychiatric health facility services
Refer to the Mental Health Services Division (MHSD) Medical Necessity Criteria discussion above for additional information.
No Wrong Door Policy for Mental Health Services
This policy allows members who directly access a treatment provider to receive an assessment and mental health services, and to have that provider reimbursed for those services by their contracted plan, even if the member is transferred to the other delivery system due to their level of impairment and mental health needs. In certain situations, members may receive coordinated, non-duplicative services in multiple delivery systems, such as when a member has an ongoing therapeutic relationship with a therapist or psychiatrist in one delivery system while requiring medically necessary services in the other.
Health Net provides or arranges for the provision of the following:
- Non-specialty mental health services (NSMHS):
- Mental health evaluation and treatment, including individual, group and family psychotherapy.
- Psychological and neuropsychological testing, when clinically indicated to evaluate a mental health condition.
- Outpatient services for purposes of monitoring drug therapy.
- Psychiatric consultation.
- Outpatient laboratory, drugs, supplies and supplements.
- Medications for Addiction Treatment (MAT), also known as medication-assisted treatment provided in primary care, inpatient hospital, emergency departments, and other contracted medical settings.
- Emergency services necessary to stabilize the member.
NSMHS listed above applies to the following populations:
- Members ages 21 and older with mild to moderate distress, or mild to moderate impairment of mental, emotional, or behavioral functioning resulting from mental health disorders, as defined by the current Diagnostic and Statistical Manual of Mental Disorders.
- Members under age 21, to the extent they are eligible for services through the Medicaid Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit, regardless of the level of distress or impairment, or the presence of a diagnosis.
- Members of any age with potential mental health disorders not yet diagnosed.
Consistent with W&I Code section 14184.402(f), clinically appropriate NSMHS are covered by Health Net even when:
- Services provided during the assessment period prior to a determination of a diagnosis, during the assessment period or prior to determination of whether NSMHS criteria are met. Health Net and county mental health plan (MHPs) will not deny or disallow reimbursement for NSMHS provided during the assessment process described above if the assessment determines that the member does not meet the criteria for NSMHS or meets the criteria for SMHS.
- Services not included in an individual treatment plan.
- The member has a co-occurring mental health condition and substance use disorder (SUD). Health Net and CMHP will not deny or disallow reimbursement for NSMHS provided to a member who meets NSMHS criteria on the basis of the member having a co-occurring SUD, when all other Medi-Cal and service requirements are met. Similarly, Health Net covers clinically appropriate SUD services delivered by Health Net providers (e.g., alcohol and drug screening, assessment, brief interventions, and referral to treatment; MAT) whether or not the member has a co-occurring mental health condition. Drug Medi-Cal (DMC) and Drug Medi-Cal Organized Delivery System (DMC-ODS) counties cover clinically appropriate DMC/DMC-ODS services delivered by DMC/DMC-ODS providers, respectively, whether or not the member has a co-occurring mental health condition.
- Concurrent NSMHS and SMHS. Members may concurrently receive NSMHS from a Health Net provider and SMHS via a CMHP provider when the services are clinically appropriate, coordinated and not duplicative. When a member meets criteria for both NSMHS and SMHS, the member should receive services based on the individual clinical need and established therapeutic relationships. Health Net and CMHP will not deny or disallow reimbursement for NSMHS provided to a member on the basis of the member also meeting SMHS criteria and/or also receiving SMHS services.
Any concurrent NSMHS and SMHS for adults and children under ages 21, will be coordinated between Health Net and the local CMHP to ensure member choice. Health Net will coordinate with local CMHP to facilitate care transitions and guide referrals for members receiving NSMHS to transition to a SMHS provider and vice versa, ensuring that the referral loop is closed, and the new provider accepts the care of the member. Such decisions should be made via a patient-centered shared decision-making process.
- Members with established therapeutic relationships with a Health Net provider may continue receiving NSMHS from the Health Net provider (billed to Health Net), even if the member simultaneously receives SMHS from a CMHP provider (billed to the CMHP), as long as the services are coordinated between the delivery systems and are non-duplicative (e.g., a member may only receive psychiatry services in one network, not both networks; a member may only access individual therapy in one network, not both networks).
- Members with established therapeutic relationships with a CMHP provider may continue receiving SMHS from the CMHP provider (billed to the CMHP), even if the member simultaneously receives NSMHS from a Health Net provider (billed to Health Net), as long as the services are coordinated between these delivery systems and are non-duplicative.
Screening and transition of care tools
Per APL 22-028, DHCS developed the following standardized adult and youth (under age 21) screening and transition of care tools for Medi-Cal managed care plans (MCPs) and county mental health plans to use:
- Screening tools to determine the most appropriate Medi-Cal mental health delivery system referral for members who are not currently receiving mental health services when they contact the MCP or county mental health plan seeking mental health services.
- Transition of care tool to ensure Medi-Cal members receive timely and coordinated care when completing a transition of services to the other delivery system or when adding a service from the other delivery system to their existing mental health treatment.