Medi-Cal: psychiatric emergency medical conditions.

Existing law provides for the Medi-Cal program, which is administered by the State Department of Health Care Services, and under which qualified low-income individuals receive health care services, which are delivered through various delivery systems, including fee-for-service and managed care. The Medi-Cal program is, in part, governed and funded by federal Medicaid program provisions. Existing law requires the department to implement managed mental health care for Medi-Cal beneficiaries through contracts with mental health plans. Under existing law, mental health plans are responsible for providing specialty mental health services to enrollees, and Medi-Cal managed care plans deliver nonspecialty mental health services to enrollees. Under existing law, emergency services and care, mental health benefits, substance use disorder benefits, and specialty mental health services are covered under the Medi-Cal program. This bill would specify that observation services for a psychiatric emergency medical condition, as defined, are covered under the Medi-Cal program, consistent with coverage under the above provisions and any other applicable law. Under the bill, the scope of coverage of those services would include facility services for observation services provided within the emergency department, or an onsite or offsite observation unit, as defined, of a general acute care hospital to a Medi-Cal beneficiary with a confirmed or suspected psychiatric emergency medical condition. Existing law imposes certain requirements on mental health plans and Medi-Cal managed care plans, including network adequacy standards and a requirement to enter into a memorandum of understanding if the 2 plans serve some of the same Medi-Cal recipients. This bill would require the applicable mental health plan and Medi-Cal managed care plan to notify each other within 24 hours from notification by a general acute care hospital of a Medi-Cal beneficiary with a condition as described above. The bill would require the memorandum of understanding to include a process to coordinate the provision of the above services, as specified. The bill would require disputes between a mental health plan and a Medi-Cal managed care plan, or between mental health plans, regarding the responsibility to pay for the charges for those services to be resolved pursuant to certain processes under existing law. The bill would require that the mental health plan be responsible for observation services for a psychiatric emergency medical condition. If those services are provided to a Medi-Cal fee-for-service beneficiary, the bill would require the department to reimburse the hospital using a specified formula. The bill would also exempt from the observation services billing requirements for emergency psychiatric services a hospital campus with a psychiatric observation unit that has been designated as a crisis stabilization unit by a mental health plan. The bill would, for purposes of meeting certain network adequacy standards under existing law, require agreements between a mental health plan and a general acute care hospital that is not licensed to provide inpatient psychiatric care to include provisions governing the coordination between the hospital and the plan for the provision of the above-described services. The bill would authorize the plan and the hospital to agree to rates of reimbursement other than the above-described fee-for-service rate. The bill would condition implementation of these provisions on any necessary federal approvals being obtained and the availability of federal financial participation. The bill would require the department to seek any necessary federal approvals for implementation of these provisions.