Medi-Cal Expansion, Mental Health Services and Changes to Medi-Cal Prior Authorization Requirements

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1 REGULATORY DECEMBER 19, 2013 UPDATE PAGES Medi-Cal Expansion, Mental Health Services and Changes to Medi-Cal Beginning January 1, 2014, Medi-Cal coverage is expanding under the Affordable Care Act (ACA) and individuals (predominately adults without children) currently considered ineligible will qualify for Medi-Cal coverage. The Medi-Cal expansion includes eligibility for anyone under 138 percent of the Federal Poverty Level (FPL). With the Medi-Cal expansion, lowincome adults with or without dependent children, low-income children who lose Medi-Cal benefits when they are classified as adults at age 19, and low-income adults with disabilities who are not eligible for Social Security Supplemental Disability Insurance (SSDI) or Supplemental Security Income (SSI) may now qualify for Medi-Cal. This updates contains information for providers regarding mental health services, including mental health service exclusions and continuity of care for members receiving mental health services after January 1. It also includes changes to the Medi-Cal prior authorization requirements as a result of the mental health services expansion, in addition to a change for out-of-network services THIS UPDATE APPLIES TO MEDI-CAL PROVIDERS: Physicians Participating Physician Groups Hospitals Ancillary Providers PROVIDER SERVICES (888) MENTAL HEALTH SERVICES EXPANSION On January 1, 2014, CalViva Health is offering the following expanded mental health services: Individual and group mental health evaluation and treatment (psychotherapy) Psychological testing to evaluate a mental health condition Outpatient services that include laboratory work, medications and supplies Outpatient services for the purposes of monitoring medication therapy Psychiatric consultation Services Excluded from CalViva Health Coverage The following specialty mental health services continue to be provided by the county mental health plans (CMHPs) for members who meet medical necessity criteria. Providers should direct members who are receiving or eligible for specialty mental health services to the CMHPs. Medical necessity criteria for specialty mental health services is available on the provider website at provider.healthnet.com in the Provider Library > Operations Manuals > Public Health > Mental Health > DMH Medical Necessity Criteria. Outpatient services - Mental health services, including assessments, plan development, therapy and rehabilitation and collateral - Medication support - Day treatment services and day rehabilitation - Crisis intervention and stabilization CalViva Health is a licensed health plan in California that provides services to Medi-Cal enrollees in Fresno, Kings and Madera counties. CalViva Health is contracting with Health Net Community Solutions, Inc. to provide and arrange for network services. Health Net Community Solutions, Inc. is a subsidiary of Health Net, Inc. Health Net is a registered service mark of Health Net, Inc. All rights reserved.

2 - 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 The following alcohol and drug treatment services are excluded from CalViva Health s coverage responsibility, but are provided by county alcohol and other drug (AOD) programs: Outpatient services - Outpatient drug-free program - Intensive outpatient (newly expanded to additional populations) - Residential services (newly expanded to additional populations) - Narcotic treatment program - Naltrexone New services - Voluntary inpatient detoxification services Primary care physicians (PCPs) continue to be responsible for screening and brief intervention (SBI) for alcohol use. PCPs are responsible for performing all preliminary testing and procedures necessary to develop a diagnosis prior to referring members to county AOD programs. Screening tools are available on the provider website at provider.healthnet.com in the Provider Library > Forms to assist PCPs in the detection of alcohol use. Screening tools include the Staying Healthy Assessment (SHA), which is the Department of Health Care Services (DHCS)-approved Individual Health Education Behavioral Assessment (IHEBA). ACCESSING CARE CalViva Health Medi-Cal members obtain mental health services through MHN, Health Net's behavioral health subsidiary. Members do not need to contact their PCP, participating physician group (PPG) or attending physician to request a referral for behavioral health care services. CalViva Health members obtain behavioral health office visits directly through MHN's extensive behavioral health network. All other outpatient behavioral health services require prior authorization. CalViva Health members may request assistance obtaining care by contacting the CalViva Health Member Services Department telephone number listed on their CalViva Health identification (ID) card. Participating providers may also refer members to MHN for the expanded mental health services. PRIOR AUTHORIZATION REQUIREMENT CHANGES Changes Effective January 1, 2014 As a result of the mental health services expansion, effective January 1, 2014, the Medi-Cal prior authorization requirements for fee-for-service (FFS) providers in Fresno, Kings and Madera counties have been revised, and are attached for reference. The following service requires prior authorization from MHN at (800) for all members: Outpatient behavioral health services, with the exception of office visits Page 2 of 12 December 19, 2013 Provider Update

3 Changes Effective February 27, 2014 Effective February 27, 2014, prior authorization is required for referrals to non-participating providers for adult Medi-Cal members ages 21 and over, with the exception of: Self-referred services allowed under the Medi-Cal plan for: - Family planning - Pregnancy termination - HIV counseling and testing - Immunizations at the local health department (LHD) - Sexually transmitted infections (STIs) Referrals to non-participating providers continue to require prior authorization for pediatric members under 21; however, the self-referral exceptions allowed under the Medi-Cal plan, as noted above, have been added. Additionally, the following clarifications for services that do not require prior authorization have been added to the Sensitive, Confidential or Other Services Not Requiring Prior Authorization Adult and Pediatric section of the prior authorization requirements: Preventive services from a participating provider Urgently needed services when the member is outside his or her county Certified nurse midwife and obstetrical/gynecological (OB/GYN) services from a participating provider do not require prior authorization Providers should replace any previously distributed prior authorization requirements lists for Medi-Cal members with the attached list. Currently effective prior authorization requirements are available on the provider website at provider.healthnet.com under Working With Health Net > Contractual > Services Requiring Prior Authorization, and in the Provider Library under Operations Manuals > Prior Authorizations. Information regarding CalViva Health s prior authorization policies and procedures is also available in the operations manuals. The revised requirements containing the behavioral health services addition for pediatric and adult members will be available online as of January 1, The revised requirements containing the prior authorization requirement for referral to non-participating providers for adult members and clarification regarding services that do not require prior authorization will be available online as of February 27, ADDITIONAL INFORMATION If you have questions regarding the information contained in this update, contact CalViva Health at (888) Providers may also contact the MHN Physician Help Line at (800) to assist with the referral process, member eligibility and benefits, or to schedule a consultation with an MHN medical director or psychiatrist. Page 3 of 12 December 19, 2013 Provider Update

4 Inpatient Hospital Admission Notification Fax Line: - (800) Prior Authorization Request Fax Line: - (800) Prior Authorization Request Telephone Lines: - (800) ; (800) ; (800) Other Contact Information: - California Children s Services (CCS): (includes CCS contact information by county) - CalViva Health: (888) or - CCS paneling inquiries: (916) County Mental Health for substance abuse services: (includes contact list by county) - Denti-Cal: (800) Eligibility & Benefits Telephone Line: (800) Medi-Cal general information: - Medi-Cal Member Services Department: (800) Medications, including self-injectables requiring prior authorization: Health Net Pharmaceutical Services (HNPS) Telephone Line: (800) , Fax Line: (800) MHN for listed behavioral health service: (800) Nurse Advice Line (24 hours, seven days a week): (800) Regional Centers: (for individuals with developmental disabilities) - Transportation services for non-emergency purposes: (800) ; CalViva Health: (888) Note: The following services are subject to prior authorization before they can be performed. When faxing requests, please attach pertinent medical records, treatment plans, test results, and evidence of conservative treatment to support the medical appropriateness of the request. All elective admissions to long-term care facilities, including, but not limited to: - Extended care facility (ECF) - Intermediate care facility (ICF) - Skilled nursing facility (SNF) All elective medical and surgical inpatient hospitalizations, including, but not limited to: Inpatient Admissions: Adult and Pediatric - Acute care hospital - Acute or sub-acute rehabilitation facility All emergency hospitalizations within 24 hours of hospital admission All hospitalizations to a non-participating hospital once emergency stabilization is complete Procedures performed during acute inpatient hospitalization are included under the inpatient prior authorization (excluding experimental and investigational procedures). Procedures in emergency situations do not require prior authorization. Reviewed: 12/06/2013 Page 1 of 5

5 Outpatient Procedures/Services/Equipment for Pediatric Members Under Age 21 Behavioral health (outpatient services) - Speech therapy authorized by MHN at (800) Referrals to non-participating providers - Prior authorization not required for office visits (excluding self-referral services allowed under the Medi-Cal plan for: family Cardiac procedures planning, pregnancy termination, HIV Cosmetic services, evaluation and procedure counseling and testing, immunizations at the Durable medical equipment (DME) local health department (LHD), and sexually Experimental and investigational services Formulas, therapeutic and supplemental Home health services Hospice care Hyperbaric oxygen therapy Medications requiring prior authorization: contact HNPS at (800) or fax pharmacy prior authorization form to HNPS at (800) Mobility assessments for mobility-related DME Orthotics and prosthetics Outpatient infusion therapy, including, but not limited to: - Blood transfusions - Chemotherapy Outpatient elective surgery Radiation therapy Rehabilitation services: - Physical therapy evaluation and treatment - Occupational therapy Reviewed: 12/06/2013 Page 2 of 5 transmitted infections (STIs)) Testing and in-office procedures performed by pediatric sub-specialists, including, but not limited to: - Cardiologists - Dermatologists - Endocrinologists - Gastroenterologists - Geneticists - Nephrologists - Neurologists - Ophthalmologists - Orthopedists - Otolaryngologists (ear, nose and throat) - Podiatrists - Pulmonologists - Urologists Transplant-related evaluation services prior to acceptance for transplant Outpatient Procedures/Services/Equipment for Adult Members Ages 21 and Over Effective February 27, 2014, referrals to Bariatric surgeries, such as laparoscopic non-participating providers (except selfreferred gastric banding services allowed under the Medi-Cal Behavioral health (outpatient services) plan for: family planning, pregnancy authorized by MHN at (800) termination, HIV counseling and testing, - Prior authorization not required for immunizations at the local health office visits department (LHD), and sexually transmitted Cosmetic services, evaluation and procedure infections (STIs))

6 Dermatologic laser treatment for any diagnosis - - Power wheelchairs Scooters DME, including the following: Genetic testing - Bilevel positive airway pressure (BiPAP) Hyperbaric oxygen therapy or continuous positive airway pressure Mobility assessments for mobility-related (CPAP) DME - Custom-made items (including orthotics) Nocturnal oximetry studies - Hospital beds Physical, occupational and speech therapy - Items with a total Medi-Cal purchase evaluations, including mobility assessments price greater than $500 - Oxygen Medication : Adult and Pediatric Outpatient pharmaceuticals authorized by Novantrone, Orencia, Prolastin, Health Net Reclast, Remicade, Remodulin, - Hemophilia factors and intravenous Rituxan (rheumatoid arthritis only), immunoglobulin (IVIG) Refer members Tysabri, Vpriv, Zemaira to Coram Healthcare at (888) Other medications: (for members ages 21 and over) Aranesp, Botox, Dysport, - Intravenous (IV) infusion medications: Lucentis, Makena, Myobloc, Actemra, Aldurazyme, Aralast, Nplate, Omontys, Prolia, Benlysta, Boniva, Ceredase, Provenge, Stelara, Synagis, Cerezyme, Cinryze, Fabrazyme, Ventavis, Xeomin, Xgeva, Flolan, Glassia, Krystexxa, Xiaflex, Xolair Lumizyme, Myozyme, Naglazyme, Prior Authorization Limitations and Exclusions: Adult and Pediatric Authorization for carve-out services not covered by Health Net, such as CCS-eligible conditions, require prior authorization from the local CCS office (does not apply to adults ages 21 and over) CCS services must be provided by CCS-paneled providers and at CCS-approved facilities (does not apply to adults ages 21 and over) Any services related to CCS-eligible medical conditions must be approved by the CCS program. Refer to the California Code of Regulations, Title 22, Division 2, Part 2, Subdivision 7, CCS, Chapter 4, Medical Eligibility, Article 4, available online at Routine laboratory and radiology services must be performed at a Health Net participating facilities Services and supplies that are not Medi-Cal benefits, or which are not listed with an allowed amount on the Medi-Cal website at require specific authorization and payment, per invoice, with submission of invoice with the claim or are subject to a mutually agreeable payment rate negotiated before the services and supplies are provided Requests for authorizations for services typically provided by regional center are referred to the appropriate regional center for consideration Non-ambulance transport for medically necessary outpatient services is available upon request by a provider or member who contacts Health Net Medi-Cal Member Services at (800) ; CalViva Health: (888) Reviewed: 12/06/2013 Page 3 of 5

7 Specialty mental health services and select substance use disorder services are covered by the county mental health program. If coordination assistance with the county mental health program is needed, contact Health Net Medi-Cal Member Services Emergency room (ER) services after stabilization of an emergency medical condition or when the medical screening exam (MSE) does not demonstrate an emergency medical condition are subject to review by Health Net and may not be paid Cosmetic surgery is not a benefit of the Medi-Cal program. Cosmetic surgery requests are reviewed for possible reconstructive benefits, as well as medical necessity, using the Department of Health Care Services (DHCS) definition of cosmetic surgery Authorizations for services commonly included in the local educational agency (LEA) carve-out are referred to the local school district. These include speech therapy, occupational therapy and audiology services for children ages three and over, and psychological testing for attention deficit disorder (ADD) and attention deficit hyperactivity disorder (ADHD) Preventive care services for members under age 21 must be documented on a PM 160 Information Only (INF) form, and submitted to Health Net electronically or by mail. This includes partial PM 160 INF forms when the wellness visit and vaccine or tests are performed on distinct days. For information on completing and submitting PM 160 INF forms, refer to the Health Net provider website at provider.healthnet.com > Provider Library > Operations Manuals. Once in the Medi-Cal operations manual, select Public Health > Child Health and Disability Prevention (CHDP) Program > PM 160 INF Form Information Sensitive, Confidential or Other Services Not Requiring Prior Authorization: Adult and Pediatric Referral or prior authorization is not required for the following sensitive services, and the services may be obtained from any qualified in-network or out-of-network provider: - Minor consent services those covered services of a sensitive nature that minors do not need parental consent to access or obtain. Such services are those related to sexual assault, including rape; drug or alcohol abuse (for children age 12 and older); family planning services; pregnancy, including pregnancy termination; HIV counseling and testing; sexually transmitted infection (STI) diagnosis and treatment (for children age 12 or older); and outpatient mental health services) - Therapeutic and elective pregnancy termination - Family planning, STI diagnosis and treatment, HIV testing and counseling, and sexual assault services Referral or prior authorization is not required for Comprehensive Perinatal Services Program (CPSP) services. Services may be obtained from any participating CPSP providers. Refer to the CPSP website at for more information on locating a CPSP provider Other services not requiring prior authorization: - Pregnancy care with a participating network obstetrician - Preventive services from a participating provider - Services for emergency medical conditions - Specialist referral (initial referral to participating specialist) Reviewed: 12/06/2013 Page 4 of 5

8 - Urgently needed services when the member is outside his or her county Certified nurse midwife and obstetrical/gynecological (OB/GYN) services from a participating provider do not require prior authorization Reviewed: 12/06/2013 Page 5 of 5