Common use of SERVICES AND ACCESS PROVISIONS Clause in Contracts

SERVICES AND ACCESS PROVISIONS. 1. CERTIFICATION OF ELIGIBILITY Contractor will, in cooperation with County, comply with Section 14705.5 of California Welfare and Institutions Code to obtain a certification of a client’s eligibility for SMHS under Medi-Cal. 2. ACCESS TO SPECIALTY MENTAL HEALTH SERVICES A. In collaboration with the County, Contractor will work to ensure that individuals to whom the Contractor provides SMHS meet access criteria, as per DHCS guidance specified in BHIN 21- 073. Specifically, the Contractor will ensure that the clinical record for each client includes information as a whole indicating that client’s presentation and needs are aligned with the criteria applicable to their age at the time-of-service provision as specified below. B. For enrolled clients under 21 years of age, Contractor shall provide all medically necessary SMHS required pursuant to Section 1366d(r) of Title 42 of the United States Code. Covered SMHS shall be provided to enrolled clients who meet either of the following criteria, (I) or (II) below. If a client under age 21 meets the criteria as described in (I) below, the beneficiary meets criteria to access SMHS; it is not necessary to establish that the beneficiary also meets the criteria in (II) below. I. The client has a condition placing them at high risk for a mental health disorder due to experience of trauma evidenced by any of the following: scoring in the high-risk range under a trauma screening tool approved by DHCS, involvement in the child welfare system, juvenile justice involvement, or experiencing homelessness. II. The client has at least one of the following: a. A significant impairment b. A reasonable probability of significant deterioration in an important area of life functioning c. A reasonable probability of not progressing developmentally as appropriate. d. A need for SMHS, regardless of presence of impairment, that are not included within the mental health benefits that a Medi-Cal Managed Care Plan (MCP) is required to provide. e. A diagnosed mental health disorder, according to the criteria in the current editions of the Diagnostic and Statistical Manual of Mental Disorders (DSM) and the International Classification of Diseases and Related Health Problems (ICD). f. A suspected mental health disorder that has not yet been diagnosed. g. Significant trauma placing the client at risk of a future mental health condition, based on the assessment of a licensed mental health professional. C. For clients 21 years of age or older, Contractor shall provide covered SMHS for clients who meet both of the following criteria, (I) and (II) below: I. The client has one or both of the following: a. Significant impairment, where impairment is defined as distress, disability, or dysfunction in social, occupational, or other important activities. b. A reasonable probability of significant deterioration in an important area of life functioning. II. The client’s condition as described in paragraph (I) is due to either of the following: a. A diagnosed mental health disorder, according to the criteria in the current editions of the DSM and ICD. b. A suspected mental disorder that has not yet been diagnosed. 3. ADDITIONAL CLARIFICATIONS A. Criteria I. A clinically appropriate and covered mental health prevention, screening, assessment, treatment, or recovery service listed within Exhibit A of this Agreement can be provided and submitted to the County for reimbursement under any of the following circumstances: a. The services were provided prior to determining a diagnosis, including clinically appropriate and covered services provided during the assessment process; b. The service was not included in an individual treatment plan; or c. The client had a co-occurring substance use disorder.

SERVICES AND ACCESS PROVISIONS. 1. CERTIFICATION OF ELIGIBILITY Contractor will, in cooperation with County, comply with Section 14705.5 of California Welfare and Institutions Code to obtain a certification of a client’s eligibility for SMHS under Medi-Cal. 2. ACCESS TO SPECIALTY MENTAL HEALTH SERVICES A. In collaboration with the County, Contractor will work to ensure that individuals to whom the Contractor provides SMHS meet access criteria, as per DHCS guidance specified in BHIN 21- 073. Specifically, the Contractor will ensure that the clinical record for each client includes information as a whole indicating that client’s presentation and needs are aligned with the criteria applicable to their age at the time-of-service provision as specified below. B. For enrolled clients under 21 years of age, Contractor shall provide all medically necessary SMHS required pursuant to Section 1366d(r1396d(r) of Title 42 of the United States Code. Covered SMHS shall be provided to enrolled clients who meet either of the following criteria, (I) or (II) below. If a client under age 21 meets the criteria as described in (I) below, the beneficiary meets criteria to access SMHS; it is not necessary to establish that the beneficiary also meets the criteria in (II) below. I. The client has a condition placing them at high risk for a mental health disorder due to experience of trauma evidenced by any of the following: scoring in the high-risk range under a trauma screening tool approved by DHCS, involvement in the child welfare system, juvenile justice involvement, or experiencing homelessness. II. The client has at least one of the following: a. A significant impairment b. A reasonable probability of significant deterioration in an important area of life functioning c. A reasonable probability of not progressing developmentally as appropriate. d. A need for SMHS, regardless of presence of impairment, that are not included within the mental health benefits that a Medi-Cal Managed Care Plan (MCP) is required to provide. e. A diagnosed mental health disorder, according to the criteria in the current editions of the Diagnostic and Statistical Manual of Mental Disorders (DSM) and the International Classification of Diseases and Related Health Problems (ICD). f. A suspected mental health disorder that has not yet been diagnosed. g. Significant trauma placing the client at risk of a future mental health condition, based on the assessment of a licensed mental health professional. C. For clients 21 years of age or older, Contractor shall provide covered SMHS for clients who meet both of the following criteria, (I) and (II) below: I. The client has one or both of the following: a. Significant impairment, where impairment is defined as distress, disability, or dysfunction in social, occupational, or other important activities. b. A reasonable probability of significant deterioration in an important area of life functioning. II. The client’s condition as described in paragraph (I) is due to either of the following: a. A diagnosed mental health disorder, according to the criteria in the current editions of the DSM and ICD. b. A suspected mental disorder that has not yet been diagnosed. 3. ADDITIONAL CLARIFICATIONS A. Criteria I. A clinically appropriate and covered mental health prevention, screening, assessment, treatment, or recovery service listed within Exhibit A of this Agreement can be provided and submitted to the County for reimbursement under any of the following circumstances: a. The services were provided prior to determining a diagnosis, including clinically appropriate and covered services provided during the assessment process; b. The service was not included in an individual treatment plan; or c. The client had a co-occurring substance use disorder. B. Diagnosis Not a Prerequisite I. Per BHIN 21-073, a mental health diagnosis is not a prerequisite for access to covered SMHS. This does not eliminate the requirement that all Medi-Cal claims, including SMHS claims, include a current Centers for Medicare & Medicaid Services (CMS) approved ICD diagnosis code. 4. MEDICAL NECESSITY A. Contractor will ensure that services provided are medically necessary in compliance with BHIN 21-073 and pursuant to Welfare and Institutions Code section 14184.402(a). Services provided to a client must be medically necessary and clinically appropriate to address the client’s presenting condition. Documentation in each client’s chart as a whole will demonstrate medical necessity as defined below, based on the client’s age at the time-of- service provision. B. For individuals 21 years of age or older, a service is “medically necessary” or a “medical

SERVICES AND ACCESS PROVISIONS. 1. CERTIFICATION OF ELIGIBILITY Contractor will, in cooperation with County, comply with Section 14705.5 of California Welfare and Institutions Code to obtain a certification of a client’s eligibility for SMHS under Medi-Cal. 2. ACCESS TO SPECIALTY MENTAL HEALTH SERVICES A. In collaboration with the County, Contractor will work to ensure that individuals to whom the Contractor provides SMHS meet access criteria, as per DHCS guidance specified in BHIN 21- 073. Specifically, the Contractor will ensure that the clinical record for each client includes information as a whole indicating that client’s presentation and needs are aligned with the criteria applicable to their age at the time-of-time of service provision as specified below. B. For enrolled clients under 21 years of age, Contractor shall provide all medically necessary SMHS required pursuant to Section 1366d(r1396d(r) of Title 42 of the United States Code. Covered SMHS shall be provided to enrolled clients who meet either of the following criteria, (I) or (II) below. If a client under age 21 meets the criteria as described in (I) below, the beneficiary meets criteria to access SMHS; it is not necessary to establish that the beneficiary also meets the criteria in (II) below. I. The client has a condition placing them at high risk for a mental health disorder due to experience of trauma evidenced by any of the following: scoring in the high-risk range under a trauma screening tool approved by DHCS, involvement in the child welfare system, juvenile justice involvement, or experiencing homelessness. II. The client has at least one of the following: a. A significant impairment b. A reasonable probability of significant deterioration in an important area of life functioning c. A reasonable probability of not progressing developmentally as appropriate. d. A need for SMHS, regardless of presence of impairment, that are not included within the mental health benefits that a Medi-Cal Managed Care Plan (MCP) is required to provide.. AND the client’s condition as described in subparagraph (II a-d) above is due to one of the following: e. A diagnosed mental health disorder, according to the criteria in the current editions of the Diagnostic and Statistical Manual of Mental Disorders (DSM) and the International Classification of Diseases and Related Health Problems (ICD). f. A suspected mental health disorder that has not yet been diagnosed. g. Significant trauma placing the client at risk of a future mental health condition, based on the assessment of a licensed mental health professional. C. For clients 21 years of age or older, Contractor shall provide covered SMHS for clients who meet both of the following criteria, (I) and (II) below: I. The client has one or both of the following: a. Significant impairment, where impairment is defined as distress, disability, or dysfunction in social, occupational, or other important activities. b. A reasonable probability of significant deterioration in an important area of life functioning. II. The client’s condition as described in paragraph (I) is due to either of the following: a. A diagnosed mental health disorder, according to the criteria in the current editions of the DSM and ICD. b. A suspected mental disorder that has not yet been diagnosed. 3. ADDITIONAL CLARIFICATIONS A. Criteria I. A clinically appropriate and covered mental health prevention, screening, assessment, treatment, or recovery service listed within Exhibit A of this Agreement can be provided and submitted to the County for reimbursement under any of the following circumstances: a. The services were provided prior to determining a diagnosis, including clinically appropriate and covered services provided during the assessment process; b. The service was not included in an individual treatment plan; or c. The client had a co-occurring substance use disorder.