Common use of Additional Coverage Requirements and Clarifications Clause in Contracts

Additional Coverage Requirements and Clarifications. 18.5.1 The target population for DMC-ODS SUD services includes clients who are enrolled in Medi-Cal, reside in Marin County, and meet the criteria for DMC-ODS services as per established requirements above. 18.5.2 Consistent with Welfare & Institutions Code § 14184.402(f), covered SUD prevention, screening, assessment, treatment, and recovery services are reimbursable Medi-Cal services when: 18.5.2.1 Services are provided prior to the completion of an assessment or prior to the determination of whether DMC-ODS access criteria are met, or prior to the determination of a diagnosis. 18.5.2.1.1 Clinically appropriate and covered DMC-ODS services provided to clients over the age of 21 are reimbursable during the assessment process. Similarly, if the assessment determines that the client does not meet the DMC-ODS access criteria after initial assessment, those clinically appropriate and covered DMC- ODS services provided are reimbursable. 18.5.2.1.2 All Medi-Cal claims shall include a current CMS approved International Classification of Diseases (ICD) diagnosis code. In cases where services are provided due to a suspected SUD that has not yet been diagnosed, options are available in the CMS approved ICD-10 code list, for example, codes for “Other specified” and “Unspecified” disorders, or “Factors influencing health status and contact with health services”. 18.5.2.2 Prevention, screening, assessment, treatment, or recovery services were not included in an individual treatment plan, or if the client signature was absent from the treatment plan. 18.5.2.3 While most DMC-ODS providers are expected to adopt problem lists as specified in BHIN 23-068, treatment plans continue to be required for some services in accordance with federal law. Treatment plans are required by federal law for: Narcotic Treatment Programs (NTPs) and Peer Support Services. 18.5.2.4 Medically necessary covered DMC-ODS services delivered by Contractor shall be covered and reimbursable Medi-Cal services whether or not the client has a co-occurring mental health condition.

Additional Coverage Requirements and Clarifications. 18.5.1 The target population for DMC-ODS SUD services includes clients who are enrolled in Medi-Cal, reside in Marin County, and meet the criteria for DMC-ODS services as per established requirements above. 18.5.2 Consistent with Welfare & Institutions Code § 14184.402(f), covered SUD prevention, screening, assessment, treatment, and recovery services are reimbursable Medi-Cal services when: 18.5.2.1 Services are provided prior to the completion of an assessment or prior to the determination of whether DMC-ODS access criteria are met, or prior to the determination of a diagnosis. 18.5.2.1.1 Clinically appropriate and covered DMC-ODS services provided to clients over the age of 21 are reimbursable during the assessment process. Similarly, if the assessment determines that the client does not meet the DMC-ODS access criteria after initial assessment, those clinically appropriate and covered DMC- ODS services provided are reimbursable. 18.5.2.1.2 All Medi-Cal claims shall include a current CMS approved International Classification of Diseases (ICD) diagnosis code. In cases where services are provided due to a suspected SUD that has not yet been diagnosed, options are available in the CMS approved ICD-10 code list, for example, codes for “Other specified” and “Unspecified” disorders, or “Factors influencing health status and contact with health services”. 18.5.2.2 Prevention, screening, assessment, treatment, or recovery services were not included in an individual treatment plan, or if the client signature was absent from the treatment plan. 18.5.2.3 While most DMC-ODS providers are expected to adopt problem lists as specified in BHIN 2322-068019, treatment plans continue to be required for some services in accordance with federal law. Treatment plans are required by federal law for: Narcotic Treatment Programs (NTPs) and Peer Support Services. 18.5.2.4 Medically necessary covered DMC-ODS services delivered by Contractor shall be covered and reimbursable Medi-Cal services whether or not the client has a co-occurring mental health condition.

Additional Coverage Requirements and Clarifications. 18.5.1 6.1. The target population for DMC-ODS SUD services includes clients who are enrolled in Medi-Medi- Cal, reside in Marin Countythe COUNTY, and meet the criteria for DMC-ODS services as per established requirements above. 18.5.2 6.2. Consistent with Welfare & Institutions Code § 14184.402(f), covered SUD prevention, screening, assessment, treatment, and recovery services are reimbursable Medi-Cal services when: 18.5.2.1 6.2.1. Services are provided prior to the completion of an assessment or prior to the determination of whether DMC-ODS access criteria are met, or prior to the determination of a diagnosis. 18.5.2.1.1 6.2.1.1. Clinically appropriate and covered DMC-ODS services provided to clients over the age of 21 are reimbursable during the assessment process. Similarly, if the assessment determines that the client does not meet the DMC-ODS access criteria after initial assessment, those clinically appropriate and covered DMC- DMC-ODS services provided are reimbursable. 18.5.2.1.2 6.2.1.2. All Medi-Cal claims shall include a current CMS approved International Classification of Diseases (ICD) diagnosis code. In cases where services are provided due to a suspected SUD that has not yet been diagnosed, options are available in the CMS approved ICD-10 code list, for example, codes for “Other specified” and “Unspecified” disorders, or “Factors influencing health status and contact with health services”. 18.5.2.2 6.2.2. Prevention, screening, assessment, treatment, or recovery services were not included in an individual treatment plan, or if the client signature was absent from the treatment plan. 18.5.2.3 6.2.2.1. While most DMC-ODS providers are expected to adopt problem lists as specified in BHIN 2322-068019, treatment plans continue to be required for some services in accordance with federal law. 6.2.2.2. Treatment plans are required by federal law for: • Narcotic Treatment Programs (NTPs) and • Peer Support Services 6.2.3. The beneficiary has a co-occurring mental health condition. 18.5.2.4 6.2.3.1. Medically necessary covered DMC-ODS services delivered by Contractor CONTRACTOR shall be covered and reimbursable Medi-Cal services whether or not the client has a co-occurring mental health condition.

Additional Coverage Requirements and Clarifications. 18.5.1 a. The target population for DMC-ODS SUD services includes clients who are enrolled in Medi-Cal, reside in Marin the County, and meet the criteria for DMC-ODS services as per established requirements above. 18.5.2 b. Consistent with Welfare & Institutions Code § 14184.402(f), covered SUD prevention, screening, assessment, treatment, and recovery services are reimbursable Medi-Cal services when: 18.5.2.1 c. Services are provided prior to the completion of an assessment or prior to the determination of whether DMC-ODS access criteria are met, or prior to the determination of a diagnosis. 18.5.2.1.1 d. Clinically appropriate and covered DMC-ODS services provided to clients over the age of 21 are reimbursable during the assessment process. Similarly, if the assessment determines that the client does not meet the DMC-ODS access criteria after initial assessment, those clinically appropriate and covered DMC- DMC-ODS services provided are reimbursable. 18.5.2.1.2 e. All Medi-Cal claims shall include a current CMS approved International Classification of Diseases (ICD) diagnosis code. In cases where services are provided due to a suspected SUD that has not yet been diagnosed, options are available in the CMS approved ICD-10 code list, for example, codes for “Other specified” and “Unspecified” disorders, or “Factors influencing health status and contact with health services.”. 18.5.2.2 f. Prevention, screening, assessment, treatment, or recovery services were not included in an individual treatment plan, or if the client signature was absent from the treatment plan. 18.5.2.3 g. While most DMC-ODS providers are expected to adopt problem lists as specified in BHIN 2322-068019, treatment plans continue to be required for some services in accordance with federal law. . h. Treatment plans are required by federal law for: : i. Narcotic Treatment Programs (NTPs) and ) ii. Peer Support Services iii. The beneficiary has a co-occurring mental health condition. 18.5.2.4 i. Medically necessary covered DMC-ODS services delivered by Contractor shall be covered and reimbursable Medi-Cal services whether or not the client has a co-occurring mental health condition.

Additional Coverage Requirements and Clarifications. 18.5.1 6.1. The target population for DMC-ODS SUD services includes clients who are enrolled in Medi-Medi- Cal, reside in Marin Countythe COUNTY, and meet the criteria for DMC-ODS services as per established requirements above. 18.5.2 6.2. Consistent with Welfare & Institutions Code § 14184.402(f), covered SUD prevention, screening, assessment, treatment, and recovery services are reimbursable Medi-Cal services when: 18.5.2.1 6.2.1. Services are provided prior to the completion of an assessment or prior to the determination of whether DMC-ODS access criteria are met, or prior to the determination of a diagnosis. 18.5.2.1.1 6.2.1.1. Clinically appropriate and covered DMC-ODS services provided to clients over the age of 21 are reimbursable during the assessment process. Similarly, if the assessment determines that the client does not meet the DMC-ODS access criteria after initial assessment, those clinically appropriate and covered DMC- DMC-ODS services provided are reimbursable. 18.5.2.1.2 6.2.1.2. All Medi-Cal claims shall include a current CMS approved International Classification of Diseases (ICD) diagnosis code. In cases where services are provided due to a suspected SUD that has not yet been diagnosed, options are available in the CMS approved ICD-10 code list, for example, codes for “Other specified” and “Unspecified” disorders, or “Factors influencing health status and contact with health services”. 18.5.2.2 6.2.2. Prevention, screening, assessment, treatment, or recovery services were not included in an individual treatment plan, or if the client signature was absent from the treatment plan. 18.5.2.3 6.2.2.1. While most DMC-ODS providers are expected to adopt problem lists as specified in BHIN 2322-068019, treatment plans continue to be required for some services in accordance with federal law. 6.2.2.2. Treatment plans are required by federal law for: : 6.2.2.2.1. Narcotic Treatment Programs (NTPs) and Peer Support Services. 18.5.2.4 Medically necessary covered DMC-ODS services delivered by Contractor shall be covered and reimbursable Medi-Cal services whether or not the client has a co-occurring mental health condition.)

Additional Coverage Requirements and Clarifications. 18.5.1 The target population for DMC-ODS SUD services includes clients members who are enrolled in Medi-Cal, reside in Marin Placer County, and meet the criteria for DMC-ODS services as per established requirements above. 18.5.2 . Consistent with Welfare & Institutions Code § 14184.402(f), covered SUD prevention, screening, assessment, treatment, and recovery services are reimbursable Medi-Cal services when: 18.5.2.1 2.5.1. Services are provided prior to the completion determination of an assessment a diagnosis or prior to the determination of whether DMC-ODS access criteria are met, or prior to the determination of a diagnosis. 18.5.2.1.1 2.5.1.1. Clinically appropriate and covered DMC-ODS services provided to clients members over the age of 21 are reimbursable during the assessment processprocess as described in the “Initial Assessment and Services Provided During the Assessment Process”. 2.5.1.2. Similarly, COUNTY shall not disallow reimbursement for clinically appropriate and covered DMC-ODS services provided during the assessment process if the assessment subsequently determines that the client member does not meet the criteria listed under the “DMC-ODS access criteria after initial assessment, those clinically appropriate and covered DMC- ODS services provided are reimbursable.Access Criteria for Members After Assessment” subsection. DRAFT 18.5.2.1.2 All 2.5.1.3. This does not eliminate the requirement that all Medi-Cal claims shall claims, including DMC-ODS claims, include a current CMS approved International Classification of Diseases Diseases, Tenth Revision (ICDICD-10-CM) diagnosis code. code.4 In cases where services are provided due to a suspected SUD that has not yet been diagnosed, options are available in the CMS approved ICD-10 ICD-10-CM code list, for example, codes for “Other specified” and “Unspecified” disorders, ,” or “Factors influencing health status and contact with health services”.” For additional information regarding code selection during the assessment period for outpatient behavioral health services, please refer to BHIN 22-013. 18.5.2.2 Prevention2.5.2. The prevention, screening, assessment, treatment, or recovery services were not included in an individual treatment plan, or if the client signature was absent from the treatment plan. 18.5.2.3 While most DMC-ODS providers are expected to adopt problem lists 2.5.2.1. DHCS guidance on documentation requirements that took effect as specified of January 1, 2024 can be found in BHIN 23-068, . NTPs must comply with the NTP treatment plans continue to be required for some services plan components set forth in accordance with federal law. Treatment plans are required by federal law for: Narcotic Treatment Programs (NTPs) and Peer Support Services42 CFR 8.12. 18.5.2.4 2.5.3. The member has a co-occurring mental health condition. 2.5.3.1. Medically necessary covered DMC-ODS services delivered by Contractor shall be CONTRACTOR are covered and reimbursable Medi-Cal services whether or not the client member has a co-occurring mental health condition. COUNTY shall not disallow reimbursement for covered DMC-ODS services provided to a member who has a co-occurring mental health condition if the member meets the criteria listed under the “DMC-ODS Access Criteria for Members After Assessment” subsection. For additional information regarding covered services for members with co-occurring SUD and mental health conditions please refer to BHIN 22-011. 2.6. DMC-ODS ACCESS CRITERIA FOR MEMBERS AFTER ASSESSMENT: 2.6.1. Members 21 years of age and older: To qualify for DMC-ODS services after the initial assessment process, Members 21 years of age and older must meet one of the following criteria: 2.6.1.1. Have at least one diagnosis from the most current edition of the Diagnostic and Statistical Manual (DSM) of Mental Disorders for Substance-Related and Addictive Disorders, with the exception of Tobacco-Related Disorders and Non-Substance-Related Disorders, OR 2.6.1.2. Have had at least one diagnosis from the most current edition of the DSM for Substance-Related and Addictive Disorders, with the exception of Tobacco- Related Disorders and Non-Substance-Related Disorders, prior to being incarcerated or during incarceration, determined by substance use history. DRAFT 2.6.2. Members under the age of 21: Members under age 21 qualify to receive all medically necessary DMC-ODS services as required pursuant to Section 1396d(r) of Title 42 of the United States Code. Federal EPSDT statutes and regulations require states to furnish all Medicaid-coverable, appropriate, and medically necessary services needed to correct and ameliorate health conditions, regardless of whether those services are covered in the state’s Medicaid State Plan. Consistent with federal guidance, services need not be curative or completely restorative to ameliorate a health condition, including substance misuse and SUDs. Services that sustain, support, improve, or make more tolerable substance misuse or an SUD are considered to ameliorate the condition and are thus covered as EPSDT services. DMC-ODS plans are obligated to provide early intervention services under the outpatient modality to members under the age of 21 at risk of developing an SUD, regardless of whether they meet diagnostic criteria for SUD, and even if the member is not participating in the full array of outpatient treatment services. For additional information regarding EPSDT requirements, please refer to BHIN 22-003.