California Advancing and Innovating Medi-Cal, or CalAIM, is a transformational plan to modernize the State's Medicaid program. The CalAIM initiative is designed to improve the quality of life and health outcomes of Medi-Cal enrollees, including those with the most complex health and social needs. The goal is to ensure access to the right care, in the right place, at the right time. CalAIM includes a series of far-reaching initiatives that together represent broad reforms of Medi-Cal's programs and systems. Department of Health Care Services (DHCS) will implement it in partnership with Medi-Cal providers, Managed Care Plans (MCPs), Counties, Community-Based Organizations (CBOs) and other stakeholders.
Timeline: These changes will span a multi-year period. The first reform started in January 2022 and additional reforms are expected and will be phased in through 2027, see CalAIM timeline and schedule
Milestones, Actions & Deliverables: Behavioral Health Quality Improvement Plan (BHQIP)
DHCS Additional Information: CalAIM
Important CalAIM Related DHCS Information Notices
January 1, 2022
Drug Medi-Cal Organized Delivery System (DMC-ODS) – Medical Necessity Determination and Level of Care Determination Requirements for DMC Treatment Program Services
DHCS is aligning the medical necessity and level of care determination processes across the behavioral health delivery systems. DHCS has issued guidance to the Counties on medical necessity and level of care determination requirements for substance use disorder (SUD) treatment services provided to DMC-ODS beneficiaries. The changes supersede any medical necessity criteria and level of care determination requirements for the provision of SUD treatment services provided to DMC beneficiaries set forth in California Code of Regulations Title 22, Section 51341.1 and in any information notice or other guidance published prior to January 1, 2022.
For more details: DHCS Behavioral Health Information Notice: 21-071
Specialty Mental Health Services (SMHS) - Criteria for Beneficiary Access to Behavioral Health Services and Medical Necessity and Other Coverage
To achieve this aim, DHCS is clarifying the responsibilities of Mental Health Plans (MHPs), including updating the criteria for access to SMHS, for both adults and beneficiaries under age 21. These criteria were developed based on significant feedback from stakeholders.
For more details: DHCS Behavioral Health Information Notice: 21-073
DMC-ODS Requirements from 2022-2026
DHCS provided new DMC-ODS program requirements pursuant to CalAIM that include program updates, which replace the Section 1115 Standard Terms and Conditions used to describe the DMC-ODS program for the years 2015-2021. The following DHCS policy guidance implements those updates. In accordance with W&I § 14184.102(d), until county contract amendments are executed, DMC-ODS counties shall adhere to the terms of this Information Notice where current contracts are silent or in conflict with the terms of this Information Notice.
For more details: DHCS Behavioral Health Information Notice: 21-075
To inform Mental Health Plan (MHP), Drug Medi-Cal (DMC) and Drug Medi-Cal Organized Delivery System's (DMC-ODS) selection of International Classification of Diseases, Tenth ReCovision (ICD-10) codes prior to completing the assessment and finalizing a diagnosis in outpatient settings.
Please review the DHCS Information notice 22-013 below regarding Z-codes the MHP, DMC and DMC-ODS programs and providers may use during the assessment phase of a beneficiary's treatment when a diagnosis has yet to be established.
For more details: DHCS Behavioral Health Information Notice: 22-013
July 1, 2022
No Wrong Door
This policy ensures that Medi-Cal beneficiaries receive timely mental health services without delay regardless of the delivery system where they seek care, and that beneficiaries are able to maintain treatment relationships with trusted providers without interruption.
Clinically appropriate and covered Drug Medi-Cal (DMC) services delivered by DMC providers and DMC-ODS services delivered by DMC-ODS providers are covered by DMC counties and DMC-ODS counties, respectively, whether or not the beneficiary has a co-occurring mental health condition.
Clinically appropriate and covered SMHS delivered by MHP providers are covered Medi-Cal services whether or not the beneficiary has a co-occurring SUD. MHPs must not deny or disallow reimbursement for SMHS provided to a beneficiary who meets SMHS criteria on the basis of the beneficiary having a co-occurring SUD, when all other Medi-Cal and service requirements are met.
For more details: DHCS Behavioral Health Information Notice: 22-011
Documentation Redesign - Requirements for all Specialty Mental Health Services, Drug Medi-Cal and Drug Medi-Cal-Organized Delivery System Services (DMC-ODS)
DHCS is streamlining and standardizing clinical documentation requirements across Medi-Cal Specialty Mental Health Services (SMHS), Drug Medi-Cal (DMC), and Drug Medi-Cal Organized Delivery System (DMC-ODS) services. These updated documentation requirements better align with Centers for Medicare and Medicaid Services (CMS) national coding standards and physical health care documentation practices. These updated standards will also be used when behavioral health payment reform is implemented.
For more details: DHCS Behavioral Health Information Notice: 22-019
January 1, 2023
Standardized Screening & Transition Tools
As part of CalAIM, Mental Health Plans must implement standardized screening and transition of care tools for Specialty Mental Health Services.
The Screening and Transition of Care Tools for Medi-Cal Mental Health Services guide referrals to the Medi-Cal mental health delivery system (i.e., Medi-Cal Managed Care Health Plan (MCP) or MHP) that is expected to best support each beneficiary. DHCS is requiring MCPs and MHPs to use the Screening and Transition of Care Tools for beneficiaries under age 21 (youth) and for beneficiaries age 21 and over (adults).
The Transition of Care Tools for Medi-Cal Mental Health Services (hereafter referred to as the Transition of Care Tool) ensures that beneficiaries who are receiving mental health services from one delivery system receive timely and coordinated care when their existing services need to be transitioned to the other delivery system, or when services need to be added to their existing mental health treatment from the other delivery system.
For more details: dhcs.ca.gov
July 1, 2023
Behavioral Health CPT Coding Transition
Effective July 1, 2023, the Department of Health Care Services (DHCS) transitioned from a cost-based reimbursement process to a fee-based schedule; and Mental Health Plans must transition from Healthcare Common Procedure Coding System (HCPCS) codes to a combination of HCPCS and Common Procedural Terminology (CPT) codes.
For more details:dhcs.ca.gov
County BHPs Transition to FFS and Intergovernmental Transfers (IGTs)
DHCS Behavioral Health Information Notice: forthcoming