California Code of Regulations
Title 9 - Rehabilitative and Developmental Services
Division 1 - Department of Mental Health
Chapter 11 - Medi-Cal Specialty Mental Health Services
Subchapter 1 - General Provisions
Article 3 - Administration
Section 1810.345 - Scope of Covered Specialty Mental Health Services
Current through Register 2024 Notice Reg. No. 38, September 20, 2024
(a) The MHP of a beneficiary shall provide or arrange and pay for specialty mental health services to the beneficiary when the medical necessity criteria in Sections 1820.205, 1830.205, or 1830.210 are met and when specialty mental health services are required to assess whether the medical necessity criteria are met. The MHP of a beneficiary shall be required to provide specialty mental health services only to beneficiaries who:
(b) Except as provided elsewhere in this Chapter, the MHP shall not be required to establish a formal arrangement within the MHP's organization or through contracts with providers for any specific specialty mental health service, but shall ensure that the type or types of specialty mental health services provided to each individual beneficiary are adequate to meet the needs of the beneficiary as described in the medical necessity criteria in Sections 1820.205, 1830.205, or 1830.210.
(c) When appropriate based on the mental health condition of the beneficiary, the MHP of a beneficiary shall ensure that covered specialty mental health services described in Section 1810.247(a) are directed toward the maximum reduction of the mental disability and restoration of the beneficiary to the best possible functional level to the extent required by the Medi-Cal State Plan under rehabilitative mental health services. The Medi-Cal State Plan is California's State plan for medical assistance as described in Title 42, Section 1396 and 1396 a, United States Code.
(d) In accordance with title 42 CFR section 438.210(a)(3)-(4), the MHP may place appropriate limits on a service.
(e) Notwithstanding section 1830.220 regarding out-of-plan services, the MHP is financially responsible for post-stabilization care services obtained within or outside of the MHP's provider network that are provided in compliance with title 42 CFR section 422.113(c)(1)-(3).
(f) The MHP shall obtain prior approval from the Department if the MHP intends to refuse to provide or arrange and pay for a covered service because the MHP objects to the service on moral or religious grounds.
(g) The Department may exclude psychiatric nursing facility services from the specialty mental health services covered by the MHP until the Department determines that all necessary systems are in place at the State level to ensure proper payment of the providers of psychiatric nursing facility services and proper claiming of federal funds pursuant to Subchapter 4, beginning with Section 1840.100. The Department shall insure that the contract between the MHP and the Department and the allocation to the MHP pursuant to Section 1810.330 reflect the exclusion or inclusion of these services.
1. New section
filed 10-31-97 as an emergency; operative 11-1-97 (Register 97, No. 44). A
Certificate of Compliance must be transmitted to OAL by 3-2-98 or emergency language
will be repealed by operation of law on the following day.
2. New section
refiled 3-2-98 as an emergency; operative 3-2-98 (Register 98, No. 10). A
Certificate of Compliance must be transmitted to OAL by 6-30-98 or emergency
language will be repealed by operation of law on the following day.
3.
New section refiled 6-17-98 as an emergency; operative 6-30-98 (Register 98, No.
25). Pursuant to Chapter 324 (Statutes of 1998) Item 4440-103-0001(4), a Certificate
of Compliance must be transmitted to OAL by 7-1-99 or emergency language will be
repealed by operation of law on the following day.
4. Editorial
correction of HISTORY 3 (Register 98, No. 39).
5. Editorial correction
extending Certificate of Compliance date to 7-1-2001 pursuant to Chapter 50
(Statutes of 1999) Item 4440-103-0001(4) (Register 99, No. 33). Notwithstanding any
other provision of law, emergency regulations adopted pursuant to Welfare and
Institutions Code section
14680
to implement the second phase of mental health managed care as provided in this part
shall remain in effect until permanent regulations are adopted, or June 30, 2006,
whichever occurs first.
6. Editorial correction of HISTORY 5 (Register
2000, No. 42).
7. Editorial correction of HISTORY 5 and repealer and new
section filed 5-19-2006; operative 6-18-2006 (Register 2006, No. 20).
8.
New subsections (d)-(f)(2), subsection relettering and amendment of NOTE filed
10-18-2010; operative 11-17-2010 (Register 2010, No. 43).
Note: Authority cited: Section 14680, Welfare and Institutions Code. Reference: Sections 5775, 5777, 14007.5, 14011, 14142, 14145 and 14682, Welfare and Institutions Code; Title 42, United States Code, Section 1396 and 1396 a; and Title 42 Code of Federal Regulations, Sections 438.102(a)(2), 422.113(c)(1)-(3) and 438.114.
