State of california

Service Delivery, Administrative and Operational Requirements

1. Provision of Services.

1. 
   The Contractor shall provide, or arrange and pay for, all medically necessary Covered Mental Health Services to beneficiaries, as defined for the purposes of this contract, of «County» County.
   

2. 
   The Contractor shall ensure that all medically necessary Covered Mental Health Services are sufficient in amount, duration, or scope to reasonably be expected to achieve the purpose for which the services are furnished. The Contractor shall not arbitrarily deny or reduce the amount, duration, or scope of a medically necessary Covered Mental Health Service solely because of diagnosis, type of illness, or condition of the beneficiary except as specifically provided in the medical necessity criteria applicable to the situation as provided in Title 9, California Code of Regulations (CCR), Sections 1820.205, 1830.205, and 1830.210.
   

3. 
   The Contractor shall make all medically necessary Covered Mental Health Services available in accordance with Title 9, CCR, Sections 1810.345 and 1810.405 and Title 42 CFR, 438.210 and shall ensure:
   

1. 
   The availability of services to address beneficiaries' emergency psychiatric conditions 24 hours a day, 7 days a week.
   

2. 
   The availability of services to address beneficiaries' urgent conditions as defined in Title 9, CCR, Section 1810.253, 24 hours a day, 7 days a week.
   
   
   
3. 
   Timely access to routine services determined by the Contractor to be required to meet beneficiaries' needs.
   

4. 
   The Contractor shall provide second opinions in accordance with Title 9, CCR, Section 1810.405.
   

5. 
   The Contractor shall provide out-of-plan services in accordance with Title 9, CCR, Section 1830.220 and Section 1810.365. The timeliness standards specified in Title 9 CCR, Section 1810.405 apply to out-of-plan services as well as in-plan services.
   

6. 
   The Contractor shall provide a beneficiary’s choice of the person providing services to the extent feasible in accordance with Title 9, CCR, Section 1830.225.
   

7. 
   In determining whether a service is covered under this contract based on the diagnosis of the beneficiary, the Contractor shall not exclude a beneficiary solely on the ground that the provider making the diagnosis has used the International Classification of Diseases (ICD) diagnosis system rather than the system contained in the Diagnostic and Statistical Manual (DSM) of the American Psychiatric Association.
   

8. 
   For services provided pursuant to Section 3 of this Exhibit, the Contractor shall consider the following ICD-9 diagnoses codes as included. For any other service, the Contractor may consider these codes as included or may require the provider to use DSM IV coding.
   

Table 1 - Included ICD-9 Diagnoses - All Places of Services except Hospital Inpatient

295.00 – 298.9	302.8 - 302.9	311 - 313.82
299.1 – 300.89	307.1	313.89 – 314.9
301.0 – 301.6	307.3	332.1 – 333.99*
301.8 – 301.9	307.5 - 307.89	787.6
302.1 – 302.6	308.0 - 309.9

*Note: Treatment of diagnoses 332.1 - 333.99, Medication Induced Movement Disorders, is a covered service only when the Medication Induced Movement Disorder is related to one or more included diagnoses.

290.12 – 290.21	299.10 - 300.15	308.0 – 309.9
290.42 – 290.43	300.2 - 300.89	311 – 312.23
291.3	301.0 - 301.5	312.33 - 312.35
291.5 - 291.89	301.59 - 301.9	312.4 – 313.23
292.1 - 292.12	307.1	313.8 – 313.82
292.84 – 292.89	307.20 - 307.3	313.89 - 314.9
295.00 – 299.00	307.5 - 307.89	787.6

2. Availability and Accessibility of Service.

1. 
   The Contractor shall ensure the availability and accessibility of adequate numbers and types of providers of medically necessary services. At a minimum, the Contractor shall ensure an adequate number of providers and appropriate types of providers by considering:
   

1. 
   The anticipated number of Medi-Cal eligible clients.
   

2. 
   The expected utilization of services, taking into account the characteristics and mental health needs of beneficiaries pursuant to Title 42, CFR, 438.207(b).
   

3. 
   The expected number and types of providers in terms of training and experience needed to meet expected utilization.
   

4. 
   The geographic location of providers and their accessibility to beneficiaries, considering distance, travel time, means of transportation ordinarily used by Medi-Cal beneficiaries, and physical access for disabled beneficiaries.
   

2. 
   The Contractor shall ensure that treatment for urgent conditions is authorized within one hour of the request per Title 9, CCR, Section 1810.405(c).
   

3. 
   Pursuant to Title 42 CFR, Section 438.206(c)(1)(ii), if a subcontract provider also serves individuals who are not Medi-Cal beneficiaries, the Contractor shall require that the hours of operation during which services are provided to Medi-Cal beneficiaries are no less than the hours of operation during which the provider offers services to non-Medi-Cal beneficiaries. If the provider only serves Medi-Cal beneficiaries, the Contractor shall require that hours of operation are comparable to the hours the provider makes available for Medi-Cal services that are not covered by the Contractor, or another Mental Health Plan.
   

4. 
   Pursuant to ,Title 42, CFR, 438.207, whenever there is a change in the Contractor’s operation that would cause a decrease of 25 percent or more in services or providers available to beneficiaries, the Contractor shall report this to the Department, including details regarding the change and plans to maintain adequate services and providers available to beneficiaries.
   

5. 
   Access Standards (Title 42, CFR Section 438.206)
   

1. 
   Out-of-Network Providers. Pursuant to Title 42, CFR, Section 438.206(b)(4), and to the extent required by CCR Title 9, Section 1830.220 for inpatient services, if the Contractor is unable to provide necessary medical services covered under the contract to a particular beneficiary, the entity must adequately and timely cover these services out of network for the beneficiary, for as long as the entity is unable to provide them.
   
2. 
   Out-of-Network Providers. Pursuant to Title 42, CFR, Section 438.206(b)(5) and consistent with CCR, Title 9, Section 1830.220, the Contractor shall ensure that out-of-network providers coordinate authorization and payment with the Contractor. The Contractor must ensure that cost to the beneficiary for services provided out of network pursuant to an authorization is no greater than it would be if the services were furnished within the Contractor’s network, consistent with CCR, Title 9, Section 1810.365.
   

3. 
   Timely Access. Pursuant to Title 42, CFR, Section 438.206(c)(1)(i), the Contractor must meet and require its providers to meet Department standards for timely access to care and services, taking into account the urgency of need for services.
   

4. 
   Timely Access. Pursuant to Title 42, CFR, Section 438.206(c)(1)(iii), services must be available to beneficiaries 24 hours a day, 7 days a week, when medically necessary.
   

5. 
   Timely Access Monitoring. Pursuant to Title 42, CFR, Section 438.206(c)(1)(iv), (v) and (vi), the Contractor must:
   

a) Establish mechanisms to ensure that network providers comply with the timely access requirements;

6. 
   Documentation of adequate capacity and services. Pursuant to Title 42, CFR, Section 438.207(b), the Contractor must, if requested by the Department, submit documentation to the Department, in a format specified by the Department, and after receiving reasonable advance notice of its obligation to demonstrate that the Contractor:
   

1. 
   Offers an appropriate range of specialty mental health services that is adequate for the anticipated number of beneficiaries for the service area.
   

2. 
   Maintains a network of providers that is sufficient in number, mix, and geographic distribution to meet the needs of the anticipated number of beneficiaries in the service area.
   

7. 
   Primary care and coordination of health care services. The Contractor must implement procedures to:
   

1. 
   Coordinate the services the Contractor furnishes or arranges to be furnished to the beneficiary with the services the beneficiary receives from any other MCO, PIHP, or PAHP.
   

2. 
   Share with other MCOs, PIHPs, and PAHPs serving the beneficiary the results of its identification and assessment of any beneficiary with special health care needs (defined as adults who have a serious mental disorder and children with a serious emotional disturbance as defined in Welfare and Institutions Code Section 5600.3) so that those activities need not be duplicated.
   

3. 
   Ensure that, in the course of coordinating care, each beneficiary's privacy is protected in accordance with Title 45, CFR Parts 160 and 164 to the extent that such provisions are applicable.
   

4. 
   The Contractor shall enter into a Memorandum of Understanding (MOU) with any Medi-Cal managed care plan serving the Contractor’s beneficiaries in accordance with Title 9, CCR, Section 1810.370. The Contractor shall notify the Department in writing if the Contractor is unable to enter into an MOU or if an MOU is terminated, providing a description of the Contractor’s good faith efforts to enter into or maintain the MOU.
   

(a) The MHP shall monitor the effectiveness of its MOU with Physical Health Care Plans.