New Resource Demystifies Medi-Cal's Mental Health Coverage Under the ACA

Catherine Teare, Associate Director, High-Value Care

September 27, 2016
Catherine Teare
Catherine Teare

Following the birth of her first child in 2012, Sonia was diagnosed with postpartum depression. Her primary care doctor prescribed medication and recommended psychotherapy. However, psychotherapy was not covered through her Medi-Cal managed care plan. Sonia (not her real name) discovered that her depression wasn't severe enough to qualify her for specialty mental health services through her county.

But three years later, when Sonia's second baby arrived, the situation had changed with the 2014 expansion of Medi-Cal outpatient mental health benefits. After receiving a referral from her doctor, Sonia's managed care plan connected her with a licensed mental health provider. While continuing her prescribed medication, Sonia participated in several individual therapy sessions and a weekly group for postpartum moms. She now feels better equipped to manage her depression.

More Mental Health BenefitsMoving Medi-Cal Forward #MediCal4ward

Among the changes introduced by the Affordable Care Act (ACA) in California, relatively little attention has been paid to the 2014 expansion of mental health benefits under Medi-Cal. Like Sonia, 13 million Medi-Cal beneficiaries are entitled to services for "mild-to-moderate" mental health conditions. Yet there is a distinct lack of awareness about this mental health benefit — what is covered, how it is administered, and how it fits into the array of services provided by the California mental health system. That's why the California Health Care Foundation published The Circle Expands: Understanding Medi-Cal Coverage of Mild-to-Moderate Mental Health Conditions by Harbage Consulting. It answers common questions about the benefit and can serve as a resource for advocates, consumer groups, and policymakers.

Access to mental health services has historically been worse for people on Medi-Cal than for other Californians, even though people with low incomes are more likely to face episodic and chronic mental health problems. Until 2014, Medi-Cal beneficiaries with mental health conditions that were not severe enough to meet the criteria for specialty mental health services (which are provided by county mental health plans) did not have many options. People with anxiety and depression that was mild or moderate could get only limited outpatient mental health services delivered by their primary care physician or by a small network of fee-for-service mental health providers.

New Requirements and How They Work

Now Medi-Cal managed care plans must deliver an expanded set of mental health services, including individual and group psychotherapy, psychological testing, psychiatric consultation, and medication management. This chart from The Circle Expands describes the shift in more detail.

Medi-Cal Mental Health Benefits Prior to and Starting in 2014

Medi-Cal managed care plans are required to contract with network providers to deliver mental health services, and while some contract directly with providers, a majority (59%) subcontract with a managed behavioral health organization (MBHO) to support administration of the new mental health benefit. MBHOs take on responsibilities that may include developing the provider network, negotiating provider rates, and administering claims adjudication and reimbursement. These subcontracts are complicated and can be confusing to providers and consumers alike. The Circle Expands explains these contracting relationships and managed care plans' responsibilities. In addition to the map below, it also includes a list of all Medi-Cal managed care plans and the MBHOs they contract with, by county.

California Managed Care Plans and Managed Behavioral Health Care Organizations, by County

Coordination Is Key

Of course, Medi-Cal beneficiaries' health status can fluctuate based on their circumstances and their access to care (or lack thereof); many people may move between "mild-to-moderate" and "severe" categories. As was discussed extensively at CHCF's July 13 briefing, The Future of Delivery System Reform in Medi-Cal, coordination between Medi-Cal managed care plans and county mental health systems is essential. The Circle Expands outlines the requirements for memoranda of understanding between plans and counties to facilitate this coordination, which is discussed in more detail in another useful resource, Promising Practices to Integrate Physical and Mental Health Care for Medi-Cal Members, written by the Center for Health Care Strategies and funded by our colleagues at the Blue Shield of California Foundation. This publication offers recommendations for how managed care plans can work together with MBHOs and also coordinate with county mental health agencies to provide whole-person care in a fractured financing and delivery system.

The mild-to-moderate benefit under Medi-Cal offers a tremendous opportunity to improve access to treatment for anxiety, depression, and other common mental illnesses. Up to 20% of adult Californians experience these disorders in any given year. But ultimately, the benefit is only as good as its implementation and adoption. Together, I hope these resources can help consumers, managed care plans, advocates, county agencies, and other stakeholders work together to ensure Medi-Cal beneficiaries get the mental health services they need and deserve.