Medi-Cal Managed Care

HELLO! I am Steven Camp Board Certified Behavior Analyst (BCBA). 14 Years Experience working in Applied Behavior Analysis and Autism treatment. Master’s Degree in Special Education. Expert Consult for Autism, ABA Therapy, and the Specialty Kids Intervention Team at Inland Empire Health Plan. Executive Clinical Director and Founder of Collaborative Autism Management Programs contracted with Tricare. Parent of an 8-year with Cerebral Palsy. HELLO! I am Steven Camp

Topics Covered 1. Understanding Covered Benefits 2. Recent Changes to Managed Care 3. ASD Diagnostic Services 4. Behavioral Health Services

Covered Benefits Understanding the Hierarchy Evidence of Coverage Department of Health Care Services (DHCS) Medi-Cal Provider Manual/Title 22 All Plan Letters Nationally Recognized Clinical Criteria Subcommittee Guidelines

Evidence of Coverage The Member handbook informs the recipient what is covered and what is not covered. Covered benefits need to be medically necessary based on criteria.

DHCS Oversight Medi-Provide Manuals Provides parameters for the delivery of healthcare services for Medi-Cal recipients. All Plan Letters- Conveys information or interpretation of changes in policy or procedure at the Federal or State levels. Provides instruction to contractors on how to implement these changes on an operational basis.

Criteria Managed Care Plans use one or more of the following criteria: Apollo Managed Care InterQual Milliman Care Guidelines (MCG) These guideline are based on the recent medical literal and best practices and are updated annually.

UM Subcommittee Guidelines Health Plans have the ability to create their own medical guidelines when other criteria is silent on the treatment parameters. Subcommittee guidelines are developed by experts based on review of evidenced based medical literature. The guideline is presented at a committee meeting with a group of network providers.

Recent Changes New All Plan Letter outlining new guidelines for Behavioral Health Treatment. Behavioral Health Treatment is often referred to as or known as Applied Behavior Analysis. Behavioral Health Treatment consist of many different evidence based treatments.

APL Changes In July 2018 the BHT Benefit will expand coverage of the population eligible to receive services. Regardless of Diagnosis, or Completion of a Comprehensive Diagnostic Evaluation (CDE). A licensed physician and surgeon or a licensed psychologist may decide that the CDE is medically appropriate, completion of a CDE is not required for every member.

BHT Coverage In order to be eligible for BHT services, a Medi-Cal member must meet all of the following coverage criteria: Be under 21 years of age. Have a recommendation from a licensed physician and surgeon or a licensed psychologist that evidence-based BHT services are medically necessary. Be medically stable. Be without a need for 24-hour medical/nursing monitoring or procedures provided in a hospital or intermediate care facility for persons with intellectual disabilities (ICF/ID).

BHT Recommendation BHT is medically necessary after the Provider has completed a comprehensive developmental surveillance and screening, and have recommended BHT services is clinically warranted to treat persistent developmentally inappropriate behavior and/or diagnoses that may be able to be corrected or ameliorated with BHT services. Aberrant behaviors include but are not limited to self-injury, aggression, and deficits in language skills, daily living skills, and social skills.

Surveillance/Screening Developmental Surveillance There are five components of developmental surveillance: Eliciting and attending to the parents’ concerns about their child’s development; Documenting and maintaining a developmental history; Making accurate observations of the child; Identifying risk and protective factors; and Maintaining an accurate record of documenting the process and findings. Developmental Screening To improve the early identification of children with developmental disability, the AAP recommends that all infants and young children be routinely screened for developmental delays using a validated screening tool/test. Development encompasses cognitive, language, and motor, as well as behavioral, social-emotional, and mental health domains. The goal of developmental surveillance and screening is the identification of children who have or are at risk for developmental delays or inappropriate behavioral problems so that services can be provided in a timely manner.

Behavioral Health Treatment BHT may or may not include ABA therapy. BHT interventions consist of the following: Behavior Interventions Cognitive Behavior Intervention Package Comprehensive Behavioral Treatment for Young Children Language Training Modeling Naturalistic Teaching Strategies Parent Training Package Peer Training Package Pivotal Response Treatment Schedules Scripting Self-Management Social Skills Package Story-based Interventions

BHT Timeframe Once a Member meets the criteria for BHT services, IEHP will authorize a BHT Assessment, which is often referred to as a Functional Behavior Assessment. The assessment authorization is effective for 60 days and the provider is allotted 10 hours of direct/indirect hours to complete the assessment to develop the BHT treatment plan. The BHT Treatment Plan will make the recommendation for ongoing BHT services. The BHT Treatment Plan is updated and reviewed at the minimum of every 6-months.

ASD Diagnostic The Gold Standard in Autism diagnostic is a Comprehensive Diagnostic Evaluation, this consist of the following: Comprehensive unclothed medical examination (by the primary care physician/pediatrician as required by EPSDT) A parent/guardian interview; Direct play observation; Review of relevant medical, psychological, and/or school records; Cognitive/developmental assessment; Measure of adaptive functioning; Language assessment (by a speech language pathologist), Sensory evaluation (by and occupational therapist); If indicated, neurological and/or genetic assessment to rule out biological issues (by a developmental pediatrician, pediatric neurologist, and/or geneticist).

CDE This medical evaluation and diagnostic will assist parents with getting Inland Regional Center eligibility. The CDE can be very beneficial to parents when it comes to educational needs and special education determination. The CDE will make referrals for the following: Medical ABA, Speech, Occupational Therapy Community Inland Regional Center School District County SART, PCIT, TBS, Wrap Services

Behavioral Health The additional Behavioral Health Services are available to your through Medi-Cal: Individual Therapy Family Therapy Group Therapy Medication Management (Psychiatry Services) Complex Case Management Nurtition Consult (for ASD and Developmental Disabilities)

Any questions? You can contact me at scamp@collaborativeautism.org THANKS! Any questions? You can contact me at scamp@collaborativeautism.org