1. DRUG MEDI-CAL TITLE 22 TRAINING
CALIFORNIA CODE OF REGULATIONS
Title 22 Drug Medi-Cal
Section effective 6/25/14

2. DRUG MEDI-CAL TITLE 22 TRAINING
PRESENTATION OUTLINE
Admission/Physical Exam
Treatment Planning
Counseling Sessions
Progress Notes
Continuing Services
Discharge
Additional Requirements

3. DMC Background
Drug Medi-Cal (DMC) is a drug and alcohol treatment program funded through the federal Medicaid program The services provided must be contained in an approved State Medicaid Plan (approved by CMS) The California Federal Financial Participation (FFP) is 50% federal funds and 50% state or local funds The primary regulations that govern DMC are contained in Title 22, Sections (program requirements), (claim submission requirements) and (reimbursement rates and requirements) Program Integrity emergency regulations for Section became effective on 6/25/14

4. DRUG MEDI-CAL TITLE 22 TRAINING
DRUG MEDI-CAL SUD TREATMENT SERVICE MODALITIES
Outpatient Drug Free (ODF)
ODF Regular and Perinatal
Day Care Habilitative (DCH)
DCH EPSDT and Perinatal
Perinatal Residential Substance Abuse
Naltrexone
Narcotic Treatment Programs will not be
addressed in this presentation

5. DRUG MEDI-CAL TITLE 22 TRAINING
JOB ONE!
Know and follow the regulations
WHY?
Clients
Funding
Did I say Clients?

6. PROVIDER RESPONSIBILITIES
Establish Medical Necessity (physician)
Establish and maintain individual Beneficiary record
Provide treatment services
Document, document, document
Submit claims for reimbursement
AND
The Double Top Secret Magic Passwords to Success
Follow the TIMELINES in the regs
PROVIDER RESPONSIBILITIES

7. PROVIDER DON’TS
Do not sign patient names to any document or sign-in sheet Do not sign any document using the Medical Director’s or anyone else’s signature (no signature stamps allowed) Do not intentionally submit erroneous billings Do not falsify any Medi-Cal record/document (e.g., progress notes, treatment plans, etc.) Do not back date/forward date any signature Sign blank documents Do not allow unqualified staff to provide services

8. ADMISSION TO TREATMENT
Almost everything you want to know about DMC admission criteria
ADMISSION TO TREATMENT

9. DRUG MEDI-CAL TITLE 22 TRAINING
For each Beneficiary the provider shall complete:
Personal history
Medical history
Substance use history
Assessment of the physical condition
ADMISSION CRITERIA
Section (h)

10. DRUG MEDI-CAL TITLE 22 TRAINING
INTAKE /ASSESSMENT
The Basis for Establishing Medical Necessity
The evaluation or analysis of the cause or nature of the disorders listed below using DSM codes:
Section (b)(13)
The assessment of treatment needs to provide medically necessary treatment services by a physician includes
Mental Emotional Psychological Behavioral and Substance Use
May also include a physical examination and laboratory testing by staff lawfully authorized to provide such services

11. DRUG MEDI-CAL TITLE 22 TRAINING
ADDITIONAL PERINATAL REQUIREMENTS
Sections 50260, 51303, (c)(1), (g)(1)(A)(iii)
Beneficiary must be eligible for and received Medi-Cal during the last month of pregnancy
Must have medical documentation that substantiates the Beneficiary’s pregnancy and last day of pregnancy.
Rate is applicable during pregnancy and for the 60-day postpartum period beginning on the last day of pregnancy
Eligibility ends on the last day of the month in which the 60th day occurs

12. PHYSICAL EXAM REQUIREMENTS
DRUG MEDI-CAL TITLE 22 TRAINING
PHYSICAL EXAM REQUIREMENTS
Section (h)(1)(A)(iv)(a)(b)&(c)
A physical examination can be conducted by the program’s physician, registered nurse practitioner or physician’s assistant, within thirty (30) days of admission OR Physician can review documentation of most recent (within 12 months) physical examination Include obtaining a physical examination as a treatment plan goal WHY IS A FOCUS ON PHYSICAL HEALTH IMPORTANT?

13. PHYSICAL HEALTH AND SUD
SUD complicates and leads to serious health conditions
Increased risk of pregnancy complications, cancer, and gastrointestinal, cardiovascular, pulmonary, renal, hematological, gynecological and metabolic problems.
Arthritis, asthma, hypertension and ischemic heart disease – 2x more prevalent in SUD patients
Over half of people w/SUD have another health condition
SUD has negative impact on mental health and behavior
Risk-taking behavior creates high risk for communicable diseases and other serious injury
People w/SUD incur 2x-3x the total medical expenses of people who do not have SUD

14. Physical Examination Waivers are no longer an option for Drug Medi-Cal Programs

15. DRUG MEDI-CAL TITLE 22 TRAINING
MEDICAL NECESSITY
Sections 51303, (h)(1)(A)(v) (vi)
The physician shall document the basis for the DSM code diagnosis indicating medical necessity in the Beneficiary’s individual record within thirty (30) calendar days of the Beneficiary’s date of admission to treatment.

16. TREATMENT PLANNING

17. DRUG MEDI-CAL TITLE 22 TRAINING
TREATMENT PLANNING
Section (h)(2)
The treatment plan for each Beneficiary must:
Be individualized
Be based on the information obtained during the intake and assessment process
Attempt to engage the Beneficiary to meaningfully participate in the preparation of the initial treatment plan and updated treatment plans – Bene must sign! If Bene refuses, documentation of strategy to engage Bene must be added to Tx plan.
Be legible – including staff names; names of counselors, therapists, physicians, etc. Must sign and date.

18. DRUG MEDI-CAL TITLE 22 TRAINING
MUST INCLUDE THE FOLLOWING EIGHT (8) ELEMENTS…
Section (h)(2)(A)(i)
A statement of the problems to be addressed
Goals to be reached which address each problem
Action steps which will be taken by the provider, and/or Beneficiary to accomplish identified goals
Target dates for the accomplishment of action steps and goals

19. EIGHT ELEMENTS Cont. Section 51341.1(h)(2)(A)(i)
A description of the services, including the type and frequency of counseling to be provided
Group counseling must be a specific number of sessions over a specific period of time
If individual counseling is planned, it must be on the treatment plan
6) The assignment of a primary therapist or
counselor
7) The Beneficiary’s DSM code diagnosis

20. DRUG MEDI-CAL TITLE 22 TRAINING
LAST BUT VERY IMPORTANT
8) If the Beneficiary has not had a physical examination within the twelve (12) month period prior to the date of admission, a goal that the Beneficiary have a physical examination must be added to the treatment plan.
AND
If documentation of a Beneficiary’s physical examination, which was performed during the prior twelve (12) months, indicates a significant medical illness, a goal that the Beneficiary obtain appropriate treatment for the illness must be added to the treatment plan.

21. INITIAL TREATMENT PLAN TIMELINES Section 51341.1(h)(2)(A)(ii)
DRUG MEDI-CAL TITLE 22 TRAINING
Therapist/Counselor - shall complete, sign and date the initial treatment plan within thirty (30) calendar days of the admission to treatment date. Beneficiary – shall review, approve, sign and date the initial treatment plan, indicating whether the beneficiary participated in preparation of the plan, within thirty (30) calendar days of the admission to treatment date. Physician - shall review the initial treatment plan to determine whether the services are medically necessary, sign, and date the initial treatment plan within fifteen (15) calendar days of signature by the therapist or counselor.
INITIAL TREATMENT PLAN TIMELINES Section (h)(2)(A)(ii)

22. UPDATED TREATMENT PLAN TIMELINES Section 51341.1(h)(2)(A)(iii)
DRUG MEDI-CAL TITLE 22 TRAINING
Therapist/Counselor shall complete, sign and date the updated treatment plan no later than ninety (90) calendar days after signing the initial treatment plan, and no later than every ninety (90) calendar days thereafter (unless a change in problem identification or focus of treatment occurs) The Beneficiary shall review, approve, sign and date the updated treatment plan, indicating whether the Beneficiary participated in preparation of the plan within thirty (30) calendar days of signature by the therapist or counselor. The Physician shall review each updated treatment plan to determine whether the services are medically necessary and sign and date the updated treatment plan within fifteen (15) calendar days of signature by the therapist or counselor.
UPDATED TREATMENT PLAN TIMELINES Section (h)(2)(A)(iii)

23. DRUG MEDI-CAL TITLE 22 TRAINING
BENEFICIARY CONTACT REQUIREMENTS
Section (d)(2)(A) (h)(4)(A)
Minimum of two provider/beneficiary contacts per day period (for ODF – 2 group counseling sessions)
Requirement may be waived by the physician if:
Fewer contacts are clinically appropriate;
The Beneficiary is making progress towards treatment plan goals

24. BENEFICIARY CONTACT Cont
BENEFICIARY CONTACT Cont. Exceptions must be noted, signed and dated by the physician in the Beneficiary’s record However If the Beneficiary does not attend treatment for more than 30 days, the provider must discharge the Beneficiary.

25. DRUG MEDI-CAL TITLE 22 TRAINING
Covered So Far
Admission/Physical Exam
Treatment Planning
Counseling Sessions
Progress Notes
Continuing Services
Discharge
Additional Requirements

26. DRUG MEDI-CAL TITLE 22 TRAINING
GROUP COUNSELING
Section (b)(11)

27. GROUP COUNSELING SESSIONS Sections 51341.1(b)(11), 51341.1(g)(2)
DRUG MEDI-CAL TITLE 22 TRAINING
Must be conducted in a confidential setting
Must have a group sign-in sheet that includes:
A typed or printed list of the Beneficiary’s names and the signature of each Beneficiary that attended the counseling session
A typed or printed name and signature of counselor(s) facilitating session (certifying accuracy and completeness)
The date of the counseling session
The start and end times of the counseling session
The topic of the counseling session
GROUP COUNSELING SESSIONS Sections (b)(11), (g)(2)

28. REQUIREMENTS BY MODALITY Section 51341.1(b)(11)
DRUG MEDI-CAL TITLE 22 TRAINING
REQUIREMENTS BY MODALITY Section (b)(11)
ODF
Must have at least four (4) and no more than ten (10) participants in any one group counseling session
In order to bill DMC, at least one of the four (4) to ten (10) participants must be a DMC Beneficiary

29. REQUIREMENTS BY MODALITY Section 51341.1(b)(11) DCH
Must have at least two (2) and no more than twelve (12) participants in any one group counseling session
In order to bill DMC, at least one of the two (2) to twelve (12) participants must be a DMC beneficiary
REQUIREMENTS BY MODALITY Section (b)(11) DCH

30. A Beneficiary that is under the age of 18 years cannot participate in group counseling sessions with any participants that are 18 years or older
UNLESS
The group counseling sessions are held at a
provider’s certified school site
AGE LIMITS

31. INDIVIDUAL COUNSELING
DRUG MEDI-CAL TITLE 22 TRAINING
INDIVIDUAL COUNSELING

32. DRUG MEDI-CAL TITLE 22 TRAINING
INDIVIDUAL COUNSELING
Section (b)(10)
Must be face to face contact at a DMC certified location to bill for the service
No home visits, no hospital visits, no telephone contacts

33. INDIVIDUAL COUNSELING LIMITS FOR ODF
Intake/Assessment
Treatment Planning
Discharge Planning
Collateral
Crisis

34. DRUG MEDI-CAL TITLE 22 TRAINING
COLLATERAL SERVICES COUNSELING
Section (b)(4)
Face-to-face session
With persons significant in the life of the Beneficiary
Personal, not professional, relationships
Focusing on the treatment needs of the Beneficiary
Supporting the achievement of the Beneficiary’s treatment goals
Beneficiary does not have to attend

35. DRUG MEDI-CAL TITLE 22 TRAINING
CRISIS INTERVENTION COUNSELING
Section (b)(7)
Face-to-face contact with a Beneficiary in crisis
Crisis is an actual relapse, or
Unforeseen event or circumstance causing an imminent threat of relapse
Services shall:
Focus on alleviating crisis problems, and
Limited to stabilization of the emergency

36. PROGRESS NOTES
Counselor/therapist must legibly print, sign and date the progress note!

37. DRUG MEDI-CAL TITLE 22 TRAINING
For each individual and group counseling session the therapist or counselor who conducted the counseling session shall record a progress note for each Beneficiary who participated within seven (7) calendar days of the session that includes the following: The topic of the session A description of the Beneficiary's progress on the treatment plan problems, goals, action steps, objectives, and/or referrals Information on the Beneficiary's attendance, including the date, start and end times of each individual and group counseling session
ODF Section (h)(3)(A)

38. DCH/PERINATAL RESIDENTIAL Section 51341.1(h)(3)(B)
DRUG MEDI-CAL TITLE 22 TRAINING
At minimum, one (1) progress note, per calendar week, should be recorded for each Beneficiary and should include: A description of the Beneficiary's progress on the treatment plan problems, goals, action steps, objectives, and/or referrals A record of the Beneficiary's attendance at each counseling session including the date, start and end times and topic of the counseling session
DCH/PERINATAL RESIDENTIAL Section (h)(3)(B)

39. DRUG MEDI-CAL TITLE 22 TRAINING
Progress notes should tell the beneficiary’s treatment story

40. DRUG MEDI-CAL TITLE 22 TRAINING
Covered So Far
Admission/Physical Exam
Treatment Planning
Counseling Sessions
Progress Notes
Continuing Services
Discharge
Additional Requirements

41. To treat or not to treat, That is the Question
CONTINUING TREATMENT

42. MEDICAL NECESSITY OF CONTINUED SERVICES Section 51341.1(h)(5)(A)(ii)
No sooner than 5 months and no later than 6 months after admission, or the completion of the most recent justification, the need for continued treatment must be determined by the physician.

43. CONTINUED SERVICES JUSTIFICATION
The physician must document the medical necessity determination to continue services based on review of the Beneficiary’s:
Personal, medical and substance use history
Most recent physical exam
Treatment plan goals
Progress in treatment (progress notes)
Therapist/counselor recommendations
Prognosis

44. DISCHARGE

45. DRUG MEDI-CAL TITLE 22 TRAINING
DISCHARGE PLAN
Section (h)(6)(A)
Discharge Plans must be completed in the thirty (30) calendar days prior to the last face-to-face treatment session on all Beneficiaries by the therapist/counselor.
The Discharge Plan is a document developed by the counselor and the Beneficiary that identifies the Beneficiary’s
Relapse triggers
Support plan
The Discharge Plan must be signed by the counselor and the Beneficiary and a copy provided to the Beneficiary. The Discharge Plan will become part of the individual record.

46. DRUG MEDI-CAL TITLE 22 TRAINING
RELAPSE TRIGGERS
Section (b)(26)

47. SUPPORT PLAN Section (b)(28) A list of individuals and/or organizations and activities that can provide support and assistance to a Beneficiary to maintain sobriety.

48. DISCHARGE SUMMARY Section 51341.1(h)(6)(B)
When a provider has lost contact or the Beneficiary is not available for 30 days, the provider will complete a Discharge Summary that shall include:
Duration of treatment as determined by admission and discharge dates
Reason for discharge
Narrative summary of treatment episode
Beneficiary’s prognosis

49. DRUG MEDI-CAL TITLE 22 TRAINING
FAIR HEARING
Section (p)
Providers shall inform Beneficiaries of their right to a fair hearing related to:
Denial
Involuntary discharge
Reduction in DMC services
As these relate to their eligibility or benefits.

50. DRUG MEDI-CAL TITLE 22 TRAINING
FAIR HEARING
Section (p)
At least 10 calendar days prior to the effective date of the intended action the provider must give the Beneficiary a written notice that includes:
A statement of the action the provider intends to take
The reason for the intended action
A citation of the specific regulation(s) supporting the intended action
Informing the Beneficiary of his/her right to a fair hearing for the purpose of appealing the intended action
Informing the Beneficiary that the provider must continue treatment only if the beneficiary appeals in writing within 10 days of the notice
Must include the address where the request for a fair hearing must be submitted

51. Additional Requirements

52. DRUG MEDI-CAL TITLE 22 TRAINING
MULTIPLE SERVICES SAME DAY
Section
ODF
Return visit shall not create a hardship on Beneficiary
Document time of day of each visit
Progress note shall clearly reflect that an effort to provide all services in one visit was made and the return visit was unavoidable;
The return visit shall clearly document a crisis or collateral service
The provider must complete the DHCS MC 7700 form and place in Beneficiary record Or

53. DRUG MEDI-CAL TITLE 22 TRAINING
MULTIPLE SERVICES SAME DAY Section
DCH
The return visit shall clearly document a crisis service
Crisis services shall be documented in the progress notes
Provider must complete the DHCS MC 7700 form and place in Beneficiary record

54. DRUG MEDI-CAL TITLE 22 TRAINING
SHARE OF COST
Section (h)(7)
Except where share of cost, as defined in Section 50090, is applicable, providers shall accept proof of eligibility for Drug Medi-Cal as payment in full for treatment services rendered. Providers shall not charge fees to a Beneficiary for access to Drug Medi-Cal substance use disorder services or for admission to a Drug Medi-Cal treatment program.

55. ADDITIONAL INFORMATION
DRUG MEDI-CAL TITLE 22 TRAINING
Contact DHCS Provider Enrollment with application and certification inquiries as well as programmatic changes such as relocation or administration adjustments
For additional Title 22 Regulation information
ADDITIONAL INFORMATION

56. DRUG MEDI-CAL TITLE 22 TRAINING
Questions for this presentation will be collected and responded to at a later date.