CurrentLA Care HealthPolicy MMUM-080

Health Coverage: Mental Health and Substance Use Disorder

Defines L.A. Care Health Plan's coverage obligations, utilization management processes, and requirements for mental health and substance use disorder (MH/SUD) services under California SB 855; applies to L.A. Care Covered lines of business and delegated behavioral health entities.

Policy Summary

PayerLA Care Health

PolicyHealth Coverage: Mental Health and Substance Use Disorder

Policy CodePolicy MMUM-080

Change TypeNo material change

Effective DateJan 1, 2025

Next Review DateN/A

Key ActionObtain prior authorization when advance approval is required and process requests through the Utilization Management referral process per MMUM-002.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

SB 855Regulatory driver

CarelonDelegated BH manager

60 daysPOC review interval

L.A. Care CoveredLines of business

MMUM-002Monitoring

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Covered MH/SUD Services

Covered when services are Medically Necessary and consistent with generally accepted standards of care per Cal. Code Regs. Tit. 28 §1300.74.72.01.

General MH/SUD coverage: Services for prevention, diagnosis, and treatment of mental health conditions and substance use disorders when medically necessary and consistent with generally accepted standards of care

Includes emergency, urgent, physician, ambulatory, diagnostic, preventive, hospice, drug testing, gender dysphoria care, polysomnography, reconstructive surgery where applicable

Home Health Care Coverage

Home health services covered when ALL of the following conditions are satisfied:

Home health coverage criteria: (A) Enrollee is confined to the home except for infrequent or relatively short duration absences, or absences attributable to receiving medical treatment, due to a mental health condition or substance use disorder; (B) Skilled nursing care on an intermittent basis, physical therapy, occupational therapy, or speech-language pathology services are Medically Necessary for evaluation or treatment of the enrollee's mental health condition or substance use disorder or its symptoms; (C) An enrollee's physician, physician assistant, nurse practitioner, or clinical nurse specialist attests that conditions (A) and (B) are met and establishes and periodically reviews, no less frequently than once every 60 days, a plan of care that includes the specified services and the frequency and duration of visits

Part-time defined as combined skilled nursing and home health aide services <8 hours/day and <35 hours/week

Any quantitative or nonquantitative treatment limitations applied to mental health or substance use disorder benefits must be no more restrictive than those permitted under the applicable regulatory article and Medicare, and are subject to prior review by the Department. This parity requirement applies to limits on eligibility and on coverage of home health care services and aligns with L.A. Care’s obligation to implement Senate Bill 855 provisions for MH/SUD parity.

Covered services include those that are Medically Necessary and consistent with generally accepted standards of care under California regulations. For home health care specifically, coverage is provided when all program conditions are met, including clinician attestation and an established plan of care with periodic review. Providers should follow Utilization Management procedures and prior authorization requirements where advance approval is specified.

Provider Responsibilities and Utilization Management

Prior Authorization

Prior Authorization and UM processing

Prior Authorization is required where advance approval is specified. Utilization Management (UM) will determine benefit coverage and medical necessity; providers must obtain prior authorization for services that require advance approval before delivery to avoid denial of coverage.

Prior Authorization required when specified in policy or benefit plan
Failure to obtain prior authorization may result in denial of coverage

Documentation Required

UM process adherence

All requests must be submitted and managed through the Utilization Management referral process. Providers must follow MMUM-002 'Referral Request Management' and MMUM-013 as applicable; failure to follow the UM process may affect coverage determinations and timeliness of notifications.

Submit requests per MMUM-002 Referral Request Management
Adhere to UM criteria and disclosure requirements per MMUM-013

Documentation Required

Home health plan-of-care documentation

For home health services, the enrollee's physician, physician assistant, nurse practitioner, or clinical nurse specialist must attest that the conditions for skilled care are met and must establish and review a plan of care at least every 60 days. The plan of care must specify services, frequency, and duration.

Attestation by authorized clinician that criteria in sections 3.1.2.1 and 3.1.2.2 are met
Plan of care established and reviewed no less frequently than every 60 days
Plan must include specified services and frequency/duration of visits

Note

Provider-facing operational note: ensure prior authorization, UM referral submission, and home health plan-of-care documentation are retained in the medical record and are available for review upon request.

Retain prior authorization approvals and UM communications in the chart
Make plan-of-care documentation available for audits and UM review

Definitions

inv-12: Behavioral Health Treatment (BHT)

DefinitionBehavioral Health Treatment (BHT) means professional services and treatment programs, including applied behavior analysis and evidence-based behavior intervention programs that develop or restore functioning for individuals with pervasive developmental disorder or autism

Scope - interventionsIncludes applied behavior analysis (ABA) and a variety of evidence-based behavioral interventions identified by nationally recognized research reviews

Delivery settingsDesigned to be delivered primarily in the home and in other community settings

PurposeTeach skills through behavioral observation, reinforcement, or prompting to teach each step of targeted behavior; not experimental

inv-13: Medically Necessary

DefinitionMedically Necessary or Medical Necessity means those reasonable and necessary services, procedures, treatments, supplies, devices, equipment, facilities, or drugs that a medical practitioner, exercising prudent clinical judgment, would provide to a patient for purposes of evaluating, diagnosing, or treating an injury or disease, or its symptoms, to protect life, to prevent significant illness or significant disability, or to alleviate severe pain

StandardsMust be consistent with nationally accepted standards of medical practice (credible scientific evidence, specialty society recommendations, and views of practitioners)

EPSDT for <21For Medi‑Cal beneficiaries under age 21, Medical Necessity is expanded to include EPSDT requirements

inv-14: Prior Authorization

DefinitionPrior Authorization is the formal process requiring a health care provider to obtain advance approval for coverage of specific services or procedures

Determinations madeAllows for benefit determination, determination of Medical Necessity and clinical appropriateness, level of care assessment, and assignment of length of stay or appropriate facility placement

SynonymsAlso referred to as Preauthorization or PreCertification; used for prior-authorization review

Level of Care and Service Intensity Criteria

Outpatient / Early intervention

ASAM 0.5 and early interventions: Screening, brief intervention, referral to treatment, primary care-based interventions, and specialty services for persons with hazardous or at-risk substance use who do not meet SUD diagnostic criteria (ASAM level 0.5)

Uses ASAM Criteria or most recent edition

UM continued stay: UM determinations for level of care and length of stay performed per UM processes and regulatory guidelines

See MMUM-002 for referral and determination timelines

Applied Behavior Analysis (BHT/ABA) Criteria

BHT (ABA) Criteria

Behavioral Health Treatment (BHT) scope

BHT definition: BHT includes applied behavior analysis and evidence-based behavior intervention programs for individuals with pervasive developmental disorder or autism; services teach skills through behavioral observation, reinforcement, or prompting; are based on reliable evidence and are not experimental

Designed primarily for delivery in home and community settings

Treatment Modalities Covered

General MH/SUD services

Covered treatment modalities when Medically Necessary and consistent with standards of care:

Included modalities: Emergency care, urgent care, physician services (including consultation and referral and prescription drugs when furnished by a provider), ambulatory care (including PT/OT/speech/infusion), diagnostic laboratory and radiologic services, preventive services, hospice, drug testing, gender dysphoria-related care per WPATH standards, polysomnography, and reconstructive surgery as specified

Services must be medically necessary and consistent with generally accepted standards of care per Cal. Code Regs.

Visit Limits and Home Health Definitions

inv-18: Home health skilled nursing and home health aide services

Part-time home health definitionPart-time means combined skilled nursing services and home health aide services are furnished less than eight hours per day and less than 35 hours per week

Included servicesPart-time skilled nursing care (RNs, LPNs under RN supervision, or psychiatrically trained nurses) and part-time home health aide services for personal care

Context of coverageDefined for purposes of home health services covered under a physician/clinician-prepared plan of care