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Home My WebLink Aboutqa_informing-materials_acbhd-2026-integrated-member-handbook_4-28-2026 Member Handbook Specialty Mental Health Services and Drug Medi-Cal Organized Delivery System Alameda County Behavioral Health Department Administration Offices 2000 Embarcadero Cove Oakland, CA 94606 The Alameda County Behavioral Health Department (ACBHD) ACCESS Program and Helpline are available 24/7. ACCESS Program: 1-800-491-9099 Helpline: 1-844-682-7215 (TTY:711) Effective Date: February 1, 2026 1 1 The handbook must be offered at the time the member first accesses services. Page 2 NOTICE OF AVAILABILITY OF LANGUAGE ASSISTANCE SERVICES AND AUXILIARY AIDS AND SERVICES English ATTENTION: If you need help in your language, contact your service provider or call ACBHD ACCESS at 1-800-491-9099 (TTY: 711). Aids and services for people with disabilities, like documents in braille and large print, are also available by contacting your service provider or calling ACBHD ACCESS at 1-800-491-9099 (TTY: 711). These services are free of charge. Arabic)( ﺔﯾﺑرﻌﻟا ـﺑ لﺻﺗا وأ كﺑ صﺎﺧﻟا ﺔﻣدﺧﻟا دوزﻣﺑ لﺎﺻﺗﻹﺎﺑ مﻗ ،كﺗﻐﻠﺑ ةدﻋﺎﺳﻣ ﻰﻟإ ﺔﺟﺎﺣﺑ تﻧﻛ اذإ :هﺎﺑﺗﻧﻹا ﻰﺟرﯾACBHD ACCESS مﻗرﻟا ﻰﻠﻋ9099-491-800-1 )TTY :711 يوذ صﺎﺧﺷﻸﻟ تﺎﻣدﺧو تادﻋﺎﺳﻣ ﺎًﺿﯾأ ﺎﻧﯾدﻟ رﻓوﺗﺗ .( كﺑ صﺎﺧﻟا ﺔﻣدﺧﻟا دوزﻣﺑ لﺎﺻﺗﻻا ﻖﯾرط نﻋ كﻟذو ،ةرﯾﺑﻛ فورﺣﺑ ﺔﻋوﺑطﻣﻟاو لﯾارﺑ طﺧﺑ ﺔﺑوﺗﻛﻣﻟا تادﻧﺗﺳﻣﻟا لﺛﻣ ،ﺔﻗﺎﻋﻹا ـﺑ لﺎﺻﺗﻻا وأACBHD ACCESS مﻗرﻟا ﻰﻠﻋ9099-491-800-1 )TTY :711تﺎﻣدﺧ ﻲھ تﺎﻣدﺧﻟا هذھ لﻛ .( . Հայերեն (Armenian) ՈՒՇԱԴՐՈՒԹՅՈՒՆ: Եթե Ձեզ անհրաժեշտ է օգնություն Ձեր լեզվով, զանգահարեք ACBHD ACCESS 1-800-491-9099 (TTY: 711): Հասանելի են նաև աջակցման ծառայություններ և ռեսուրսներ հաշմանդամություն ունեցող անձանց համար, օրինակ՝ նյութեր Բրայլի գրատիպով կամ խոշորատառ տպագրությամբ։ Զանգահարեք ACBHD ACCESS 1-800-491-9099 (TTY: 711): Այս ծառայությունները տրամադրվում են անվճար։ ែខ្មរ (Cambodian) ចំណ‌ំ៖ េបើអ្នក្រត�វកាᶰរជំនួយជ‌ភាាសារបស់អ្នក សូ មទាȐក់ទងអ្នកផ្ដល់េសវ‌កម្មរបស់អ្នក ឬេ� ទូរសព្ទេ� ACBHD ACCESS តាԳមេលខ 1-800-491-9099 (TTY: 711)។ ជំនួយ និងេសវ‌កម្ម ស្រមាȐប់ជនពិកាᶰរ ដូចជ‌ឯកសារសរេសរជ‌អក្សរសា្ទ ប និងឯកសារសរេសរជ‌អក្សរពុម្ពធំៗ ក៏ ឣ‍ចរកបានផងែដរេដ‌យទាȐក់ទងេ�អ្នកផ្ដល់េសវ‌កម្មរបស់អ្នក ឬេ�ទូរសព្ទេ� ACBHD ACCESS តាԳមេលខ 1-800-491-9099 (TTY: 711)។ េសវ‌កម្មទាȐំងេនះមិនគិតៃថ្លេឡើយ។ 繁體中文 (Chinese) 注意：如果您需要使用本民族语言获得帮助，请联系您的服务提供商或拨打 ACBHD ACCESS 电话1-800-491-9099（TTY：711）。通过与您的服务提供商联系或拨打 ACBHD ACCESS 电话 1-800-491-9099（TTY：711），还可获得为残疾人提供的辅助工具和服务，如盲文和大字印刷文件。这些服务均免费。 ﯽﺳرﺎﻓ (Farsi) ﮫﺟوﺗ : رﮔاﮏﻣﮐ دﻧﻣزﺎﯾﻧ دوﺧ نﺎﺑز ﮫﺑدﯾﺗﺳھﺎﺑ ، هرﺎﻣﺷ ﺎﯾ دوﺧ تﺎﻣدﺧ هدﻧﻧﮐ مھارﻓ 1-800-491-9099 (TTY: 711) ACBHD ACCESS دﯾرﯾﮕﺑ سﺎﻣﺗ .ﮏﻣﮐﮫﺧﺳﻧ دﻧﻧﺎﻣ ،تﯾﻟوﻠﻌﻣ یاراد دارﻓا صوﺻﺧﻣ تﺎﻣدﺧ و ﺎھ و لﯾرﺑ طﺧ یﺎھ Page 3 گرزﺑ فورﺣ ﺎﺑ پﺎﭼ سﺎﻣﺗ ﻖﯾرط زا زﯾﻧﺎﺑ هرﺎﻣﺷ ﺎﯾ دوﺧ تﺎﻣدﺧ هدﻧﻧﮐ مھارﻓ 1-800-491-9099 (TTY: 711) ACBHD ACCESS تﺳا دوﺟوﻣ .ﯽﻣ ﮫﺋارا نﺎﮕﯾار تﺎﻣدﺧ نﯾادﻧوﺷ . �हंद� (Hindi) ध्यान दें: अगर आपको अपनी भाषा में सहायता क� आवश्यकता है तो 1-800-491-9099 (TTY: 711) पर कॉल करें। अगर आपको दृिष्ट बा�धत लोगों के �लए सहायता और सेवाएँ, जैसे ब्रेल �ल�प में और बड़े �प्रंट में दस्तावेज़ चा�हए तो अपने सेवा प्रदाता से संपकर् करें या ACBHD ACCESS को 1-800-491-9099 (TTY: 711) पर कॉल करें। ये सेवाएँ �नःशुल्क हैं। Hmoob (Hmong) CEEB TOOM: Yog koj xav tau kev pab txhais ua koj hom lus, tiv tauj rau koj tus kws muab kev pab cuam los sis hu rau ACBHD ACCESS ntawm 1-800-491-9099 (TTY: 711). Muaj cov kev pab txhawb thiab kev pab cuam rau cov neeg xiam oob qhab, xws li puav leej muaj ua cov ntawv su rau neeg dig muag thiab luam tawm ua tus ntawv loj los ntawm kev tiv tauj rau koj tus kws muab kev pab cuam los sis hu rau ACBHD ACCESS ntawm 1-800-491-9099 (TTY: 711). Cov kev pab cuam no yog pab dawb xwb. 日本語 (Japanese) 注意日本語での対応が必要な場合は 1-800-491-9099 (TTY: 711)へお電話ください。点字の資料や文字の拡大表示など、障がいをお持ちの方のためのサービスも用意しています。 1-800-491-9099 (TTY: 711)へお電話ください。これらのサービスは無料で提供しています。 한국어 (Korean) 유의사항: 귀하의 언어로 도움을 받고 싶으시면 귀하의 서비스 제공자에게 문의하거나 ACBHD ACCESS에 1-800-491-9099 (TTY: 711) 번으로 문의하십시오. 점자나 큰 활자로 된 문서와 같이 장애가 있는 분들을 위한 도움과 서비스도 귀하의 서비스 제공자에게 연락하거나 ACBHD ACCESS에 1-800-491-9099 (TTY: 711) 번으로 연락하여 이용할 수 있습니다. 이러한 서비스는 무료로 제공됩니다. Page 4 ພາສາລາວ (Laotian) ປະກາດ: ຖ້າທ່ານຕ້ອງການຄວາມຊ່ວຍເຫຼືອເປັນພາສາຂອງທ່ານ ໃຫ້ໂທຫາຜູ້ໃຫ້ບໍລິການຂອງທ່ານ ຫຼື ໂທຫາ ACBHD ACCESS ທີ່ເບີ 1-800-491-9099 (TTY: 711). ຍັງມີຄວາມຊ່ວຍເຫຼືອ ແລະ ການບໍລິການສໍາລັບຄົນພິການ ເຊັ່ນເອກະສານທີ່ເປັນອັກສອນນູນ ແລະ ໂຕພິມໃຫຍ່ ໂດຍໃຫ້ຕິດຕໍ່ຫາ ໂທຫາຜູ້ໃຫ້ບໍລິການຂອງທ່ານ ຫຼື ໂທຫາ ACBHD ACCESS ທີ່ເບີ 1-800-491-9099] (TTY: 711). ການບໍລິການເຫຼົ່ານີ້ບໍ່ຕ້ອງເສຍຄ່າໃຊ້ຈ່າຍໃດໆ. Mien LONGC HNYOUV JANGX LONGX OC: Beiv taux meih qiemx longc mienh tengx faan benx meih nyei waac nor douc waac daaih lorx ACBHD ACCESS 1-800-491-9099 (TTY: 711). Liouh lorx jauv-louc tengx aengx caux nzie gong-bunx aengx caux ninh mbuo wuaaic mienh, beiv taux longc benx nzangc-pokc bun hluo mbiutc aamz caux benx domh sou se mbenc nzoih bun longc. Douc waac daaih lorx ACBHD ACCESS 1-800-491-9099 (TTY: 711). Naaiv nzie weih jauv-louc se benx wang-henh tengx mv zuqc cuotv nyaanh oc. ਪੰਜਾਬੀ (Punjabi) ਿਧਆਨ ਿਦਓ: ਜੇ ਤੁਹਾਨੂੰ ਆਪਣੀ ਭਾਸ਼ਾ ਿਵੱਚ ਮਦਦ ਦੀ ਲੋੜ ਹੈ ਤਾਂ ਆਪਣੇ ਸੇਵਾ ਪ�ਦਾਤਾ ਨਾਲ ਸੰਪਰਕ ਕਰੋ ਜਾਂ ACBHD ACCESS ਨੂੰ 1-800-491-9099 (TTY: 711) ਤੇ ਕਾਲ ਕਰੋ। ਅਪਾਹਜ ਲੋਕਾਂ ਲਈ ਸਹਾਇਤਾ ਅਤੇ ਸੇਵਾਵਾਂ, ਿਜਵੇਂ ਿਕ ਬ�ੇਲ ਅਤੇ ਮੋਟੀ ਛਪਾਈ ਿਵੱਚ ਦਸਤਾਵੇਜ਼, ਤੁਹਾਡੇ ਸੇਵਾ ਪ�ਦਾਤਾ ਨਾਲ ਸੰਪਰਕ ਕਰਕੇ ਜਾਂ ACBHD ACCESS ਨੂੰ 1-800-491-9099 (TTY: 711) 'ਤੇ ਕਾਲ ਕਰਕੇ ਵੀ ਪ�ਾਪਤ ਕੀਤੇ ਜਾ ਸਕਦੇ ਹਨ। ਇਹ ਸੇਵਾਵਾਂ ਮੁਫ਼ਤ ਹਨ| Русский (Russian) ВНИМАНИЕ! Если вам нужна помощь на вашем языке, обратитесь к поставщику услуг или позвоните в ACBHD ACCESS по телефону 1-800-491-9099 (TTY: 711). Помощь и услуги для людей с ограниченными возможностями, например документы, напечатанные шрифтом Брайля или крупным шрифтом, также можно получить, обратившись к поставщику услуг или позвонив в ACBHD ACCESS по телефону 1-800- 491-9099 (TTY: 711). Эти услуги предоставляются бесплатно. Español (Spanish) ATENCIÓN: Si necesita ayuda en su idioma, comuníquese con su proveedor de servicios o llame a ACBHD ACCESS al 1-800-491-9099 (TTY: 711). Las ayudas y servicios para personas con discapacidades, como documentos en braille y letra grande, también están disponibles comunicándose con su proveedor de servicios o llamando a ACBHD ACCESS al 1-800-491-9099 (TTY: 711). Estos servicios son gratuitos. Page 5 Tagalog (Filipino) ATENSIYON: Kung kailangan mo ng tulong sa iyong wika, makipag-ugnayan sa iyong tagapagbigay ng serbisyo o tumawag sa ACBHD ACCESS sa 1-800-491-9099 (TTY: 711). Makukuha rin ang mga tulong at serbisyo para sa mga taong may kapansanan, tulad ng mga dokumento sa braille at malaking print sa pamamagitan ng pakikipag-ugnayan sa iyong tagpagbigay ng serbisyo o pagtawag sa ACBHD ACCESS sa 1-800-491-9099 (TTY: 711). Libre ang mga serbisyong ito. ภาษาไทย (Thai) โปรดทราบ: หากคุณต้องการความช่วยเหลือเป็ นภาษาของคุณ กรุณาติดต่อผู้ให้บริการของคุณหรือติดต่อ ACBHD ACCESS ที่หมายเลข 1-800-491-9099 (TTY: 711) นอกจากนี้ยังพร ้อมให้ความช่วยเหลือและบริการต่าง ๆ สําหรับบุคคลที่มีความพิการด้วย เช่น เอกสารต่าง ๆ ที่เป็ นอักษรเบรลล ์และเอกสารที่พิมพ์ด้วยตัวอักษรขนาดใหญ่ โดยติดต่อผู้ให้บริการของคุณหรือติดต่อ ACBHD ACCESS ที่หมายเลข 1-800-491-9099 (TTY: 711) ไม่มีค่าใช ้จ่ายสําหรับบริการเหล่านี้ Українська (Ukrainian) УВАГА! Якщо вам потрібна допомога вашою мовою, зверніться до постачальника послуг або зателефонуйте до ACBHD ACCESS за номером 1-800-491-9099 (TTY: 711). Допоміжні засоби та послуги для людей з обмеженими можливостями, наприклад, документи, надруковані шрифтом Брайля або великим шрифтом, також можна отримати, звернувшись до свого постачальника послуг або зателефонувавши до ACBHD ACCESS за номером 1-800-491-9099 (TTY: 711). Ці послуги є безкоштовними. Tiếng Việt (Vietnamese) CHÚ Ý: Nếu quý vị cần trợ giúp bằng ngôn ngữ của mình, vui lòng liên hệ với nhà cung cấp dịch vụ của quý vị hoặc gọi cho ACBHD ACCESS theo số 1-800-491-9099 (TTY: 711). Khi liên hệ với nhà cung cấp dịch vụ của quý vị hoặc gọi cho ACBHD ACCESS theo số 1-800- 491-9099 (TTY: 711), quý vị cũng sẽ được hỗ trợ và nhận dịch vụ dành cho người khuyết tật, như tài liệu bằng chữ nổi Braille và chữ in khổ lớn. Các dịch vụ này đều miễn phí. Page 6 TABLE OF CONTENTS OTHER LANGUAGES AND FORMATS ............................................................................... 7 COUNTY CONTACT INFORMATION ................................................................................. 9 PURPOSE OF THIS HANDBOOK .................................................................................... 11 BEHAVIORAL HEALTH SERVICES INFORMATION ......................................................... 12 ACCESSING BEHAVIORAL HEALTH SERVICES ............................................................. 15 SELECTING A PROVIDER ............................................................................................... 23 YOUR RIGHT TO ACCESS BEHAVIORAL HEALTH RECORDS AND PROVIDER DIRECTORY INFORMATION USING SMART DEVICES ........................................................................ 26 SCOPE OF SERVICES .................................................................................................... 27 AVAILABLE SERVICES BY TELEPHONE OR TELEHEALTH .............................................. 51 THE PROBLEM RESOLUTION PROCESS: TO FILE A GRIEVANCE, APPEAL, OR REQUEST A STATE FAIR HEARING .................................................................................................... 52 ADVANCE DIRECTIVE .................................................................................................... 64 RIGHTS AND RESPONSIBILITIES ................................................................................... 65 NONDISCRIMINATION NOTICE ..................................................................................... 76 NOTICE OF PRIVACY PRACTICES ................................................................................. 79 WORDS TO KNOW ........................................................................................................ 86 ADDITIONAL INFORMATION FROM YOUR COUNTY ...................................................... 96 Page 7 OTHER LANGUAGES AND FORMATS Other languages If you need help in your language call 1-800-491-9099 (TTY: 711). Aids and services for people with disabilities, like documents in braille and large print, are also available. Call 1-800-491-9099 (TTY: 711). These services are free of charge. Other formats You can get this information in other formats, such as braille, 20-point font large print, audio, and accessible electronic formats at no cost to you. Call the county telephone number listed on the cover of this handbook (TTY: 711). The call is toll free. Interpreter Services The county provides oral interpretation services from a qualified interpreter, on a 24-hour basis, at no cost to you. You do not have to use a family member or friend as an interpreter. We discourage the use of minors as interpreters, unless it is an emergency. The county can also provide Page 8 auxiliary aids and services to a family member, friend, or anyone else with who it is appropriate to communicate with on your behalf. Interpreter, linguistic and cultural services are available at no cost to you. Help is available 24 hours a day, 7 days a week. For language help or to get this handbook in a different language, call the county telephone number listed on the cover of this handbook (TTY: 711). The call is toll free. Page 9 COUNTY CONTACT INFORMATION We are here to help. The following county contact information will help you get the services you need. IMPORTANT TELEPHONE NUMBERS Emergency 911 24/7 Helpline for Substance Use Disorder Services (844) 682-7215 (TTY: 711) 24/7 ACCESS Program for Mental Health Services (510) 346-1000 or (800) 491-9099 (TTY: 711) Public Website https://www.acbhcs.org/ Provider Directory https://acbh.my.site.com/Prov iderDirectory/s/ Digital Access to Health Information https://www.acbhcs.org/plan- administration/health- records-request-digital-copy/ Request for Copy of Health Records https://www.acbhcs.org/plan- administration/health- records-request-hard-copy/ Consumer Grievance and Appeal Line (800) 779-0787 Patient Rights Advocates (510) 835-2505 Page 10 Who Do I Contact If I’m Having Suicidal Thoughts? If you or someone you know is in crisis, please call the 988 Suicide and Crisis Lifeline at 988 or the National Suicide Prevention Lifeline at 1-800-273-TALK (8255). Chat is available at https://988lifeline.org/. To access your local programs, please call the 24/7 Access Line listed previous page. Page 11 PURPOSE OF THIS HANDBOOK Why is it important to read this handbook? Your county has a mental health plan that offers mental health services known as “specialty mental health services”. Additionally, your county has a Drug Medi-Cal Organized Delivery System that provides services for alcohol or drug use, known as “substance use disorder services”. Together these services are known as ”behavioral health services”, and it is important that you have information about these services so that you can get the care you need. This handbook explains your benefits and how to get care. It will also answer many of your questions. You will learn: • How to receive behavioral health services through your county. • What benefits you can access. • What to do if you have a question or problem. • Your rights and responsibilities as a member of your county. • If there is additional information about your county, which may be indicated at the end of this handbook. If you do not read this handbook now, you should hold on to it so you can read it later. This book is meant to be used along with the book you got when you signed up for your Medi- Cal benefits. If you have any questions about your Medi-Cal benefits, call the county using the phone number on the front of this book. Where Can I Go for More Information About Medi-Cal? Visit the Department of Health Care Services website at https://www.dhcs.ca.gov/services/medi-cal/eligibility/Pages/Beneficiaries.aspx for more information about Medi-Cal. Page 12 BEHAVIORAL HEALTH SERVICES INFORMATION How to Tell if You or Someone You Know Needs Help? Many people go through hard times in life and may experience mental health or substance use conditions. The most important thing to remember is that help is available. If you or your family member are qualified for Medi-Cal and need behavioral health services, you should call the 24/7 Access Line listed on the cover of this handbook. Your managed care plan can also help you contact your county if they believe you or a family member need behavioral health services that the managed care plan does not cover. Your county will help you find a provider for the services you may need. The list below can help you decide if you or a family member needs help. If more than one sign is present or happens for a long time, it may be a sign of a more serious problem that requires professional help. Here are some common signs you might need help with a mental health condition or substance use condition: Thoughts and Feelings • Strong mood changes, possibly with no reason, such as: o Too much worry, anxiety, or fear o Too sad or low o Too good, on top of the world o Moody or angry for too long • Thinking about suicide • Focusing only on getting and using alcohol or drugs • Problems with focus, memory or logical thought and speech that are hard to explain • Problems with hearing, seeing, or sensing things that are hard to explain or that most people say don’t exist Physical • Many physical problems, possibly without obvious causes, such as: Page 13 o Headaches o Stomach aches o Sleeping too much or too little o Eating too much or too little o Unable to speak clearly • Decline in looks or strong concern with looks, such as: o Sudden weight loss or gain o Red eyes and unusually large pupils o Odd smells on breath, body, or clothing Behavioral • Having consequences from your behavior because of changes to your mental health or using alcohol or drugs, such as: o Having issues at work or school o Problems in relationships with other people, family, or friends o Forgetting your commitments o Not able to carry out usual daily activities • Avoiding friends, family, or social activities • Having secretive behavior or secret need for money • Becoming involved with the legal system because of changes to your mental health or using alcohol or drugs Members Under the Age of 21 How Do I Know when a Child or Person Under the Age of 21 Needs Help? You may contact your county or managed care plan for a screening and assessment for your child or teenager if you think they are showing signs of a behavioral health condition. If your child or teenager qualifies for Medi-Cal and the screening or assessment shows that behavioral health services are needed, then the county will arrange for your child or teenager to receive behavioral health services. Your managed care plan can also help you Page 14 contact your county if they believe your child or teenager needs behavioral health services that the managed care plan does not cover. There are also services available for parents who feel stressed by being a parent. Minors 12 years of age or older, may not need parental consent to receive outpatient mental health treatment or counseling if the attending professional person believes the minor is mature enough to participate in the behavioral health services. Minors 12 years of age or older, may not need parental consent to receive medical care and counseling to treat a substance use disorder related problem. Parental or guardian involvement is required unless the attending professional person determines that their involvement would be inappropriate after consulting with the minor. The list below can help you decide if your child or teenager needs help. If more than one sign is present or persists for a long time, it may be that your child or teenager has a more serious problem that requires professional help. Here are some signs to look out for: • A lot of trouble paying attention or staying still, putting them in physical danger or causing school problems • Strong worries or fears that get in the way of daily activities • Sudden huge fear without reason, sometimes with racing heart rate or fast breathing • Feels very sad or stays away from others for two or more weeks, causing problems with daily activities • Strong mood swings that cause problems in relationships • Big changes in behavior • Not eating, throwing up, or using medicine to cause weight loss • Repeated use of alcohol or drugs • Severe, out-of-control behavior that can hurt self or others • Serious plans or tries to harm or kill self • Repeated fights, use of a weapon, or serious plan to hurt others Page 15 ACCESSING BEHAVIORAL HEALTH SERVICES How Do I Get Behavioral Health Services? If you think you need behavioral health services such as mental health services and/or substance use disorder services, you can call your county using the telephone number listed on the cover of this handbook. Once you contact the county, you will receive a screening and be scheduled for an appointment for an assessment. You can also request behavioral health services from your managed care plan if you are a member. If the managed care plan determines that you meet the access criteria for behavioral health services, the managed care plan will help you to get an assessment to receive behavioral health services through your county. Ultimately, there is no wrong door for getting behavioral health services. You may even be able to receive behavioral health services through your managed care plan in addition to behavioral health services through your county. You can access these services through your behavioral health provider if your provider determines that the services are clinically appropriate for you and as long as those services are coordinated and not duplicative. In addition, keep the following in mind: • You may be referred to your county for behavioral health services by another person or organization, including your general practitioner/doctor, school, a family member, guardian, your managed care plan, or other county agencies. Usually, your doctor or the managed care plan will need your consent or the permission of the parent or caregiver of a child, to make the referral directly to the county, unless there is an emergency. • Your county may not deny a request to do an initial assessment to determine whether you meet the criteria for receiving behavioral health services. • Behavioral health services can be provided by the county or other providers the county contracts with (such as clinics, treatment centers, community-based Page 16 organizations, or individual providers). Where Can I Get Behavioral Health Services? You can get behavioral health services in the county where you live, and outside of your county if necessary. Each county has behavioral health services for children, youth, adults, and older adults. If you are under 21 years of age, you are eligible for additional coverage and benefits under Early and Periodic Screening, Diagnostic, and Treatment. See the “Early and Periodic Screening, Diagnostic, and Treatment” section of this handbook for more information. Your county will help you find a provider who can get you the care you need. The county must refer you to the closest provider to your home, or within time or distance standards who will meet your needs. When Can I Get Behavioral Health Services? Your county has to meet appointment time standards when scheduling a service for you. For mental health services, the county must offer you an appointment: • Within 10 business days of your non-urgent request to start services with the mental health plan; • Within 48 hours if you request services for an urgent condition that does not require prior authorization; • Within 96 hours of an urgent condition that does require prior authorization; • Within 15 business days of your non-urgent request for an appointment with a psychiatrist; and, • Within 10 business days from the prior appointment for nonurgent follow up appointments for ongoing conditions. For substance use disorder services, the county must offer you an appointment: Page 17 • Within 10 business days of your non-urgent request to start services with a substance use disorder provider for outpatient and intensive outpatient services; • Within 48 hours if you request services for an urgent condition that does not require prior authorization; • Within 96 hours of an urgent condition that does require prior authorization; • Within 3 business days of your request for Narcotic Treatment Program services; • A follow-up non-urgent appointment within 10 days if you’re undergoing a course of treatment for an ongoing substance use disorder, except for certain cases identified by your treating provider. However, these times may be longer if your provider has determined that a longer waiting time is medically appropriate and not harmful to your health. If you have been told you have been placed on a waitlist and feel the length of time is harmful to your health, contact your county at the telephone number listed on the cover of this handbook. You have the right to file a grievance if you do not receive timely care. For more information about filing a grievance, see “The Grievance Process” section of this handbook. What Are Emergency Services? Emergency services are services for members experiencing an unexpected medical condition, including a psychiatric emergency medical condition. An emergency medical condition has symptoms so severe (possibly including severe pain) that an average person could reasonably expect the following might happen at any moment: • The health of the individual (or the health of an unborn child) could be in serious trouble • Causes serious harm to the way your body works • Causes serious damage to any body organ or part A psychiatric emergency medical condition occurs when an average person thinks that someone: Page 18 • Is a current danger to themselves or another person because of a mental health condition or suspected mental health condition. • Is immediately unable to provide for their needs, such as; food, clothing, shelter, personal safety, or access necessary medical care because of a mental health condition or suspected mental health condition and/or severe substance use disorder. Emergency services are covered 24 hours a day, seven days a week for Medi-Cal members. Prior authorization is not required for emergency services. The Medi-Cal program will cover emergency conditions, whether the condition is due to a physical health or mental health condition (thoughts, feelings, behaviors which are a source of distress and/or dysfunction in relation to oneself or others). If you are enrolled in Medi-Cal, you will not receive a bill to pay for going to the emergency room, even if it turns out to not be an emergency. If you think you are having an emergency, call 911 or go to any hospital or other setting for help. Who Decides Which Services I Will Receive? You, your provider, and the county are all involved in deciding what services you need to receive. A behavioral health professional will talk with you and will help determine what kind of services are needed. You do not need to know if you have a behavioral health diagnosis or a specific behavioral health condition to ask for help. You will be able to receive some services while your provider completes an assessment. If you are under the age of 21, you may also be able to access behavioral health services if you have a behavioral health condition due to trauma, involvement in the child welfare system, juvenile justice involvement, or homelessness. Additionally, if you are under age 21, the county must provide medically necessary services to help your behavioral health condition. Services that sustain, support, improve, or make more tolerable a behavioral health condition are considered medically necessary. Page 19 Some services may require prior authorization from the county. Services that require prior authorization include Intensive Home-Based Services, Day Treatment Intensive, Day Rehabilitation, Therapeutic Behavioral Services, Therapeutic Foster Care and Substance Use Disorder Residential Services. Call your county using the telephone number on the cover of this handbook to request additional information. The county’s authorization process must follow specific timelines. • For a standard substance use disorder authorization, the county must decide on your provider’s request within five (5) business days. o If you or your provider request, or if the county thinks it is in your interest to get more information from your provider, the timeline can be extended for up to another 14 calendar days. An example of when an extension might be in your interest is when the county thinks it might be able to approve your provider’s request for authorization if the county had additional information from your provider and would have to deny the request without the information. If the county extends the timeline, the county will send you a written notice about the extension. • For a standard prior mental health authorization, the county must decide based on your provider’s request as quickly as your condition requires, but not to exceed five (5) business days from when the county receives the request. o For example, if following the standard timeframe could seriously jeopardize your life, health, or ability to attain, maintain, or regain maximum function, your county must rush an authorization decision and provide notice based on a timeframe related to your health condition that is no later than 72 hours after receipt of the service request. Your county may extend the time for up to 14 additional calendar days after the county receives the request if you or your provider request the extension or the county provides justification for why the extension is in your best interest. Page 20 In both cases, if the county extends the timeline for the provider’s authorization request, the county will send you a written notice about the extension. If the county does not make a decision within the listed timelines or denies, delays, reduces, or terminates the services requested, the county must send you a Notice of Adverse Benefit Determination telling you that the services are denied, delayed, reduced or terminated, inform you that you may file an appeal, and give you information on how to file an appeal. You may ask the county for more information about its authorization processes. If you don’t agree with the county’s decision on an authorization process, you may file an appeal. For more information, see the "Problem Resolution” section of this handbook. What Is Medical Necessity? Services you receive must be medically necessary and clinically appropriate to address your condition. For members 21 years of age and older, a service is medically necessary when it is reasonable and necessary to protect your life, prevent significant illness or disability, or improve severe pain. For members under the age of 21, a service is considered medically necessary if it corrects, sustains, supports, improves, or makes more tolerable a behavioral health condition. Services that sustain, support, improve, or make more tolerable a behavioral health condition are considered medically necessary and covered as Early and Periodic Screening, Diagnostic, and Treatment services. How Do I Get Other Mental Health Services That Are Not Covered by the County? If you are enrolled in a managed care plan, you have access to the following outpatient mental health services through your managed care plan: • Mental health evaluation and treatment, including individual, group and family Page 21 therapy. • Psychological and neuropsychological testing, when clinically indicated to evaluate a mental health condition. • Outpatient services for purposes of monitoring prescription drugs. • Psychiatric consultation. To get one of the above services, call your managed care plan directly. If you are not in a managed care plan, you may be able to get these services from individual providers and clinics that accept Medi-Cal. The county may be able to help you find a provider or clinic. Any pharmacy that accepts Medi-Cal can fill prescriptions to treat a mental health condition. Please note that most prescription medication dispensed by a pharmacy, called Medi-Cal Rx, is covered under the Fee-For-Service Medi-Cal program, not your managed care plan. What Other Substance Use Disorder Services Are Available from Managed Care Plans or the Medi-Cal “Fee for Service” Program? Managed care plans must provide covered substance use disorder services in primary care settings and tobacco, alcohol, and illegal drug screening. They must also cover substance use disorder services for pregnant members and alcohol and drug use screening, assessment, brief interventions, and referral to the appropriate treatment setting for members ages 11 and older. Managed care plans must provide or arrange services for Medications for Addiction Treatment (also known as Medication Assisted Treatment) provided in primary care, inpatient hospital, emergency departments, and other contracted medical settings. Managed care plans must also provide emergency services necessary to stabilize the member, including voluntary inpatient detoxification. Page 22 How Do I Get Other Medi-Cal Services (Primary Care/Medi-Cal)? If you are in a managed care plan, the county is responsible for finding a provider for you. If you are not enrolled in a managed care plan and have "regular" Medi-Cal, also called Fee- For-Service Medi-Cal, then you can go to any provider that accepts Medi-Cal. You must tell your provider that you have Medi-Cal before you begin getting services. Otherwise, you may be billed for those services. You may use a provider outside your managed care plan for family planning services. Why Might I Need Psychiatric Inpatient Hospital Services? You may be admitted to a hospital if you have a mental health condition or signs of a mental health condition that can’t be safely treated at a lower level of care, and because of the mental health condition or symptoms of mental health condition, you: • Represent a danger to yourself, others, or property. • Are unable to care for yourself with food, clothing, shelter, personal safety, or necessary medical care. • Present a severe risk to your physical health. • Have a recent, significant deterioration in the ability to function as a result of a mental health condition. • Need psychiatric evaluation, medication treatment, or other treatment that can only be provided in the hospital. Page 23 SELECTING A PROVIDER How Do I Find a Provider For The Behavioral Health Services I Need? Your county is required to post a current provider directory online. You can find the provider directory link in the County Contact section of this handbook. The directory contains information about where providers are located, the services they provide, and other information to help you access care, including information about the cultural and language services that are available from the providers. If you have questions about current providers or would like an updated provider directory, visit your county’s website or use the telephone number located on the cover of this handbook. You can get a list of providers in writing or by mail if you ask for one. Note: The county may put some limits on your choice of providers for behavioral health services. When you first start receiving behavioral health service services you can request that your county provide you with an initial choice of at least two providers. Your county must also allow you to change providers. If you ask to change providers, the county must allow you to choose between at least two providers when possible. Your county is responsible for ensuring that you have timely access to care and that there are enough providers close to you to make sure that you can get covered behavioral health services if you need them. Sometimes the county’s contracted providers choose to no longer provide behavioral health services because they may no longer contract with the county, or no longer accept Medi-Cal. When this happens, the county must make a good faith effort to give written notice to each person who was receiving services from the provider. You are required to get a notice 30 calendar days prior to the effective date of the termination or 15 calendar days after the county knows the provider will stop working. When this happens, your county Page 24 must allow you to continue receiving services from the provider who left the county, if you and the provider agree. This is called “continuity of care” and is explained below. Note: American Indian and Alaska Native individuals who are eligible for Medi-Cal and reside in counties that have opted into the Drug Medi-Cal Organized Delivery System, can also receive Drug Medi-Cal Organized Delivery System services through Indian Health Care Providers. Can I Continue To Receive Specialty Mental Health Services From My Current Provider? If you are already receiving mental health services from a managed care plan, you may continue to receive care from that provider even if you receive mental health services from your mental health provider, as long as the services are coordinated between the providers and the services are not the same. In addition, if you are already receiving services from another mental health plan, managed care plan, or an individual Medi-Cal provider, you may request “continuity of care” so that you can stay with your current provider, for up to 12 months. You may wish to request continuity of care if you need to stay with your current provider to continue your ongoing treatment or because it would cause serious harm to your mental health condition to change to a new provider. Your continuity of care request may be granted if the following is true: • You have an ongoing relationship with the provider you are requesting and have seen that provider in the last 12 months; • You need to stay with your current provider to continue ongoing treatment to prevent serious detriment to the member's health or reduce the risk of hospitalization or institutionalization. • The provider is qualified and meets Medi-Cal requirements; • The provider agrees to the mental health plan’s requirements for contracting with Page 25 the mental health plan and payment for services; and • The provider shares relevant documentation with the county regarding your need for the services. Can I Continue To Receive Substance Use Disorder Services From My Current Provider? You may request to keep your out-of-network provider for a period of time if: • You have an ongoing relationship with the provider you are requesting and have seen that provider prior to the date of your transition to the Drug Medi-Cal Organized Delivery System county. • You need to stay with your current provider to continue ongoing treatment to prevent serious detriment to the member's health or reduce the risk of hospitalization or institutionalization. Page 26 YOUR RIGHT TO ACCESS BEHAVIORAL HEALTH RECORDS AND PROVIDER DIRECTORY INFORMATION USING SMART DEVICES You can access your behavioral health records and/or find a provider using an application downloaded on a computer, smart tablet, or mobile device. Your county may have information available on their website for you to consider before choosing an application to get your information in this way. For more information on the availability of your access, contact your county by referring to the “County Contact Information” section within this handbook. Page 27 SCOPE OF SERVICES If you meet the criteria for accessing behavioral health services, the following services are available to you based on your need. Your provider will work with you to decide which services will work best for you. Specialty Mental Health Services Mental Health Services • Mental health services are individual, group, or family-based treatment services that help people with mental health conditions to develop coping skills for daily living. These services also include work that the provider does to help make the services better for the person receiving care. These kinds of things include assessments to see if you need the service and if the service is working; treatment planning to decide the goals of your mental health treatment and the specific services that will be provided; and “collateral”, which means working with family members and important people in your life (if you give permission) to help you improve or maintain your daily living abilities. • Mental health services can be provided in a clinic or provider’s office, your home or other community setting, over the phone, or by telehealth (which includes both audio-only and video interactions). The county and provider will work with you to determine the frequency of your services/appointments. Medication Support Services • These services include prescribing, administering, dispensing, and monitoring of psychiatric medicines. Your provider can also provide education on the medication. These services can be provided in a clinic, the doctor’s office, your home, a community setting, over the phone, or by telehealth (which includes both audio-only and video interactions). Page 28 Targeted Case Management • This service helps members get medical, educational, social, prevocational, vocational, rehabilitative, or other community services when these services may be hard for people with a mental health condition to get on their own. Targeted case management includes, but is not limited to: o Plan development; o Communication, coordination, and referral; o Monitoring service delivery to ensure the person’s access to service and the service delivery system; and o Monitoring the person’s progress. Crisis Intervention Services • This service is available to address an urgent condition that needs immediate attention. The goal of crisis intervention is to help people in the community so that they won’t need to go to the hospital. Crisis intervention can last up to eight hours and can be provided in a clinic or provider’s office, or in your home or other community setting. These services can also be done over the phone or by telehealth. Crisis Stabilization Services • This service is available to address an urgent condition that needs immediate attention. Crisis stabilization lasts less than 24 hours and must be provided at a licensed 24-hour health care facility, at a hospital-based outpatient program, or at a provider site certified to provide these services. Adult Residential Treatment Services • These services provide mental health treatment to those with a mental health Page 29 condition living in licensed residential facilities. They help build skills for people and provide residential treatment services for people with a mental health condition. These services are available 24 hours a day, seven days a week. Medi- Cal does not cover the room and board cost for staying at these facilities. Crisis Residential Treatment Services • These services provide mental health treatment and skill building for people who have a serious mental or emotional crisis. This is not for people who need psychiatric care in a hospital. Services are available at licensed facilities for 24 hours a day, seven days a week. Medi-Cal does not cover the room and board cost for these facilities. Day Treatment Intensive Services • This is a structured program of mental health treatment provided to a group of people who might otherwise need to be in the hospital or another 24-hour care facility. The program lasts three hours a day. It includes therapy, psychotherapy and skill-building activities. Day Rehabilitation • This program is meant to help people with a mental health condition learn and develop coping and life skills to better manage their symptoms. This program lasts at least three hours per day. It includes therapy and skill-building activities. Psychiatric Inpatient Hospital Services • These are services provided in a licensed psychiatric hospital. A licensed mental health professional decides if a person needs intensive around-the-clock treatment for their mental health condition. If the professional decides the member needs around-the-clock treatment, the member must stay in the hospital 24 hours a day. Page 30 Psychiatric Health Facility Services • These services are offered at a licensed psychiatric health facility specializing in 24-hour rehabilitative treatment of serious mental health conditions. Psychiatric health facilities must have an agreement with a nearby hospital or clinic to meet the physical health care needs of the people in the facility. Psychiatric health facilities may only admit and treat patients who have no physical illness or injury that would require treatment beyond what ordinarily could be treated on an outpatient basis. Therapeutic Behavioral Services Therapeutic Behavioral Services are intensive short-term outpatient treatment interventions for members up to age 21. These services are designed specifically for each member. Members receiving these services have serious emotional disturbances, are experiencing a stressful change or life crisis, and need additional short-term, specific support services. These services are a type of specialty mental health service available through the county if you have serious emotional problems. To get Therapeutic Behavioral Services, you must receive a mental health service, be under the age of 21, and have full-scope Medi- Cal. • If you are living at home, a Therapeutic Behavioral Services staff person can work one-to-one with you to decrease severe behavior problems to try to keep you from needing to go to a higher level of care, such as a group home for children and young people under the age of 21 with very serious emotional problems. • If you are living in an out-of-home placement, a Therapeutic Behavioral Services staff person can work with you so you may be able to move back home or to a family-based setting, such as a foster home. Therapeutic Behavioral Services will help you and your family, caregiver, or guardian Page 31 learn new ways of addressing problem behavior and increasing the kinds of behavior that will allow you to be successful. You, the Therapeutic Behavioral Services staff person, and your family, caregiver, or guardian will work together as a team to address problematic behaviors for a short period until you no longer need the services. You will have a Therapeutic Behavioral Services plan that will say what you, your family, caregiver, or guardian, and the Therapeutic Behavioral Services staff person will do while receiving these services. The Therapeutic Behavioral Services plan will also include when and where services will occur. The Therapeutic Behavioral Services staff person can work with you in most places where you are likely to need help. This includes your home, foster home, school, day treatment program, and other areas in the community. Intensive Care Coordination This is a targeted case management service that facilitates the assessment, care planning for, and coordination of services to beneficiaries under age 21. This service is for those that are qualified for the full-scope of Medi-Cal services and who are referred to the service on basis of medical necessity. This service is provided through the principles of the Integrated Core Practice Model. It includes the establishment of the Child and Family Team to help make sure there is a healthy communicative relationship among a child, their family, and involved child-serving systems. The Child and Family Team includes professional support (for example: care coordinator, providers, and case managers from child-serving agencies), natural support (for example: family members, neighbors, friends, and clergy), and other people who work together to make and carry out the client plan. This team supports and ensures children and families reach their goals. This service also has a coordinator that: • Makes sure that medically necessary services are accessed, coordinated, and delivered in a strength-based, individualized, client-driven, culturally and Page 32 language appropriate manner. • Makes sure that services and support are based on needs of child. • Makes a way to have everyone work together for the child, family, providers, etc. • Supports parent/caregiver in helping meet child’s needs • Helps establish the Child and Family Team and provides ongoing support. • Makes sure the child is cared for by other child-serving systems when needed. Intensive Home-Based Services • These services are designed specifically for each member. It includes strength- based interventions to improve mental health conditions that may interfere with the child/youth’s functioning. These services aim to help the child/youth build necessary skills to function better at home and in the community and improve their family’s ability to help them do so. • Intensive Home-Based Services are provided under the Integrated Core Practice Model by the Child and Family Team. It uses the family’s overall service plan. These services are provided to members under the age of 21 who are eligible for full-scope Medi-Cal services. A referral based on medical necessity is needed to receive these services. Therapeutic Foster Care • The Therapeutic Foster Care service model provides short-term, intensive, and trauma-informed specialty mental health services for children up to the age of 21 who have complex emotional and behavioral needs. These services are designed specifically for each member. In Therapeutic Foster Care, children are placed with trained, supervised, and supported Therapeutic Foster Care parents. Parent-Child Interaction Therapy (PCIT) • PCIT is a program that helps children ages 2-7 who have difficult behaviors and Page 33 helps their parents or caregivers learn new ways to handle them. These behaviors might include getting angry or not following rules. • Through PCIT, a parent or caregiver wears a headset while playing with their child in a special playroom. A therapist watches from another room or on video and gives advice to the parent or caregiver through the headset. The therapist helps the parent or caregiver learn how to encourage healthy behavior and improve their relationship with their child. Functional Family Therapy (FFT) • FFT is a short and focused counseling program for families and youth ages 11-18 who have difficult behaviors or trouble dealing with their emotions. This could include breaking rules, fighting, or using drugs. • FFT works with a youth’s family and sometimes other members of the youth’s support system like teachers or doctors to help reduce the youth’s unhealthy behavior. Multisystemic Therapy (MST) • MST is a family-based program for youth ages 12-17 who show serious difficulty with behavior. MST is often used for youth who have had trouble with the law or might be at risk of becoming involved with the law, or at risk of becoming removed from their home because of their behavior. • MST involves family and community supports in therapy to help youth work on behaviors such as breaking the law or using drugs. MST also helps parents learn skills to help them handle these behaviors at home, with their peers, or in other community settings. • Through MST, parents and caregivers can learn how to handle challenges with their kids or teenagers. They will also learn to better deal with issues at home, Page 34 with friends, or in their neighborhood. The program respects different cultures and focuses on helping families in their own homes and communities. It also works with schools, the police, and the courts. • How often families meet with the program can change. Some families might just need short check-ins, while others might meet for two hours every day or every week. This help usually lasts for 3 to 5 months. Justice-Involved Reentry • Providing health services to justice-involved members up to 90 days prior to their incarceration release. The types of services available include reentry case management, behavioral health clinical consultation services, peer supports, behavioral health counseling, therapy, patient education, medication services, post-release and discharge planning, laboratory and radiology services, medication information, support services, and assistance to enroll with the appropriate provider, for example a Narcotic Treatment Program to continue with Medication Assisted Treatment upon release. To receive these services, individuals must be a Medi-Cal or CHIP member, and: o If under the age of 21 in custody at a Youth Correctional Facility. o If an adult, be in custody and meet one of the health care needs of the program. • Contact your county using the telephone number on the cover of this handbook for more information on this service. Medi-Cal Peer Support Services (varies by county) • Medi-Cal Peer Support Services promote recovery, resiliency, engagement, socialization, self-sufficiency, self-advocacy, development of natural supports, and identification of strengths through structured activities. These services can be provided to you or your designated significant support person(s) and can be received at the same time as you receive other mental health or Drug Medi-Cal Page 35 Organized Delivery System services. The Peer Support Specialist in Medi-Cal Peer Support Services is an individual who has lived experience with behavioral health or substance use conditions and is in recovery, who has completed the requirements of a county’s State-approved certification program, who is certified by the county, and who provides these services under the direction of a Behavioral Health Professional who is licensed, waivered, or registered with the State. • Medi-Cal Peer Support Services include individual and group coaching, educational skill-building groups, resource navigation, engagement services to encourage you to participate in behavioral health treatment, and therapeutic activities such as promoting self-advocacy. • Members under age 21 may be eligible for the service under Early and Periodic Screening, Diagnostic, and Treatment regardless of which county they live in. • Providing Medi-Cal Peer Support Services is optional for participating counties. Refer to the “Additional Information About Your County” section located at the end of this handbook to find out if your county provides this service. Mobile Crisis Services • Mobile Crisis Services are available if you are having a mental health crisis. • Mobile Crisis Services are provided by health providers at the location where you are experiencing a crisis, including at your home, work, school, or other community locations, excluding a hospital or other facility setting. Mobile Crisis Services are available 24 hours a day, 7 days a week, and 365 days a year. • Mobile Crisis Services include rapid response, individual assessment, and community-based stabilization. If you need further care, the mobile crisis providers will also provide warm handoffs or referrals to other services. Assertive Community Treatment (ACT) (varies by county) • ACT is a service that helps people with serious mental health needs. People who Page 36 need ACT have typically been to the hospital, visited the emergency room, stayed in treatment centers and/or had trouble with the law. They might also have been homeless or not able to get help from regular clinics. • ACT tailors services to each person and their own needs. The goal is to help people feel better and learn how to live in their community. A team of different experts works together to provide all kinds of support and treatment. This team helps people with their mental health, teaches them important life skills, coordinates their care, and offers support in the community. The overall aim is to help each person recover from their behavioral health condition and live a better life within their community. • Providing ACT is optional for participating counties. Refer to the “Additional Information About Your County” section located at the end of this handbook to find out if your county provides this service. Forensic Assertive Community Treatment (FACT) (varies by county) • FACT is a service that helps people with serious mental health needs who have also had trouble with the law. It works just like the ACT program, but with some extra features to help people who are at high risk or have been previously involved with the criminal justice system. • The FACT team is made up of experts who have special training to understand the needs of people who have had trouble with the law. They provide the same types of support and treatment as ACT, like helping with behavioral health, teaching life skills, coordinating care, and offering community support. • The goal is to help each person feel better, stay out of trouble, and live a healthier life in their community. • Providing FACT is optional for participating counties. Refer to the “Additional Information About Your County” section located at the end of this handbook to find out if your county provides this service. Page 37 Coordinated Specialty Care (CSC) for First Episode Psychosis (FEP) (varies by county) • CSC is a service that helps people who are experiencing psychosis for the first time. There are many symptoms of psychosis, including seeing or hearing things that other people do not see or hear. CSC provides quick and combined support during the early stages of psychosis, which helps prevent hospital stays, emergency room visits, time in treatment centers, trouble with the law, substance use, and homelessness. • CSC focuses on each person and their own needs. A team of different experts works together to provide all kinds of help. They assist with mental health treatment, teach important life skills, coordinate care, and offer support in the community. The goal is to help people feel better, manage their symptoms, and live well in their community. • Providing CSC for FEP is optional for participating counties. Refer to the “Additional Information About Your County” section located at the end of this handbook to find out if your county provides this service. Clubhouse Services (varies by county) • Clubhouses are special places that help people recover from behavioral health conditions. They focus on people's strengths and create a supportive community. • In a Clubhouse, people can find jobs, make friends, learn new things, and develop skills to improve their health and well-being. People also work alongside Clubhouse staff to contribute to shared Clubhouse needs, like making lunch for other Clubhouse members. The goal is to help everyone be members of a community, encourage others to achieve their goals, and improve their overall quality of life. • Providing Clubhouse Services is optional for participating counties. Refer to the “Additional Information About Your County” section located at the end of this handbook to find out if your county provides this service. Page 38 Enhanced Community Health Worker (CHW) Services (varies by county) • CHWs are health workers who have special training and are trusted members of their communities. • The goal of Enhanced CHW Services is to help stop diseases, disabilities, and other health problems before they get worse. Enhanced CHW Services include all the same parts and rules as regular CHW preventive services, but they are tailored for people who need extra behavioral health support. The goal is to give extra support to keep these members healthy and well. • Some of these services include: health education and training, including control and prevention of chronic or infectious disease; behavioral, perinatal, and oral health conditions; and injury prevention; health promotion and coaching, including goal setting and creating action plans to address disease prevention and management. • Providing Enhanced CHW Services is optional for participating counties. Refer to the “Additional Information About Your County” section located at the end of this handbook to find out if your county provides this service. Supported Employment (varies by county) • The Individual Placement and Support (IPS) model of Supported Employment is a service that helps people with serious behavioral health needs find and keep competitive jobs in their community. • By participating in IPS Supported Employment, people can get better job outcomes and support their recovery from their behavioral health condition. • This program also helps improve independence, a sense of belonging, and overall health and well-being. • Providing Supported Employment is optional for participating counties. Refer to the “Additional Information About Your County” section located at the end of this Page 39 handbook to find out if your county provides this service. In-Reach Services (varies by county) • Community Transition In-Reach Services help people who are in a psychiatric hospital or facility for a long time or are at risk of staying there for a long time. The program works with you, your family, the hospital or facility, and other support people to help you move back into the community. The goal is to help you avoid long stays in the psychiatric hospital or other care centers. Substance Use Disorder Services What are Drug Medi-Cal Organized Delivery System County Services? Drug Medi-Cal Organized Delivery System county services are for people who have a substance use condition, meaning they may be misusing alcohol or other drugs, or people who may be at risk of developing a substance use condition that a pediatrician or general practitioner may not be able to treat. These services also include work that the provider does to help make the services better for the person receiving care. These kinds of things include assessments to see if you need the service and if the service is working. Drug Medi-Cal Organized Delivery System services can be provided in a clinic or provider’s office, or your home or other community setting, over the phone, or by telehealth (which includes both audio-only and video interactions). The county and provider will work with you to determine the frequency of your services/appointments. American Society of Addiction Medicine (ASAM) The county or provider will use the American Society of Addiction Medicine tool to find the appropriate level of care. These types of services are described as “levels of care,” and are defined below. Page 40 Screening, Assessment, Brief Intervention, and Referral to Treatment (American Society of Addiction Medicine Level 0.5) Alcohol and Drug Screening, Assessment, Brief Interventions, and Referral to Treatment (SABIRT) is not a Drug Medi-Cal Organized Delivery System benefit. It is a benefit in Medi- Cal Fee-for-Service and Medi-Cal managed care delivery system for members that are aged 11 years and older. Managed care plans must provide covered substance use disorder services, including this service for members ages 11 years and older. Early Intervention Services Early intervention services are a covered Drug Medi-Cal Organized Delivery System service for members under age 21. Any member under age 21 who is screened and determined to be at risk of developing a substance use disorder may receive any service covered under the outpatient level of service as early intervention services. A substance use disorder diagnosis is not required for early intervention services for members under age 21. Early Periodic Screening, Diagnosis, and Treatment Members under age 21 can get the services described earlier in this handbook as well as additional Medi-Cal services through a benefit called Early and Periodic Screening, Diagnostic, and Treatment. To be able to get Early and Periodic Screening, Diagnostic, and Treatment services, a member must be under age 21 and have full-scope Medi-Cal. This benefit covers services that are medically necessary to correct or help physical and behavioral health conditions. Services that sustain, support, improve, or make a condition more tolerable are considered to help the condition and are covered as Early and Periodic Screening, Diagnostic, and Treatment services. The access criteria for members under 21 are different and more flexible than the access criteria for adults accessing Drug Medi-Cal Page 41 Organized Delivery System services, to meet the Early and Periodic Screening, Diagnostic, and Treatment requirement and the intent for prevention and early intervention of substance use disorder conditions. If you have questions about these services, please call your county or visit the DHCS Early and Periodic Screening, Diagnostic, and Treatment webpage. Outpatient Treatment Services (American Society of Addiction Medicine Level 1) • Counseling services are provided to members up to nine hours a week for adults and less than six hours a week for members under age 21 when medically necessary. You might get more hours based on your needs. Services can be provided by someone licensed, like a counselor, in person, by telephone, or by telehealth. • Outpatient Services include assessment, care coordination, counseling (individual and group), family therapy, medication services, Medications for Addiction Treatment for opioid use disorder, Medications for Addiction Treatment for alcohol use disorder and other non-opioid substance use disorders, patient education, recovery services, and substance use disorder crisis intervention services. Intensive Outpatient Services (American Society of Addiction Medicine Level 2.1) • Intensive Outpatient Services are given to members a minimum of nine hours with a maximum of 19 hours a week for adults, and a minimum of six hours with a maximum of 19 hours a week for members under age 21 when medically necessary. Services may exceed the maximum based on individual medical necessity. Services are mostly counseling and education about addiction-related issues. Services can be provided by a licensed professional or a certified counselor in a structured setting. Intensive Outpatient Treatment Services may be provided in person, by telehealth, or by telephone. • Intensive Outpatient Services include the same things as Outpatient Services. Page 42 More hours of service is the main difference. Partial Hospitalization (varies by county) (American Society of Addiction Medicine Level 2.5) • Members under age 21 may get this service under Early and Periodic Screening, Diagnostic, and Treatment regardless of the county where they live. • Partial Hospitalization services include 20 or more hours of services per week, as medically necessary. Partial hospitalization programs have direct access to psychiatric, medical, and laboratory services and meet the identified needs which warrant daily monitoring or management but can be appropriately addressed in a clinic. Services may be provided in person, by telehealth, or by telephone. • Partial Hospitalization services are similar to Intensive Outpatient Services, with an increase in the number of hours and additional access to medical services being the main differences. Residential Treatment (subject to authorization by the county) (American Society of Addiction Medicine Levels 3.1 – 4.0) • Residential Treatment is a program that provides rehabilitation services to members with a substance use disorder diagnosis, when determined as medically necessary. The member shall live on the property and be supported in their efforts to change, maintain, apply interpersonal and independent living skills by accessing community support systems. Most services are provided in person; however, telehealth and telephone may also be used to provide services while a person is in residential treatment. Providers and residents work together to define barriers, set priorities, establish goals, and solve substance use disorder-related problems. Goals include not using substances, preparing for relapse triggers, improving personal health and social skills, and engaging in long-term care. • Residential services require prior authorization by the Drug Medi-Cal Organized Page 43 Delivery System county. • Residential Services include intake and assessment, care coordination, individual counseling, group counseling, family therapy, medication services, Medications for Addiction Treatment for opioid use disorder, Medications for Addiction Treatment for alcohol use disorder and other non-opioid substance use disorders, patient education, recovery services, and substance use disorder crisis intervention services. • Residential Services providers are required to either offer medications for addiction treatment directly on-site or help members get medications for addiction treatment off-site. Residential Services providers do not meet this requirement by only providing the contact information for Medications for Addiction Treatment providers. Residential Services providers are required to offer and prescribe medications to members covered under the Drug Medi-Cal Organized Delivery System. Inpatient Treatment Services (subject to authorization by the county) (varies by county) (American Society of Addiction Medicine Levels 3.1 – 4.0) • Beneficiaries under age 21 may be eligible for the service under Early and Periodic Screening, Diagnostic, and Treatment regardless of their county of residence. • Inpatient services are provided in a 24-hour setting that provides professionally directed evaluation, observation, medical monitoring, and addiction treatment in an inpatient setting. Most services are provided in person; however, telehealth and telephone may also be used to provide services while a person is in inpatient treatment. • Inpatient services are highly structured, and a physician is likely available on-site 24 hours daily, along with Registered Nurses, addiction counselors, and other clinical staff. Inpatient Services include assessment, care coordination, counseling, family therapy, medication services, Medications for Addiction Treatment for opioid use disorder, Medications for Addiction Treatment for Page 44 Alcohol use disorder and other non-opioid substance use disorders, patient education, recovery services, and substance use disorder crisis intervention services. Narcotic Treatment Program • Narcotic Treatment Programs are programs outside of a hospital that provide medications to treat substance use disorders, when ordered by a doctor as medically necessary. Narcotic Treatment Programs are required to give medications to members, including methadone, buprenorphine, naloxone, and disulfiram. • A member must be offered, at a minimum, 50 minutes of counseling sessions per calendar month. These counseling services can be provided in person, by telehealth, or by telephone. Narcotic Treatment Services include assessment, care coordination, counseling, family therapy, medical psychotherapy, medication services, care management, Medications for Addiction Treatment for opioid use disorder, Medications for Addiction Treatment for alcohol use disorder and other non-opioid substance use disorders, patient education, recovery services, and substance use disorder crisis intervention services. Withdrawal Management • Withdrawal management services are urgent and provided on a short-term basis. These services can be provided before a full evaluation has been done. Withdrawal management services may be provided in an outpatient, residential, or inpatient setting. • Regardless of the type of setting, the member shall be monitored during the withdrawal management process. Members receiving withdrawal management in a residential or inpatient setting shall live at that location. Medically necessary habilitative and rehabilitative services are prescribed by a licensed physician or licensed prescriber. Page 45 • Withdrawal Management Services include assessment, care coordination, medication services, Medications for Addiction Treatment for opioid use disorder, Medications for Addiction Treatment for alcohol use disorder and other non- opioid substance use disorders, observation, and recovery services. Medications for Addiction Treatment • Medications for Addiction Treatment Services are available in clinical and non- clinical settings. Medications for Addiction Treatment include all FDA-approved medications and biological products to treat alcohol use disorder, opioid use disorder, and any substance use disorder. Members have a right to be offered Medications for Addiction Treatment on-site or through a referral outside of the facility. A list of approved medications include: o Acamprosate Calcium o Buprenorphine Hydrochloride o Buprenorphine Extended-Release Injectable (Sublocade) o Buprenorphine/Naloxone Hydrochloride o Naloxone Hydrochloride o Naltrexone (oral) o Naltrexone Microsphere Injectable Suspension (Vivitrol) o Lofexidine Hydrochloride (Lucemyra) o Disulfiram (Antabuse) o Methadone (delivered only by Narcotic Treatment Programs) • Medications for Addiction Treatment may be provided with the following services: assessment, care coordination, individual counseling, group counseling, family therapy, medication services, patient education, recovery services, substance use disorder crisis intervention services, and withdrawal management services. Medications for Addiction Treatment may be provided as part of all Drug Medi-Cal Organized Delivery System services, including Outpatient Treatment Services, Intensive Outpatient Services, and Residential Treatment, for example. Page 46 • Members may access Medications for Addiction Treatment outside of the Drug Medi-Cal Organized Delivery System county as well. For instance, Medications for Addiction Treatment, such as buprenorphine, can be prescribed by some prescribers in primary care settings that work with your managed care plan and can be dispensed or administered at a pharmacy. Justice-Involved Reentry • Providing health services to justice-involved members up to 90 days prior to their incarceration release. The types of services available include reentry case management, behavioral health clinical consultation services, peer supports, behavioral health counseling, therapy, patient education, medication services, post-release and discharge planning, laboratory and radiology services, medication information, support services, and assistance to enroll with the appropriate provider, for example a Narcotic Treatment Program to continue with Medication Assisted Treatment upon release. To receive these services, individuals must be a Medi-Cal or CHIP member, and: o If under the age of 21 in custody at a Youth Correctional Facility. o If an adult, be in custody and meet one of the health care needs of the program. • Contact your county using the telephone number on the cover of this handbook for more information on this service. Medi-Cal Peer Support Services (varies by county) • Medi-Cal Peer Support Services promote recovery, resiliency, engagement, socialization, self-sufficiency, self-advocacy, development of natural supports, and identification of strengths through structured activities. These services can be provided to you or your designated significant support person(s) and can be received at the same time as you receive other mental health or Drug Medi-Cal Organized Delivery System services. The Peer Support Specialist in Medi-Cal Peer Page 47 Support Services is an individual who has lived experience with behavioral health or substance use conditions and is in recovery, who has completed the requirements of a county’s State-approved certification program, who is certified by the counties, and who provides these services under the direction of a Behavioral Health Professional who is licensed, waivered, or registered with the State. • Medi-Cal Peer Support Services include individual and group coaching, educational skill-building groups, resource navigation, engagement services to encourage you to participate in behavioral health treatment, and therapeutic activities such as promoting self-advocacy. • Members under age 21 may be eligible for the service under Early and Periodic Screening, Diagnostic, and Treatment regardless of which county they live in. • Providing Medi-Cal Peer Support Services is optional for participating counties. Refer to the “Additional Information About Your County” section located at the end of this handbook to find out if your county provides this service. Recovery Services • Recovery Services can be an important part of your recovery and wellness. Recovery services can help you get connected to the treatment community to manage your health and health care. Therefore, this service emphasizes your role in managing your health, using effective self-management support strategies, and organizing internal and community resources to provide ongoing self- management support. • You may receive Recovery Services based on your self-assessment or your provider’s assessment of risk of relapsing. You may also receive Recovery Services in person, by telehealth, or by telephone. • Recovery Services include assessment, care coordination, individual counseling, group counseling, family therapy, recovery monitoring, and relapse prevention components. Page 48 Care Coordination • Care Coordination Services consists of activities to provide coordination of substance use disorder care, mental health care, and medical care, and to provide connections to services and supports for your health. Care Coordination is provided with all services and can occur in clinical or non-clinical settings, including in your community. • Care Coordination Services include coordinating with medical and mental health providers to monitor and support health conditions, discharge planning, and coordinating with ancillary services including connecting you to community- based services such as childcare, transportation, and housing. Contingency Management (varies by county) • Members under age 21 may be eligible for the service under Early and Periodic Screening, Diagnostic, and Treatment regardless of their county of residence. • Providing Contingency Management Services is optional for participating counties. Refer to the “Additional Information About Your County” section located at the end of this handbook to find out if your county provides this service. • Contingency Management Services are an evidence-based treatment for stimulant use disorder where eligible members will participate in a structured 24 week outpatient Contingency Management service, followed by six or more months of additional treatment and recovery support services without incentives. • The initial 12 weeks of Contingency Management services include a series of incentives for meeting treatment goals, specifically not using stimulants (e.g., cocaine, amphetamine, and methamphetamine). Participants must agree to urine drug tests as often as determined by the Contingency Management services program. The incentives consist of cash equivalents (e.g., gift cards). • Contingency Management Services are only available to members who are receiving services in a non-residential setting operated by a participating provider Page 49 and are enrolled and participating in a comprehensive, individualized course of treatment. Mobile Crisis Services • Mobile Crisis Services are available if you are having a substance use crisis. • Mobile Crisis Services are provided by health providers at the location where you are experiencing a crisis, including at your home, work, school, or other community locations, excluding a hospital or other facility setting. Mobile Crisis Services are available 24 hours a day, 7 days a week, and 365 days a year. • Mobile Crisis Services include rapid response, individual assessment, and community-based stabilization. If you need further care, the mobile crisis providers will also provide warm handoffs or referrals to other services. Traditional Health Care Practices • Traditional health care practices are expected to improve access to culturally responsive care; support these facilities' ability to serve their patients; maintain and sustain health; improve health outcomes and the quality and experience of care; and reduce existing disparities in access to care. • Traditional health care practices encompass two new service types: Traditional Healer and Natural Helper services. Traditional Healer services include music therapy (such as traditional music and songs, dancing, drumming), spirituality (such as ceremonies, rituals, herbal remedies) and other integrative approaches. Natural Helper services may help with navigational support, psychosocial skill building, self-management, and trauma support. • Contact your county using the telephone number on the cover of this handbook for more information about this service. Enhanced Community Health Worker (CHW) Services (varies by county) • CHWs are health workers who have special training and are trusted members of Page 50 their communities. • The goal of Enhanced CHW Services is to help stop diseases, disabilities, and other health problems before they get worse. Enhanced CHW Services include all the same parts and rules as regular CHW preventive services, but they are tailored for people who need extra behavioral health support. The goal is to give extra support to keep these members healthy and well. • Some of these services include: health education and training, including control and prevention of chronic or infectious disease; behavioral, perinatal, and oral health conditions; and injury prevention; health promotion and coaching, including goal setting and creating action plans to address disease prevention and management. Providing Enhanced CHW Services is optional for participating counties. Refer to the “Additional Information About Your County” section located at the end of this handbook to find out if your county provides this service. Supported Employment (varies by county) • The Individual Placement and Support (IPS) model of Supported Employment is a service that helps people with serious behavioral health needs find and keep competitive jobs in their community. • By participating in IPS Supported Employment, people can get better job outcomes and support their recovery from their behavioral health condition. • This program also helps improve independence, a sense of belonging, and overall health and well-being. • Providing Supported Employment is optional for participating counties. Refer to the “Additional Information About Your County” section located at the end of this handbook to find out if your county provides this service Page 51 AVAILABLE SERVICES BY TELEPHONE OR TELEHEALTH In-person, face-to-face contact between you and your provider is not always required for you to be able to receive behavioral health services. Depending on your services, you might be able to receive your services through telephone or telehealth. Your provider should explain to you about using telephone or telehealth and make sure you agree before beginning services via telephone or telehealth. Even if you agree to receive your services through telehealth or telephone, you can choose later to receive your services in-person or face-to-face. Some types of behavioral health services cannot be provided only through telehealth or telephone because they require you to be at a specific place for the service, such as residential treatment services or hospital services. Page 52 THE PROBLEM RESOLUTION PROCESS: TO FILE A GRIEVANCE, APPEAL, OR REQUEST A STATE FAIR HEARING What If I Don’t Get the Services I Want From My County? Your county must have a way for you to work out any problems related to the services you want or are receiving. This is called the problem-resolution process and it could involve the following: • The Grievance Process: A verbal or written expression of unhappiness about anything regarding your specialty mental health services, substance use disorder services, a provider, or the county. Refer to the Grievance Process section in this handbook for more information. • The Appeal Process: An appeal is when you don’t agree with the county's decision to change your services (e.g., denial, termination, or reduction to services) or to not cover them. Refer to the Appeal Process section in this handbook for more information. • The State Fair Hearing Process: A State Fair Hearing is a meeting with an administrative law judge from the California Department of Social Services (CDSS) if the county denies your appeal. Refer to the State Fair Hearing section in this handbook for more information. Filing a grievance, appeal, or requesting a State Fair Hearing will not count against you and will not impact the services you are receiving. Filing a grievance or appeal helps to get you the services you need and to solve any problems you have with your behavioral health services. Grievances and appeals also help the county by giving them the information they can use to improve services. Your county will notify you, providers, and parents/guardians of the outcome once your grievance or appeal is complete. The State Fair Hearing Office will notify you and the provider of the outcome once the State Fair Hearing is complete. Note: Learn more about each problem resolution process below. Page 53 Can I Get Help With Filing an Appeal, Grievance, or State Fair Hearing? Your county will help explain these processes to you and must help you file a grievance, an appeal, or to request a State Fair Hearing. The county can also help you decide if you qualify for what’s called an “expedited appeal” process, which means it will be reviewed more quickly because your health, mental health, and/or stability are at risk. You may also authorize another person to act on your behalf, including your provider or advocate. If you would like help, contact your county using the telephone number listed on the cover of this handbook. Your county must give you reasonable assistance in completing forms and other procedural steps related to a grievance or appeal. This includes, but is not limited to, providing interpreter services and toll-free numbers with TTY/TDD and interpreter capability. If You Need Further Assistance Contact the Department of Health Care Services, Office of the Ombudsman: • Phone: # 1-888-452-8609, Monday through Friday, 8 a.m. to 5 p.m. (excluding holidays). OR • E-mail: MMCDOmbudsmanOffice@dhcs.ca.gov. Please note: E-mail messages are not considered confidential (please do not include personal information in the e- mail message). You may also get free legal help at your local legal aid office or other groups. To ask about your State Fair Hearing rights, you can contact the California Department of Social Services Public Inquiry and Response Unit at this phone number: 1-800-952-5253 (for TTY, call 1-800-952-8349). Page 54 Grievances What Is a Grievance? A grievance is any expression of dissatisfaction you have with your behavioral health services that is not covered by the appeal or State Fair Hearing process. This includes concerns about the quality of your care, how you are treated by staff and providers, and disagreements about decisions regarding your care. Examples of grievances: • If you feel that a provider has been rude to you or has not respected your rights. • If the county needs more time to make a decision about approving a service your provider has requested for you, and you disagree with this extension. • If you are not satisfied with the quality of care you are receiving or the way your treatment plan is being communicated to you. What Is the Grievance Process? The grievance process will: • Involve simple steps to file your grievance orally or in writing. • Not cause you to lose your rights or services or be held against your provider. • Allow you to approve another person to act on your behalf. This could be a provider or an advocate. If you agree to have another person act on your behalf, you may be asked to sign an authorization form, which gives your county permission to release information to that person. • Make sure the approved person deciding on the grievance is qualified to make decisions and has not been a part of any previous level of review or decision- making. • Determine the duties of your county, provider, and yourself. • Make sure the results of the grievance are provided within the required timeline. Page 55 When Can I File a Grievance? You can file a grievance at any time if you are unhappy with the care you have received or have another concern regarding your county. How Can I File a Grievance? You may call your county’s 24/7 toll-free Access Line at any time to receive assistance with a grievance. Oral or written grievances can be filed. Oral grievances do not have to be followed up in writing. If you file your grievance in writing, please note the following: Your county supplies self-addressed envelopes at all provider sites. If you do not have a self- addressed envelope, mail your written grievances to the address provided on the front of this handbook. How Do I Know If the County Received My Grievance? Your county is required to provide you with a written letter to let you know your grievance has been received within five calendar days of receipt. A grievance received over the phone or in person, that you agree is resolved by the end of the next business day, is exempt and you may not get a letter. When Will My Grievance Be Decided? A decision about your grievance must be made by your county within 30 calendar days from the date your grievance was filed. How Do I Know If the County Has Made a Decision About My Grievance? When a decision has been made about your grievance, the county will: • Send you or your approved person a written notice of the decision; • Send you or your approved person a Notice of Adverse Benefit Determination advising you of your right to request a State Fair Hearing if the county does not notify you of the grievance decision on time; • Advise you of your right to request a State Fair Hearing. Page 56 You may not get a written notice of the decision if your grievance was filed by phone or in person and you agree your issue has been resolved by the end of the next business day from the date of filing. Note: Your county is required to provide you with a Notice of Adverse Benefit Determination on the date the timeframe expires. You may call the county for more information if you do not receive a Notice of Adverse Benefit Determination. Is There a Deadline to File a Grievance? No, you may file a grievance at any time. Do not hesitate to bring issues to the county’s attention. The county will always work with you to find a solution to address your concerns. Appeals You may file an appeal when you do not agree with the county's decision for the behavioral health services you are currently receiving or would like to receive. You may request a review of the county’s decision by using: • The Standard Appeal Process. OR • The Expedited Appeal Process. Note: The two types of appeals are similar; however, there are specific requirements to qualify for an expedited appeal (see below for the requirements). The county shall assist you in completing forms and taking other procedural steps to file an appeal, including preparing a written appeal, notifying you of the location of the form on their website or providing you with the form upon your request. The county shall also advise and assist you in requesting continuation of benefits during an appeal of the adverse benefit determination in accordance with federal regulations. Page 57 What Does the Standard Appeal Process Do? The Standard Appeal Process will: • Allow you to file an appeal orally or in writing. • Make sure filing an appeal will not cause you to lose your rights or services or be held against your provider in any way. • Allow you to authorize another person (including a provider or advocate) to act on your behalf. Please note: If you authorize another person to act on your behalf, the county might ask you to sign a form authorizing the county to release information to that person. • Have your benefits continued upon request for an appeal within the required timeframe. Please note: This is 10 days from the date your Notice of Adverse Benefit Determination was mailed or personally given to you. • Make sure you do not pay for continued services while the appeal is pending and if the final decision of the appeal is in favor of the county’s adverse benefit determination. • Make sure the decision-makers for your appeal are qualified and not involved in any previous level of review or decision-making. • Allow you or your representative to review your case file, including medical records and other relevant documents. • Allow you to have a reasonable opportunity to present evidence, testimony, and arguments in person or in writing. • Allow you, your approved person, or the legal representative of a deceased member’s estate to be included as parties to the appeal. • Give you written confirmation from your county that your appeal is under review. • Inform you of your right to request a State Fair Hearing, following the completion of the appeal process. When Can I File an Appeal? You can file an appeal with your county when: Page 58 • The county or the contracted provider determines that you do not meet the access criteria for behavioral health services. • Your healthcare provider recommends a behavioral health service for you and requests approval from your county, but the county denies the request or alters the type or frequency of service. • Your provider requests approval from the county, but the county requires more information and does not complete the approval process on time. • Your county does not provide services based on its predetermined timelines. • You feel that the county is not meeting your needs on time. • Your grievance, appeal, or expedited appeal was not resolved in time. • You and your provider disagree on the necessary behavioral health services. How Can I File an Appeal? • You may file an appeal via one of the following three methods: o Call your county’s toll-free phone number listed on the cover of this handbook. After calling, you will have to file a subsequent written appeal as well; or o Mail your appeal (The county will provide self-addressed envelopes at all provider sites for you to mail in your appeal). Note: If you do not have a self- addressed envelope, you may mail your appeal directly to the address in the front of this handbook; or o Submit your appeal by e-mail or fax. Please refer to the ‘County Contact Information’ section of this handbook to find the appropriate method (e.g., email, fax) for submitting your appeal.. How Do I Know If My Appeal Has Been Decided? You or your approved person will receive written notification from your county of the decision on your appeal. The notification will include the following information: • The results of the appeal resolution process. Page 59 • The date the appeal decision was made. • If the appeal is not resolved in your favor, the notice will provide information regarding your right to a State Fair Hearing and how to request a State Fair Hearing. Is There a Deadline to File an Appeal? You must file an appeal within 60 calendar days of the date on the Notice of Adverse Benefit Determination. There are no deadlines for filing an appeal when you do not get a Notice of Adverse Benefit Determination, so you may file this type of appeal at any time. When Will a Decision Be Made About My Appeal? The county must decide on your appeal within 30 calendar days of receiving your request. What If I Can’t Wait 30 Days for My Appeal Decision? If the appeal meets the criteria for the expedited appeal process, it may be completed more quickly. What Is an Expedited Appeal? An expedited appeal follows a similar process to the standard appeal but is quicker. Here is additional information regarding expedited appeals: • You must show that waiting for a standard appeal could make your behavioral health condition worse. • The expedited appeal process follows different deadlines than the standard appeal. • The county has 72 hours to review expedited appeals. • You can make a verbal request for an expedited appeal. • You do not have to put your expedited appeal request in writing. When Can I File an Expedited Appeal? If waiting up to 30 days for a standard appeal decision will jeopardize your life, health, or ability to attain, maintain or regain maximum function, you may request an expedited resolution of an appeal. Page 60 Additional Information Regarding Expedited Appeals: • If your appeal meets the requirements for an expedited appeal, the county will resolve it within 72 hours of receiving it. • If the county determines that your appeal does not meet the criteria for an expedited appeal, they are required to provide you with timely verbal notification and will provide you with written notice within two calendar days, explaining the reason for their decision. Your appeal will then follow the standard appeal timeframes outlined earlier in this section. • If you disagree with the county's decision that your appeal does not meet the criteria for expedited appeal, you may file a grievance. • After your county resolves your request for an expedited appeal, you and all affected parties will be notified both orally and in writing. State Fair Hearings What Is A State Fair Hearing? A State Fair Hearing is an independent review conducted by an administrative law judge from the California Department of Social Services (CDSS) to ensure you receive the behavioral health services that you are entitled to under the Medi-Cal program. Please visit the California Department of Social Services website https://www.cdss.ca.gov/hearing-requests for additional resources. What Are My State Fair Hearing Rights? You have the right to: • Request a hearing before an administrative law judge, also known as a State Fair Hearing, to address your case. • Learn how to request a State Fair Hearing. Page 61 • Learn about the regulations that dictate how representation works during the State Fair Hearing. • Request to have your benefits continue during the State Fair Hearing process if you request for a State Fair Hearing within the required timeframes. • Not pay for continued services while the State Fair Hearing is pending and if the final decision is in favor of the county’s adverse benefit determination. When Can I File for a State Fair Hearing? You can file for a State Fair Hearing if: • You filed an appeal and received an appeal resolution letter telling you that your county denied your appeal request. • Your grievance, appeal, or expedited appeal wasn’t resolved in time. How Do I Request a State Fair Hearing? You can request a State Fair Hearing: • Online: at the Department of Social Services Appeals Case Management website: https://acms.dss.ca.gov/acms/login.request.do • In Writing: Submit your request to the county welfare department at the address shown on the Notice of Adverse Benefit Determination, or mail it to: California Department of Social Services State Hearings Division P.O. Box 944243, Mail Station 9-17-37 Sacramento, CA 94244-2430 • By Fax: 916-651-5210 or 916-651-2789 You can also request a State Fair Hearing or an expedited State Fair Hearing: • By Phone: o State Hearings Division, toll-free, at 1-800-743-8525 or 1-855-795-0634. o Public Inquiry and Response, toll-free, at 1-800-952-5253 or TDD at 1-800- Page 62 952-8349. Is There a Deadline to Ask for a State Fair Hearing? You have 120 days from the date of the county’s written appeal decision notice to request a State Fair Hearing. If you didn’t receive a Notice of Adverse Benefit Determination, you may file for a State Fair Hearing at any time. Can I Continue Services While I’m Waiting for a State Fair Hearing Decision? Yes, if you are currently receiving authorized services and wish to continue receiving the services while you wait for the State Fair Hearing decision, you must request a State Fair Hearing within 10 days from the date the appeal decision notice was postmarked or delivered to you. Alternatively, you can request the hearing before the date your county says that services will be stopped or reduced. Note: • When requesting a State Fair Hearing, you must indicate that you wish to continue receiving services during the State Fair Hearing process. • If you request to continue receiving services and the final decision of the State Fair Hearing confirms the reduction or discontinuation of the service you are receiving, you are not responsible for paying the cost of services provided while the State Fair Hearing was pending. When Will a Decision Be Made About My State Fair Hearing Decision? After requesting a State Fair Hearing, it may take up to 90 days to receive a decision. Can I Get a State Fair Hearing More Quickly? If you think waiting that long will be harmful to your health, you might be able to get an answer within three working days. You can request for an Expedited State Fair Hearing by either writing a letter yourself or asking your general practitioner or mental health professional to write a letter for you. The letter must include the following information: Page 63 1. Explain in detail how waiting up to 90 days for your case to be decided can seriously harm your life, health, or ability to attain, maintain, or regain maximum function. 2. Ask for an “expedited hearing” and provide the letter with your request for a hearing. The State Hearings Division of the Department of Social Services will review your request for an expedited State Fair Hearing and determine if it meets the criteria. If your request is approved, a hearing will be scheduled, and a decision will be made within three working days from the date the State Hearings Division receives your request. Page 64 ADVANCE DIRECTIVE What is an Advance Directive? You have the right to an advance directive. An advance directive is a written document about your health care that is recognized under California law. You may sometimes hear an advance directive described as a living will or durable power of attorney. It includes information about how you would like health care provided or says what decisions you would like to be made, if or when you are unable to speak for yourself. This may include such things as the right to accept or refuse medical treatment, surgery, or make other health care choices. In California, an advance directive consists of two parts: • Your appointment of an agent (a person) making decisions about your health care; and • Your individual health care instructions. Your county is required to have an advance directive program in place. Your county is required to provide written information on the advance directive policies and explain the state law if asked for the information. If you would like to request the information, you should call the telephone number on the cover of this handbook for more information. You may get a form for an advance directive from your county or online. In California, you have the right to provide advance directive instructions to all of your healthcare providers. You also have the right to change or cancel your advance directive at any time. If you have a question about California law regarding advance directive requirements, you may send a letter to: California Department of Justice Attn: Public Inquiry Unit P. O. Box 944255 Sacramento, CA 94244-2550 Page 65 RIGHTS AND RESPONSIBILITIES County Responsibilities What is my County Responsible for? Your county is responsible for the following: • Figuring out if you meet the criteria to access behavioral health services from the county or its provider network. • Providing a screening or an assessment to determine whether you need behavioral health services. • Providing a toll-free phone number that is answered 24 hours a day, seven days a week, that can tell you how to get services from the county. The telephone number is listed on the cover of this handbook. • Making sure there are sufficient behavioral health providers nearby so that you can access the services covered by your county when necessary. • Informing and educating you about services available from your county. • Providing services in your language at no cost to you, and if needed, providing an interpreter for you free of charge. • Providing you with written information about what is available to you in other languages or alternative forms like Braille or large-size print. Refer to the “Additional Information About Your County” section located at the end of this handbook for more information. • Informing you about any significant changes in the information mentioned in this handbook at least 30 days before the changes take effect. A change is considered significant when there is an increase or decrease in the quantity or types of services offered, if there is an increase or decrease in the number of network providers, or if there is any other change that would impact the benefits you receive from the county. Page 66 • Making sure to connect your healthcare with any other plans or systems that may be necessary to help transition your care smoothly. This includes ensuring that any referrals for specialists or other providers are properly followed up on and that the new provider is willing to take care of you. • Making sure you can keep seeing your current healthcare provider, even if they are not in your network, for a certain amount of time. This is important if switching providers would harm your health or raise the chance of needing to go to the hospital. Is Transportation Available? If you struggle to attend your medical or behavioral health appointments, the Medi-Cal program helps in arranging transportation for you. Transportation must be provided for Medi-Cal members who are unable to provide transportation on their own and who have a medical necessity to receive Medi-Cal covered services. There are two types of transportation for appointments: • Non-Medical: transportation by private or public vehicle for people who do not have another way to get to their appointment. • Non-Emergency Medical: transportation by ambulance, wheelchair van, or litter van for those who cannot use public or private transportation. Transportation is available for trips to the pharmacy or to pick up needed medical supplies, prosthetics, orthotics, and other equipment. If you have Medi-Cal but are not enrolled in a managed care plan, and you need non- medical transportation to a health-related service, you can contact the non-medical transportation provider directly or your provider for assistance. When you contact the transportation company, they will ask for information about your appointment date and time. Page 67 If you need non-emergency medical transportation, your provider can prescribe non- emergency medical transportation and put you in touch with a transportation provider to coordinate your ride to and from your appointment(s). For more information and assistance regarding transportation, contact your managed care plan. Member Rights What Are My Rights as a Recipient of Medi-Cal Behavioral Health Services? As a Medi-Cal member, you have the right to receive medically necessary behavioral health services from your county. When accessing behavioral health services, you have the right to: • Be treated with personal respect and respect for your dignity and privacy. • Get clear and understandable explanations of available treatment options. • Participate in decisions related to your behavioral health care. This includes the right to refuse any treatment that you do not wish to receive. • Get this handbook to learn about county services, county obligations, and your rights. • Ask for a copy of your medical records and request changes, if necessary. • Be free from any form of restraint or seclusion that is imposed as a means of coercion, discipline, convenience, or retaliation. • Receive timely access to care 24/7 for emergency, urgent, or crisis conditions when medically necessary. • Upon request, receive written materials in alternative formats such as Braille, large- size print, and audio format in a timely manner. • Receive behavioral health services from the county that follows its state contract for availability, capacity, coordination, coverage, and authorization of care. The county is required to: Page 68 o Employ or have written contracts with enough providers to make sure that all Medi-Cal eligible members who qualify for behavioral health services can receive them in a timely manner. o Cover medically necessary services out-of-network for you in a timely manner, if the county does not have an employee or contract provider who can deliver the services. Note: The county must make sure you do not pay anything extra for seeing an out-of-network provider. See below for more information:  Medically necessary behavioral health services for individuals 21 years of age or older are services that are reasonable and necessary to protect life, to prevent significant illness or significant disability, or to alleviate severe pain. Medically necessary behavioral health services for individuals under 21 years of age are services that sustain, support, improve, or make more tolerable a behavioral health condition.  Out-of-network provider is a provider who is not on the county’s list of providers. o Upon your request, provide a second opinion from a qualified health care professional within or outside of the network at no extra cost. o Make sure providers are trained to deliver the behavioral health services that the providers agree to cover. o Make sure that the county's covered behavioral health services are enough in amount, length of time, and scope to meet the needs of Medi-Cal-eligible members. This includes making sure that the county's method for approving payment for services is based on medical necessity and that the access criteria is fairly used. o Make sure that its providers conduct thorough assessments and collaborate with you to establish treatment goals. o Coordinate the services it provides with services being provided to you Page 69 through a managed care plan or with your primary care provider, if necessary. o Participate in the state's efforts to provide culturally competent services to all, including those with limited English proficiency and diverse cultural and ethnic backgrounds. • Express your rights without harmful changes to your treatment. • Receive treatment and services in accordance with your rights described in this handbook and with all applicable federal and state laws such as: o Title VI of the Civil Rights Act of 1964 as implemented by regulations at 45 CFR part 80. o The Age Discrimination Act of 1975 as implemented by regulations at 45 CFR part 91. o The Rehabilitation Act of 1973. o Title IX of the Education Amendments of 1972 (regarding education programs and activities). o Titles II and III of the Americans with Disabilities Act. o Section 1557 of the Patient Protection and Affordable Care Act. • You may have additional rights under state laws regarding behavioral health treatment. To contact your county's Patients' Rights Advocate, please contact your county by using the telephone number listed on the cover of the handbook. Adverse Benefit Determinations What Rights Do I Have if the County Denies the Services I Want or Think I Need? If your county denies, limits, reduces, delays, or ends a service you think you need, you have the right to a written notice from the county. This notice is called a "Notice of Adverse Benefit Determination". You also have a right to disagree with the decision by asking for an appeal. The sections below inform you of the Notice of Adverse Benefit Determination and what to do if you disagree with the county’s decision. Page 70 What Is an Adverse Benefit Determination? An Adverse Benefit Determination is defined by any of the following actions taken by the county: • The denial or limited authorization of a requested service. This includes determinations based on the type or level of service, medical necessity, appropriateness, setting, or effectiveness of a covered benefit; • The reduction, suspension, or termination of a previously authorized service; • The denial, in whole or in part, of payment for a service; • The failure to provide services in a timely manner; • The failure to act within the required timeframes for standard resolution of grievances and appeals. Required timeframes are as follows: o If you file a grievance with the county and the county does not get back to you with a written decision on your grievance within 30 days. o If you file an appeal with the county and the county does not get back to you with a written decision on your appeal within 30 days. o If you filed an expedited appeal and did not receive a response within 72 hours. • The denial of a member’s request to dispute financial liability. What Is a Notice of Adverse Benefit Determination? A Notice of Adverse Benefit Determination is a written letter that your county will send you if it decides to deny, limit, reduce, delay, or end services you and your provider believe you should get. The notice will explain the process the county used to make the decision and include a description of the criteria or guidelines that were used to determine whether the service is medically necessary. This includes denial of: • A payment for a service. Page 71 • Claims for services that are not covered. • Claims for services that are not medically necessary. • Claims for services from the wrong delivery system. • A request to dispute financial liability. Note: A Notice of Adverse Benefit Determination is also used to tell you if your grievance, appeal, or expedited appeal was not resolved in time, or if you did not get services within the county’s timeline standards for providing services. Timing of the Notice The county must mail the notice: • To the member at least 10 days before the date of action for termination, suspension, or reduction of a previously authorized behavioral health service. • To the member within two business days of the decision for denial of payment or decisions resulting in denial, delay, or modification of all or part of the requested behavioral health services. Will I Always Get A Notice Of Adverse Benefit Determination When I Don’t Get The Services I Want? Yes, you should receive a Notice of Adverse Benefit Determination. If you do not receive a notice, you may file an appeal with the county or if you have completed the appeal process, you can request a State Fair Hearing. When you contact your county, indicate you experienced an adverse benefit determination but did not receive a notice. Information on how to file an appeal or request a State Fair Hearing is included in this handbook and should also be available in your provider’s office. What Will the Notice of Adverse Benefit Determination Tell Me? The Notice of Adverse Benefit Determination will tell you: • What your county did that affects you and your ability to get services. Page 72 • The date the decision will take effect and the reason for the decision. • If the reason for the denial is that the service is not medically necessary, the notice will include a clear explanation of why the county made this decision. This explanation will include the specific clinical reasons why the service is not considered medically necessary for you. • The state or federal rules the decision was based on. • Your rights to file an appeal if you do not agree with the county’s decision. • How to receive copies of the documents, records, and other information related to the county’s decision. • How to file an appeal with the county. • How to request a State Fair Hearing if you are not satisfied with the county’s decision on your appeal. • How to request an expedited appeal or an expedited State Fair Hearing. • How to get help filing an appeal or requesting a State Fair Hearing. • How long you have to file an appeal or request a State Fair Hearing. • Your right to continue to receive services while you wait for an appeal or State Fair Hearing decision, how to request continuation of these services, and whether the costs of these services will be covered by Medi-Cal. • When you have to file your appeal or State Fair Hearing request by if you want the services to continue. What Should I Do When I Get a Notice of Adverse Benefit Determination? When you get a Notice of Adverse Benefit Determination, you should read all the information in the notice carefully. If you don’t understand the notice, your county can help you. You may also ask another person to help you. You can request a continuation of the service that has been discontinued when you submit an appeal or request for a State Fair Hearing. You must request the continuation of services no later than 10 calendar days after the date the Notice of Adverse Benefit Page 73 Determination was post-marked or delivered to you, or before the effective date of the change. Can I Keep Getting My Services While I Wait for a Appeal Decision? Yes, you might be able to keep getting your services while you wait for a decision. This means you can keep seeing your provider and getting the care you need. What Do I Have to Do to Keep Getting My Services? You must meet the following conditions: • You ask to keep getting the service within 10 calendar days of the county sending the Notice of Adverse Benefit Determination or before the date the county said the service would stop, whichever date is later. • You filed an appeal within 60 calendar days of the date on the Notice of Adverse Benefit Determination. • The appeal is about stopping, reducing, or suspending a service you were already getting. • Your provider agreed that you need the service. • The time period the county already approved for the service has not ended yet. What If the County Decides I Do Not Need the Service After the Appeal? You will not be required to pay for the services you received while the appeal was pending. Member Responsibilities What are my responsibilities as a Medi-Cal member? It is important that you understand how the county services work so you can get the care you need. It is also important to: • Attend your treatment as scheduled. You will have the best result if you work with Page 74 your provider to develop goals for your treatment and follow those goals. If you do need to miss an appointment, call your provider at least 24 hours in advance, and reschedule for another day and time. • Always carry your Medi-Cal Benefits Identification Card (BIC) and a photo ID when you attend treatment. • Let your provider know if you need an oral interpreter before your appointment. • Tell your provider all your medical concerns. The more complete information that you share about your needs, the more successful your treatment will be. • Make sure to ask your provider any questions that you have. It is very important you completely understand the information that you receive during treatment. • Follow through on the planned action steps you and your provider have agreed upon. • Contact the county if you have any questions about your services or if you have any problems with your provider that you are unable to resolve. • Tell your provider and the county if you have any changes to your personal information. This includes your address, phone number, and any other medical information that may affect your ability to participate in treatment. • Treat the staff who provide your treatment with respect and courtesy. • If you suspect fraud or wrongdoing, report it: o The Department of Health Care Services asks that anyone suspecting Medi- Cal fraud, waste, or abuse to call the DHCS Medi-Cal Fraud Hotline at 1-800- 822-6222. If you feel this is an emergency, please call 911 for immediate assistance. The call is free, and the caller may remain anonymous. o You may also report suspected fraud or abuse by e-mail to fraud@dhcs.ca.gov or use the online form at http://www.dhcs.ca.gov/individuals/Pages/StopMedi-CalFraud.aspx. Page 75 Do I Have To Pay For Medi-Cal? Most people in Medi-Cal do not have to pay anything for medical or behavioral health services. In some cases you may have to pay for medical and/or behavioral health services based on the amount of money you get or earn each month. • If your income is less than Medi-Cal limits for your family size, you will not have to pay for medical or behavioral health services. • If your income is more than Medi-Cal limits for your family size, you will have to pay some money for your medical or behavioral health services. The amount that you pay is called your ‘share of cost’. Once you have paid your ‘share of cost,’ Medi-Cal will pay the rest of your covered medical bills for that month. In the months that you don’t have medical expenses, you don’t have to pay anything. • You may have to pay a ‘co-payment’ for any treatment under Medi-Cal. This means you pay an out-of-pocket amount each time you get a medical service or go to a hospital emergency room for your regular services. • Your provider will tell you if you need to make a co-payment. Page 76 NONDISCRIMINATION NOTICE Discrimination is against the law. Alameda County Behavioral Health Department (ACBHD) follows State and Federal civil rights laws. ACBHD does not unlawfully discriminate, exclude people, or treat them differently because of sex, race, color, religion, ancestry, national origin, ethnic group identification, age, mental disability, physical disability, medical condition, genetic information, marital status, gender, gender identity, or sexual orientation. ACBHD provides: • Free aids and services to people with disabilities to help them communicate better, such as: • Qualified sign language interpreters • Written information in other formats (large print, braille, audio or accessible electronic formats) • Free language services to people whose primary language is not English, such as: • Qualified interpreters • Information written in other languages If you need these services, contact your service provider or call ACBHD ACCESS at 1-800- 491-9099 (TTY: 711. Or, if you cannot hear or speak well, please call 711 (California State Relay). Upon request, this document can be made available to you in braille, large print, audio, or accessible electronic formats. HOW TO FILE A GRIEVANCE If you believe that ACBHD has failed to provide these services or unlawfully discriminated in another way on the basis of sex, race, color, religion, ancestry, national origin, ethnic group identification, age, mental disability, physical disability, medical condition, genetic information, marital status, gender, gender identity, or sexual orientation, you can file a grievance with ACBHD’s Consumer Assistance Line. You can file a grievance by phone, in writing, or in person: • By phone: Contact Consumer Assistance between 9am -5pm, Monday through Friday, by calling 1-800-779-0787. Or, if you cannot hear or speak well, please call 711 (California State Relay). • In writing: Fill out a grievance form or write a letter and send it to: Consumer Assistance 2000 Embarcadero Cove, Suite 400 Page 77 Oakland, CA 94606 • In person: Visit your provider’s office or the Mental Health Association, 2855 Telegraph Ave, Suite 501, Berkeley, CA 94705, and say you want to file a grievance. Grievance Forms are available online, visit: https://www.acbhcs.org/plan- administration/file-a-grievance/. OFFICE OF CIVIL RIGHTS – CALIFORNIA DEPARTMENT OF HEALTH CARE SERVICES You can also file a civil rights complaint with the California Department of Health Care Services, Office of Civil Rights by phone, in writing, or electronically: • By phone: Call 916-440-7370. If you cannot speak or hear well, please call 711 (California State Relay). • In writing: Fill out a complaint form or send a letter to: Department of Health Care Services Office of Civil Rights P.O. Box 997413, MS 0009 Sacramento, CA 95899-7413 Complaint forms are available at: https://www.dhcs.ca.gov/discrimination-grievance-procedures • Electronically: Send an email to CivilRights@dhcs.ca.gov. OFFICE OF CIVIL RIGHTS – U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES If you believe you have been discriminated against on the basis of race, color, national origin, age, disability or sex, you can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights by phone, in writing, or electronically: • By phone: Call 1-800-368-1019. If you cannot speak or hear well, please call Page 78 TTY/TDD 1-800-537-7697. • In writing: Fill out a complaint form or send a letter to: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 • Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html. • Electronically: Visit the Office for Civil Rights Complaint Portal at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf Page 79 NOTICE OF PRIVACY PRACTICES A statement describing the county’s policies and procedures for preserving the confidentiality of medical records is available and will be given to you upon request. If you are of the age and capacity to consent to behavioral health services, you are not required to get any other member’s authorization to get behavioral health services or to submit a claim for behavioral health services. You can ask your county to send communications about behavioral health services to another mailing address, email address, or telephone number that you choose. This is called a “request for confidential communications.” If you consent to care, the county will not give information on your behavioral health services to anyone else without your written permission. If you do not give a mailing address, email address, or telephone number, the county will send communications in your name to the address or telephone number on file. The county will honor your requests to get confidential communications in the form and format you asked for. Or they will make sure your communications are easy to put in the form and format you asked for. The county will send them to another location of your choice. Your request for confidential communications lasts until you cancel it or submit a new request for confidential communications. This Notice of Privacy Practices (“Notice”) describes how your protected health information (PHI) may be used and disclosed and how you can get access to this information, as required by the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and other laws. Please review it carefully. Who We Are This single Notice applies to all departments and programs within Alameda County Health (“AC Health”), an agency of the County of Alameda and a HIPAA-covered entity. AC Health includes the following departments and programs: Behavioral Health (Mental Health and Drug Medi-Cal Organized Delivery System (DMC-ODS) Health Plans), Public Health, Environmental Health, and additional services such as Healthcare for Homeless, Page 80 Your Information. Your Rights. Our Responsibilities. In the following sections, we’ll explain how we encourage you to take a few minutes to review this information carefully. Homelessness and Housing Services, Emergency Medical Services, Healthy Schools and Communities, Health PAC, and Social Health Information Exchange (SHIE). AC Health may share your protected health information (PHI) with individuals and organizations known as Business Associates and Qualified Service Organizations who perform essential services on our behalf. These include administrative support services such as data analysis, billing or claims processing, accreditation, auditing, laboratory services, information technology, as well as direct clinical services provided under contract through our health plans or other approved service arrangements. While providing these services, Business Associates may also collect, create, or receive PHI and share it with AC Health as necessary to support care delivery, coordination, payment, or operations. All Business Associates are legally and contractually required to protect your PHI and may only use or disclose it as permitted under HIPAA and their agreement with AC Health. Page 81 Your Information: Our Uses and Disclosures We generally use and disclose (share) your health information to provide treatment (to care for you), process payment (to bill for your services), and support healthcare operations (to ). Treat You To provide you with medical, behavioral health (mental health and substance use disorder), or dental care and coordinate your treatment across our programs and share it with other professionals who are treating you. Example: A behavioral health provider may work with your primary care provider to ensure your treatment plan supports both your Bill For Your Services We can use and share your health information to bill and get payment from Medi-Cal, Medicare, health plans or other insurance carriers. Example: We give information about you to your health insurance Run Our Organization We can use and share your health information to operate our programs, improve your care, and contact you when necessary. Example: We may use health information about you to manage your Substance Use Disorder (SUD) Treatment Records (42 CFR Part 2 Protections) Some records about substance use treatment are specifically protected under federal law (42 CFR Part 2). These rules now work with HIPAA so that your health care team can share information safely to help coordinate your care while keeping it private. How we may use and disclose your SUD treatment information depends on the type of consent you have given: General consent: If you have given us general permission, we may use and share your SUD records for treatment, payment, or healthcare operations (TPO). This lets us share your information with other health care providers and organizations involved in your care. Consent for another purpose: If you give us permission for a different purpose, we may use and disclose your SUD treatment records only in ways you allow. Without your consent: If you have not given permission, we will only Care Coordination and CalAIM Programs We participate in California Advancing and Innovating Medi-Cal (CalAIM), a program that helps coordinate care for Medi-Cal members with complex needs. As part of this effort, we may share your health information with other approved providers and organizations involved in your care, such as health plans, community-based organizations, housing providers, or behavioral health providers, to better coordinate service through programs like Page 82 Enhanced Care Management (ECM) or Community Supports. This sharing happens only as allowed by law and only when necessary to Additional Uses and Disclosures: as allowed or required by law. Public Health and Safety Issues We can share health information about you for certain situations such as: Preventing disease, injury or disability Reporting births and deaths Helping with product recalls Reporting adverse reactions to medications Reporting suspected abuse, neglect, or domestic violence Research Comply With the Law We will share information about you if state or federal laws require it, including with the U.S. Department of Health and Human Services if it Organ and Tissue Donation Requests Health Oversight Coroner, Medical Examiner, We can share health information with a coroner, medical examiner, or funeral director when an individual dies. Workers’ Compensation Government Requests and Law Enforcement We can use or disclose your health information with health oversight agencies for activities authorized by law; for special functions such as military or national security activities, or to protect the President and other authorized persons; and in limited circumstances, for law Inmates official, we may disclose your health information for your health and safety, the health and safety of others, or for the administration and Serious and Imminent Threats We may disclose your health information when needed to lessen a serious or imminent threat to the health or safety of you, the public, Lawsuits and Legal Actions Page 83 Your Rights When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you. Records You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. We will provide a copy or a summary of your health information, usually within 30 days of your request. Request Amendments You can ask us to correct health information you believe is incorrect or incomplete. We may say “no” to your request, but we’ll tell you Request Restrictions Request Confidential Communication You can ask us to contact you in a specific way (for example: home or office phone) or to send mail to a different address. We will say “yes” to all reasonable requests. You must make this request in writing, Receive an Accounting of Disclosures You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why. We will include all the disclosures except for those about treatment, payment, and healthcare operations, and certain other disclosures (such as any you asked us to make). We will provide one accounting a year for free but may charge a reasonable, cost-based fee if you ask for another one within 12 months. Get a Paper Copy of this Privacy You can ask for a paper copy of this Notice at any time, even if you have agreed to receive the Notice electronically. We will provide you Choose Someone to Act for You If you have given someone medical power of attorney or someone is your legal guardian, that person can exercise your rights and make choices about your health information. We will make sure the person File a Complaint complaint with us by calling 510-618-3333 or email us at ACHealth.Compliance@acgov.org You may also file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to: HHS Office for Civil Rights 90 7th Street, Suite 4-100 | San Francisco, CA 94103 By Phone: 1800-368-1019 Online www.hhs.gov/ocr/privacy/hipaa/complaints/ We will not retaliate against you for filing a complaint. Page 84 Your Rights Under California Law Your Rights Under California Law Some of your health information is subject to special protection under California law because it is considered sensitive information. This includes information related to HIV test results; substance use treatment; mental health; genetic testing; reproductive health services (including abortion-related care); and gender-affirming care. We may use or share this information within AC Health and with our business associates when needed to treat you, bill for your care, or run our organization. When required by law, we will obtain your Youth and Minor Confidentiality Rights required to deny access to a parent or guardian of a minor. For example: When minors legally consent, we will not share their information with parents or guardians without the minor’s written permission, unless required or permitted by law (e.g., court order, medical emergency, mandated reporting). Minor ages 12 and older can consent to certain sensitive services, including mental health, substance use disorder treatment, reproductive health services, HIV/STI testing and treatment. Minors can request that we send communication (e.g., test results, bills) to a different address, phone number, or email to protect their privacy. This is called a confidential Your Choices For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk In these cases, you have both the right and choice to tell us to: Share information with your family, close friends, or others involved in your care. Share information in a disaster relief situation. Have us communicate with you in a specific way (e.g., phone, email, office address, etc.). Ask us not to share your information with your health plan about a service you paid for out-of-pocket in full. If you are not able to tell us your preference, for example—if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or In these cases, we will not share your Marketing purposes. Sale of your information. Page 85 you give us written permission: We will not share your SUD treatment record, or any testimony about it, in any civil, criminal, administrative, or legislative proceedings against you, unless you have authorized the use or disclosure by consent, or a court has ordered it after providing you notice. Even if you have given us written permission, you may revoke it in In the case of fundraising or media campaign We may contact you for fundraising or media campaign efforts, but you can tell us not to contact you again. Our Responsibilities We are required by law to maintain the privacy and security of your protected health information. We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information. We must follow the duties and privacy practices described in this Notice and give you a copy of it. We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind. For more information visit: Changes to the Terms of This Notice We can change the terms of this Notice, and the changes will apply to all information we have about you. The new Notice will be available upon request, in our office, and on our website. Effective Date of Notice: 2013 Revised: Aug 2017; June 2022; November 2025 Page 86 WORDS TO KNOW 988 Suicide and Crisis Lifeline: A phone number that provides free, conﬁdential support for people experiencing a mental health crisis, including suicidal thoughts. It is available 24/7 to connect callers with trained counselors who can offer help and support. Administrative law judge: A judge who hears and decides cases involving adverse beneﬁt determinations. American Society of Addiction Medicine (ASAM): A professional medical society representing doctors and other healthcare professionals who specialize in addiction treatment. This organization created the ASAM Criteria, which is the national set of criteria for addiction treatment. Appeal resolution: The process of resolving a disagreement you have with a decision made by the county about coverage of a requested service. In simpler terms: It is how you get a second look at a decision you do not agree with. Application Programming Interfaces (APIs): APIs are like messengers that allow different software programs to "talk" to each other and share information. Assessment: A service activity designed to evaluate the current status of mental, emotional, or behavioral health. Authorization: Giving permission or approval. Authorized representative: Someone legally allowed to act on behalf of another person. Behavioral Health: Refers to our emotional, psychological, and social well-being. In simpler terms: It is about how we think, feel, and interact with others. Beneﬁts: Health care services and drugs covered under this health plan. Beneﬁts Identiﬁcation Card (BIC): An ID card to verify your Medi-Cal health insurance. Care Coordination Services (Coordination of Care): Helps people navigate the healthcare system. Page 87 Caregiver: Someone who provides care and support to another person who needs help. Case manager: Registered nurses or social workers who can help a member understand major health problems and arrange care with the member’s providers. Case management: It is a service to assist members in accessing needed medical, educational, social, rehabilitative, or other community services. In other words, it helps people get the care and support they need. CHIP (Children's Health Insurance Program): A government program that helps families get health insurance for their children if they cannot afford it. Civil Rights Coordinator: Ensures that an organization (like a school, company, or government agency) complies with laws that protect people from discrimination. Client-driven: Something that is focused on the needs and preferences of the client. Community-based organizations: Groups of people who work together to improve their community. Community-based adult services (CBAS): Outpatient, facility-based services for skilled nursing care, social services, therapies, personal care, family and caregiver training and support, nutrition services, transportation, and other services for members who qualify. Community-based stabilization: Helps people experiencing a mental health crisis get support within their own community instead of going to a hospital. Continuation of service: See continuity of care. Continuity of care: The ability of a plan member to keep getting Medi-Cal services from their existing out-of-network provider for up to 12 months if the provider and county agree. Copayment (co-pay): A payment a member makes, generally at the time of service, in addition to the insurer's payment. Covered Services: Medi-Cal services for which the county is responsible for payment. Covered services are subject to the terms, conditions, limitations, and exclusions of the Page 88 Medi-Cal contract, any contract amendment, and as listed in this Member Handbook (also known as the Combined Evidence of Coverage (EOC) and Disclosure Form). Culturally competent services: Providing services that are respectful of and responsive to a person's culture, language, and beliefs. Designated signiﬁcant support person(s): Person(s) who the member or the provider thinks are important to the success of treatment. This can include parents or legal guardians of a minor, anyone living in the same household, and other relatives of the member. DHCS: The California Department of Health Care Services. This is the State office that oversees the Medi-Cal program. Discrimination: The unfair or unequal treatment of someone based on their race, gender, religion, sexual orientation, disability, or other characteristics. Early and periodic screening, diagnostic, and treatment (EPSDT): Go to “Medi-Cal for Kids and Teens.” Family-based treatment services: Provides support and treatment to children and their families to address mental health challenges within the home environment. Family planning services: Services to prevent or delay pregnancy. Services are provided to members of childbearing age to enable them to determine the number and spacing of children. Fee-for-Service (FFS) Medi-Cal: Payment model in which Behavioral Health providers are paid for each individual service they provide patient, rather than a per-patient monthly or annual fee. Medi-Cal Rx is covered under this program. Financial liability: Being responsible for paying a debt or cost. Foster home: A household that provides 24-hour substitute care for children who are separated from their parents or guardians. Page 89 Fraud: An intentional act to deceive or misrepresent made by a person with knowledge that the deception or misrepresentation could result in some unauthorized beneﬁt to themselves or someone else. Full-scope Medi-Cal: Free or low-cost health care for people in California that provides more than just emergency health care. It provides medical, dental, mental health, family planning, and vision (eye) care. It also covers treatment for alcohol and drug use, medicine your doctor orders, and more. Grievance: A member’s verbal or written expression of dissatisfaction about a service covered by Medi-Cal, a managed care plan, a county, or a Medi-Cal provider. A grievance is the same as a complaint. Guardian: A person legally responsible for the care and well-being of another person, usually a child or someone who cannot care for themselves. Hospital: A place where a member gets inpatient and outpatient care from doctors and nurses. Hospitalization: Admission to a hospital for treatment as an inpatient. Indian Health Care Providers (IHCP): A health care program operated by the Indian Health Service (IHS), an Indian Tribe, Tribal Health Program, Tribal Organization or Urban Indian Organization (UIO) as those terms are deﬁned in Section 4 of the Indian Health Care Improvement Act (25 U.S.C. section 1603). Initial Assessment: An evaluation of the member to determine the need for mental health services or substance use disorder treatment. Inpatient Detoxiﬁcation: A voluntary medical acute care service for detoxiﬁcation for members with severe medical complications associated with withdrawals. Integrated Core Practice Model: A guide that outlines the values, standards, and practices for working with children, youth, and families in California. Page 90 Licensed mental health professional: Any provider who is licensed in accordance with applicable State of California law such as the following: licensed physician, licensed psychologist, licensed clinical social worker, licensed professional clinical counselor, licensed marriage and family therapist, registered nurse, licensed vocational nurse, licensed psychiatric technician. Licensed psychiatric hospital: A mental health treatment facility that is licensed to provide 24-hour inpatient care for mentally disordered, incompetent, or a danger to themselves or others. Licensed residential facility: Facilities that provide residential nonmedical services to adults who are recovering from problems related to alcohol or other drug (AOD) misuse or abuse. Managed care plan: A Medi-Cal health plan that uses only certain doctors, specialists, clinics, pharmacies, and hospitals for Medi-Cal recipients enrolled in that plan. Medi-Cal: California’s version of the federal Medicaid program. Medi-Cal offers free and low-cost health coverage to eligible people who live in California. Medi-Cal for Kids and Teens: A beneﬁt for Medi-Cal members under the age of 21 to help keep them healthy. Members must get the right health check-ups for their age and appropriate screenings to ﬁnd health problems and treat illnesses early. They must get treatment to take care of or help the conditions that might be found in the check-ups. This beneﬁt is also known as the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) beneﬁt under federal law. Medi-Cal Peer Support Specialist: An individual who has lived experience with behavioral health or substance use conditions and is in recovery, who has completed the requirements of a county’s State-approved certification program, who is certified by the county, and who provides services under the direction of a Behavioral Health Professional who is licensed, waivered, or registered with the State. Page 91 Medi-Cal Rx: A pharmacy beneﬁt service that is part of FFS Medi-Cal and known as “Medi- Cal Rx” that provides pharmacy beneﬁts and services, including prescription drugs and some medical supplies to all Medi-Cal members. Medically necessary (or medical necessity): For members 21 years of age or older, a service is medically necessary when it is reasonable and necessary to protect life, to prevent signiﬁcant illness or signiﬁcant disability, or to alleviate severe pain. For members under 21 years of age, a service is medically necessary if it is to correct or ameliorate a mental illness or condition discovered by a screening service. Medication Assisted Treatment (MAT): The use of FDA approved medication in combination with counseling or behavioral therapies to provide a “whole-patient” approach to the treatment of substance use disorder. Member: An individual who is enrolled in the Medi-Cal program. Mental health crisis: When someone is experiencing a situation where their behaviors or symptoms put themselves or others at risk and require immediate attention. Mental health plan: Each county has a mental health plan that is responsible for providing or arranging specialty mental health services to Medi-Cal members in their county. Network: A group of doctors, clinics, hospitals, and other providers contracted with the county to provide care. Non-emergency medical transportation: Transportation by ambulance, wheelchair van, or litter van for those who cannot use public or private transportation. Non-medical transportation: Transportation when traveling to and from an appointment for a Medi-Cal covered service authorized by a member’s provider and when picking up prescriptions and medical supplies. Office of the Ombudsman: Helps solve problems from a neutral standpoint to make sure that members receive all medically necessary and covered services for which plans are contractually responsible. Page 92 Out-of-home placement: A temporary or permanent removal of a child from their home to a safer environment like with a foster family or in a group home. Out-of-network provider: A provider who is not part of the county’s contracted network. Out-of-pocket: A personal cost to a member to receive covered services. This includes premiums, copays, or any additional costs for covered services. Outpatient mental health services: Outpatient services for members with mild to moderate mental health conditions including: • Individual or group mental health evaluation and treatment (psychotherapy) • Psychological testing when clinically indicated to evaluate a mental health condition • Outpatient services for the purposes of monitoring medication therapy • Psychiatric consultation • Outpatient laboratory, supplies, and supplements Participating provider (or participating doctor): A doctor, hospital, or other licensed health care professional or licensed health facility, including sub-acute facilities that have a contract with the county to offer covered services to members at the time a member gets care. Plan development: A service activity that consists of development of client plans, approval of client plans, and/or monitoring of a member’s progress. Prescription drugs: A drug that legally requires an order from a licensed provider to be dispensed, unlike over-the-counter (“OTC”) drugs that do not require a prescription. Primary care: Also known as “routine care”. These are medically necessary services and preventative care, well-child visits, or care such as routine follow-up care. The goal of these services is to prevent health problems. Primary care provider (PCP): The licensed provider a member has for most of their health care. The PCP helps the member get the care they need. A PCP can be a: Page 93 • General practitioner • Internist • Pediatrician • Family practitioner • OB/GYN • Indian Health Care Provider (IHCP) • Federally Qualiﬁed Health Center (FQHC) • Rural Health Clinic (RHC) • Nurse practitioner • Physician assistant • Clinic Prior authorization (pre-approval): The process by which a member or their provider must request approval from the county for certain services to ensure the county will cover them. A referral is not an approval. A prior authorization is the same as pre-approval. Problem resolution: The process that allows a member to resolve a problem or concern about any issue related to the county’s responsibilities, including the delivery of services. Provider Directory: A list of providers in the county’s network. Psychiatric emergency medical condition: A mental disorder in which the symptoms are serious or severe enough to cause an immediate danger to the member or others or the member is immediately unable to provide for or use food, shelter, or clothing due to the mental disorder. Psychological testing: A test that helps understand someone's thoughts, feelings, and behaviors. Referral: When a member’s PCP says the member can get care from another provider. Some covered care services require a referral and pre-approval (prior authorization). Page 94 Rehabilitative and habilitative therapy services and devices: Services and devices to help members with injuries, disabilities, or chronic conditions to gain or recover mental and physical skills. Residential shelter services: Provides temporary housing and support to people who are homeless or experiencing a housing crisis. Screening: A quick check conducted to determine the most appropriate services. Share of cost: The amount of money a member must pay toward their medical expenses before Medi-Cal will pay for services. Serious emotional disturbances (problems): Refers to a signiﬁcant mental, behavioral, or emotional disorder in children and adolescents that interferes with their ability to function at home, school, or in the community. Specialist (or specialty doctor): A doctor who treats certain types of health care problems. For example, an orthopedic surgeon treats broken bones; an allergist treats allergies; and a cardiologist treats heart problems. In most cases, a member will need a referral from their PCP to go to a specialist. Specialty mental health services (SMHS): Services for members who have mental health services needs that are higher than a mild to moderate level of impairment. Strength-based: Looking at what someone can do, instead of just focusing on their problems. Substance use disorder services: Services that help people who are struggling with addiction to drugs or alcohol. Telehealth: A way of delivering health care services through information and communication technologies to facilitate a patient’s health care. Trauma: A deep emotional and psychological distress that results from experiencing or witnessing a terrifying event. Page 95 Trauma-informed specialty mental health services: These services recognize that many people struggling with mental health issues have experienced trauma, and they provide care that is sensitive to and supportive of those who have been traumatized. Treatment Plan: A plan to address a member’s needs and monitor progress to restore the member’s best possible functional level. TTY/TDD: Devices that assist people who are deaf, hard of hearing, or have a speech impairment to make and receive phone calls. TTY stands for “Teletypewriter”. TDD stands for “Telecommunications Device for the Deaf”. Vocational services: Services that help people ﬁnd and keep jobs. Waitlist: A list of people who are waiting for something that is not currently available, but may be in the future. Warm handoff: A smooth transfer of care from one provider to another. Page 96 ADDITIONAL INFORMATION FROM YOUR COUNTY ACBHD is committed to your wellness. We respect your voice and support equity in health care services. We would like you to know that this information is readily available in the languages listed below: • Spanish: Este folleto está disponible en Español • Vietnamese: Tập sách này có bằng tiếng Việt • Korean: 이 책자는 한국어로 제공됩니다. • Chinese (Traditional): 這本手冊有中文版 • Chinese (Simplified): 这本手册有中文版 • Farsi: نﯾا تﺎﻋﻼطا ﮫﺑ نﺎﺑز ﯽﺳرﺎﻓ دوﺟوﻣ تﺳا . • Tagalog (Tagalog/Filipino): Ang impormasyong ito ay maaaring makuha sa Tagalog. • Arabic: .ﺔﯾﺑرﻌﻟا ﺔﻐﻠﻟﺎﺑ لﯾﻟدﻟا اذھ رﻓوﺗﯾ If you need this information in any language not listed above, please contact your current care provider or ACBHD at the phone number listed on the cover of this booklet. ACBHD is offering the following new services: • Multisystemic Therapy (MST) • Assertive Community Treatment (ACT) • Forensic Assertive Community Treatment (FACT) • Coordinated Specialty Care (CSC) for First Episode Psychosis • Supported Employment • Medi-Cal Peer Support Services Please contact your current service provider or call ACBHD ACCESS at 1-800-491-9099 to inquire about adding these services to your care plan.