Drug Medi-Cal
Frequently Asked Questions
1. Q: Is it true that only a dependence diagnosis qualified a client for DMC services. The definition of "Substance Abuse Diagnosis" on page 3 item 21, states "Substance abuse diagnoses" are those set forth in the Diagnostic and Statistical Manual of Mental Disorders Third Edition-Revised or Fourth edition, published by the American Psychiatric Association."
A:Title 22, Section 51341.1 is titled “Drug Medi-Cal Substance Abuse Services”. A DSM diagnosis of “substance abuse” qualifies for all aspects of the program.
Title 9 Section 10270 (b)(1) requires documentary evidence of “physical dependence,” an addiction to opiates, except as specified in (d)(5)(A) and (d)(5)(B) of that section.
2. Q: For reimbursement purposes is the admission date the CADDS date or the date of the 1st Service?
A: Title 22 specifies that the admission is the “date of the first face-to-face treatment service”. Title 22 Section 51341.1(b)(1)
The CADDS admission date is determined by the completion of specific activities. It is an administrative date particular to data gathering for ADP. It is not used to determine reimbursement by DMC.
3. Q: Can we admit to treatment under DMC a teenager who has been expelled from school for have a “pipe” but denies that he is a drug user? His mother states that he has used marijuana. The teenager has is Medi-Cal qualified. Will our monitors recoup monies if they provide services to this teenager?
A: As long as the client id DMC qualified, medical necessity established, physical or waiver was in place, treatment plan established, and all other criteria met services can be provided and billed. Title 22 (h)(1)(A)(I) states that the provider will “Develop and use criteria and procedures for the admission of beneficiaries to service,” The criteria for admission to the providers program would depend upon their modality, treatment methodology, etc.
4. Q: If the Treatment Plan is not done within the 1st 30 days, are the 1st 30 days of services unbillable or are they allowed?
A: The sessions for the first 30 days are billable and will not be recouped on a review as long as all the other Title 22 criteria are met.
5. Q: Can we bill for the following services for ODF, NTP, & DCH if they are performed by the case manager?
- Client Assessment
- Treatment Plan Development / Review
- Collateral Services
- Crisis Sessions
A: Case management is not reimbursable under Drug Medi-Cal. Title 22 Section 51341.1 defines those services which are billable to Drug Medi-Cal. Case management is not one of those services. Case management is an internal quality control mechanism whose goal is to give a degree of assurance that the care provided the client is appropriate to the diagnosis.
Drug Medi-Cal reimburses for those services provided directly to the client by the program, not the management of those services.
6. Q: Can we bill the client for the paperwork charting for a group or is the service billable only for the time of the group?
A: By the client I assume you mean drug Medi-cal. No you cannot bill for charting only for the counseling session, group or individual.
7. Q: The definition of a collateral service on page 1 Exhibit 1, of Title 22, section 51341.1, states, “Collateral services means face to face sessions with the therapists or counselors and significant persons in the life of a beneficiary, focusing on the treatment needs of the beneficiary in terms of supporting the achievement of the beneficiary's treatment goals. Significant persons are individuals that have personal, not official or professional, relationship with the beneficiary.”
It does not state the client has to be present.
A: A collateral service is the only ODF service for which a face to face with the client is not required.
8. Q: What is the length of time that the M.D. has to sign the six months Continuation of Treatment Authorization.
A: The continuation of treatment plan must be signed no sooner than 5 months and no later than 6 months from the beneficiary's admission to treatment date or the date of the most recent (last) justification for continuing services. Title 22 Section 51341.1 (h)(5)(A)(i).
9. Q: Do substance abuse programs have to do anything other than notify Medi Cal beneficiaries of their right to a fair hearing, as specified in Title 22 51341.1 Drug Medi Cal substance abuse services section p)? (We don't have Section 50953 where this is detailed).
A: Yes must notify the beneficiary of their fair hearing rights, in writing as specified in Title 22 Section 51341.1( p). Section 50953 states the procedures that will be followed during the actual fair hearing.
10. Q: Could you please forward or refer me to the document where I could view the language of this section. I cannot find it in any Title 22 documents that I have. It was referenced in a post service post payment utilization review report stating that, "D/MC patients cannot be charged fees over and above $1.00 or a co payment charge, if any, on the beneficiary's Medi Cal card".
A: Title 22 section 51341.1(h) (7) states, “Except where share of cost, as defined in Section 50090, is applicable, providers shall accept proof of eligibility for Drug Medi-Cal as payment in full for treatment services rendered. Providers shall not charge fees to beneficiaries for access to Drug Medi-Cal substance abuse services or for admission to a Drug Medi-Cal Treatment slot.”
Section 50090 states, “ Share of cost means a person’s or families net income in excess of their maintenance need that must be paid or obligated toward the cost of health services before the person or family may be certified and received Medi-Cal cards.”
11. Q: Can you tell me if there is a limit on the number of individual counseling sessions we can bill Drug Medi Cal for? Someone was stating in a meeting yesterday that we can only bill for 3 within an entire episode of care.
Second question is that I understand that for group counseling the group size must be between 4 and 10 and one must by Medi Cal. Is this correct?
A: Technically there is no limit to the number of individual counseling sessions that can be provided in an ODF modality. However, individual sessions are limited to the 5 exceptions that are listed in Title 22 section 51341.1 (d)(2)(B). Remember that the primarily means of treatment in an ODF program is Group Counseling.
Group counseling groups are limited to more than 4 and no more than 10 individuals. Title 22 section 51341.1 (b)(8)
12. Q: How many group counseling sessions can a client receive in a month?
A: Title 22 51341.1 (d)(2)(a) states “…..each beneficiary shall receive at lest two group counseling sessions per month.” There is no upper limit to the amount of sessions attended, however you can only bill for one group session per client per day.
13. Q: Is there a time requirement for a unit of service attached to Individual Counseling sessions?
A: We are under the impression that they should be :50 minutes in length and if session is under this, adjust accordingly.
Please clarify, as we are experiencing some conflict.
For ODF the maximum payable amount for an individual session would be 50 minutes, for a group session it would be 90 minutes. If sessions exceed these time limits the amount in excess would not be reimbursable. If the sessions are actually less than this time you will be reimbursed for the full amount. However, an adjustment for the actual time will accomplished when the cost-report is processed.
14. Q: We recently got Drug Medi Cal certified, and to our dismay we found that it is actually less funding than we were receiving from the County. We understand that DMC can not be billed for room and board, only TX costs. Are we able to bill the beneficiaries for their room and board outside of TX costs? We are in desperate need of funding, as we are operating on a deficit.
A: Yes you can bill the beneficiaries for room and board. Medi-Cal reimburses for treatment services only.
15. Q: I understand that each adult patient or client entering our program for substance and alcohol abuse services must have a physical examination or show documented proof of a physical examination. Does this apply to adolescents? Is it required that adolescents have a physical examination? Second, what action or what should the response be should a patient or client decline or states they do not want a physical examination?
A: Title 22 Section 51341.1 (h)(1)(A)(iii), requires the provider to complete an assessment of the physical condition of each client within 30 days of admission. This requires either a physical examination of the client or a physician’s waiver which specifies the basis for not requiring a physical examination. This applies to all Drug Medi-Cal clients including juveniles.
The client must comply with this provision if Drug Medi-Cal benefits are to be paid. Physicals can only be waived by an MD based on the criteria set in Title 22 Section 51341.1 (h)(1)(A)(iii)(b).
16. Q: I received a call this morning from one of our perinatal providers. They have a mom who sadly just had a still born birth. The mom needs to continue AOD treatment. Is she still considered to be post partum for 60 days? I've looked up the definition of "Postpartum" in Title 22 Sections 50260 and 50262.3a. It only mentions "pregnant women" or women with children and doesn't seem to address the postpartum period.
A: The term “pregnant woman” in Title 22 para.50260 is used to set the criteria for admission to a Peri-natal program. It then goes on to state “shall be eligible for all pregnancy related and postpartum services for a 60 day period, beginning on the last day of pregnancy…..etc. Eligibility for this program ends on the last day of the month in which the 60th day occurs.
17. Q: The case of the second service on the same day.
A:
- 2nd service means that the client left the facility and returned for a group or individual session (face to face).
- The progress note must contain a statement that the return did not create a hardship on the client and that every effort was made to provide all necessary services during one visit.
- If the hardship statement is in the progress note then the return can be for an individual intake, treatment planning or discharge session. The return can also be for a group counseling session.
- The second service rendered during the same day can never be duplicative.
- Title 22 requires that the ADP Form 7700 be in the clients file. If the form is not in the file the service is recoupable. Without the form the provider cannot be paid, so it must exist somewhere.
18. Q: A client attends a group session, however the primary counselor is sick and the group is run by a stand-in. The primary counselor completes the progress note and states that he was not present and writes the stand-in’s observation. Otherwise all the required elements of a progress note are present.
A: Title 22 (h)(2)(3)(A) requires “the counselor to record a progress note,” it is not specific as to which counselor that should be. However common sense would dictate that it would be a counselor that has knowledge of the session being noted. Given that the stand-in informed the primary of the all the elements necessary for the completion of the note it would not seem to be material that the comment was actually written by the primary or stand-in either would satisfy the standard. Treatment was provided, a progress note was accomplished, and all the requirements of the Title 22 were met.
19. Q: How can a provider receive training. This request usually comes after we have reviewed the program and identified significant deficiencies.
A: By requesting it though e-mail: DMCanswers@adp.state.ca.us
20. Q: Do we have sample forms to assist them in documenting as required by the regulations. Almost every program is interested in this.
A: Yes. See FORMS section.
21. Q: Are there other funding sources to assist or enhance DMC funding for services to be provided to clients with co-occurring disorders.
A: Yes. Talk to your County representative
22. Q: Can providers come to ADP as direct providers.
A: Yes; only if the County in which the provider is located does not wish to contract for DMC services.
23. Q: There are always questions, comments, complaints, etc. about the lack of clarity in the regulations, consistency in application of the regulations, county contract oversight and DMC regulations guidance by the counties, and specific questions about admission, treatment planning, and other regulation requirements that are not clear.
A: Ask questions at DMC@adp.ca.gov OR request training.