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BHSD Substance Use Treatment Services

2017 Beneficiary Handbook

Substance Use Treatment Services

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Beneficiary Handbook

Substance Use Treatment Services

2017

Santa Clara County Behavioral Health Services Department,

Substance Use Treatment, Quality Improvement Division

Executive Sponsors:

Bruce Copley, Michael Hutchinson, Kakoli Banerjee

Project Manager: Pauline Casper, MS

Table of Contents

Table of Contents ..................................................................................................................................... 3

CHAPTER 1: WHAT IS DRUG MEDI-CAL ...................................................................................... 5

CHAPTER 2: HOW TO APPLY FOR MEDI-CAL ............................................................................ 5

Eligibility ................................................................................................................................................... 6

Medical Necessity ...................................................................................................................................... 6

CHAPTER 3: SUBSTANCE USE TREATMENT SERVICES .......................................................... 7

Adults......................................................................................................................................................... 7 Outpatient Programs .................................................................................................................................. 7 Intensive Outpatient ................................................................................................................................... 8 Partial Hospitalization - Outpatient (Available 2018) ............................................................................... 8 Perinatal Outpatient ................................................................................................................................... 8 Opioid/Narcotic Treatment Programs: OTP/NTP Outpatient ................................................................... 8 Medication Assisted Treatment Services (MAT): Outpatient ................................................................... 8 Residential Programs ................................................................................................................................. 9 Withdrawal Management ........................................................................................................................ 10 Case Management Services ..................................................................................................................... 10 Recovery Services ................................................................................................................................... 10

Adolescents .............................................................................................................................................. 10 Outpatient Programs ................................................................................................................................ 10 Intensive Outpatient ................................................................................................................................. 11 Residential Programs ............................................................................................................................... 11 Case Management Services ..................................................................................................................... 11 Recovery Services ................................................................................................................................... 11

Medi-Cal and Supportive Services .......................................................................................................... 12

CHAPTER 4: ACCESS TO SERVICES ............................................................................................. 12

How to Request Substance Use Treatment Services ............................................................................... 12

Authorization of Treatment Services ....................................................................................................... 12

Language Translation Services ................................................................................................................ 12

CHAPTER 5: BENEFICIARY RIGHTS AND PROTECTIONS .................................................... 13

Notice of Privacy Practices ...................................................................................................................... 13 Advance Directives .................................................................................................................................. 15

CHAPTER 6: RESOLUTION PROCESS .......................................................................................... 16

Notice of Adverse Benefit Determination ............................................................................................... 16

Problem Resolution Process .................................................................................................................... 17

Standard Appeal ...................................................................................................................................... 18

Expedited Appeal .................................................................................................................................... 20

State Fair Hearing .................................................................................................................................... 21

Grievance ................................................................................................................................................. 24

APPENDIX............................................................................................................................................. 26

Adult Provider List .................................................................................................................................. 26

Adolescent Provider List ......................................................................................................................... 27

Chapter 1: What is Drug Medi-Cal Medi-Cal is California's Medicaid health care program. This program pays for a variety of medical services for children and adults with limited income and resources. Medi-Cal is supported by federal and state taxes. You can apply for Medi-Cal benefits regardless of sex, race, religion, color, national origin, sexual orientation, marital status, age, disability, or veteran status. If you are found (or determined) eligible, you can get Medi-Cal as long as you continue to meet the eligibility requirements. Drug Medi-Cal (DMC) is a type of health insurance that pays for Substance Use Treatment services for Medi-Cal members. The State contracts with the Santa Clara County - Substance Use Treatment Services (SUTS) to provide treatment services to Medi-Cal beneficiaries. These benefits are rendered by a group of providers in Santa Clara County who have an agreement with the SUTS Managed Care Plan (MCP) to provide outpatient, intensive outpatient, residential and withdrawal management services. The MCP is responsible for the coordination of these services. Drug Medi-Cal pays for youth over age 12 and adults who want and need Substance Use Treatment services through our SUTS managed system of care. The MCP ensures available, accessible, and quality care for all Medi-Cal beneficiaries.

Chapter 2: How to Apply for Medi-Cal Automatic Mandatory Enrollment If you are already placed with a provider and you have not enrolled for Medi-Cal, your provider will assist you in doing so. If you wish to apply prior to entering treatment, please note the following: One can apply for Medi-Cal in person or online. Apply for Medi-Cal online www.mybenefitscalwin.org This website allows you to see if you are eligible for Medi-Cal and apply for benefits. Apply in Person

http://www.mybenefitscalwin.org/

• Social Services Agency Assistance Application Center 1867 Senter Road San Jose, CA 95112 408-758-3800 1-877-962-3633 North County

• 1330 W. Middlefield Road

Mountain View, CA 94043 408-758-3800 1-877-962-3633 North County

• Central Wellness & Benefits Center (CWBC)

2221 Enborg Lane San Jose, CA 95128 408-885-6220

Eligibility Medi-Cal eligibility is on a month-to month basis. You must qualify every month to receive coverage. If your income or family’s monthly income is less than the Medi-Cal limits, they will pay the entire cost of your treatment on a monthly basis. If your income is more than Medi-Cal monthly limits, you will have to pay a portion of your treatment costs out of pocket. It is similar to what private insurance refers to as a deductible cost. It is called ‘share-of-cost’ and must be paid monthly, prior to Medi-Cal payments. 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 you do not have medical expenses, you do not pay anything. You may have to make a co-payment for treatment under Medi-Cal. That is an out-of-pocket amount each time you get a medical or Substance Use Disorder (SUD) treatment service. Your provider will tell you if you need to make share-of-cost or co-payments.

Medical Necessity Your healthcare benefits must meet medical necessity criteria. Medical Necessity is a list of criteria used by Medi-Cal to ensure that beneficiaries are experiencing

significant impairment as a result of substance use. You must have at least one diagnosis from the Diagnostic and Statistical Manual of Mental Disorders for a Substance-Related and Addictive Disorder (DSM-5). Certain exceptions are made for youth under age 21, who must be ‘at risk’ for developing a Substance Use Disorder (SUD). You must also meet the American Society for Addiction Medicine (ASAM) definition of medical necessity services. ASAM Criteria are national treatment standards for substance use conditions. The State will pay for only those services that meet the proper criteria for medical necessity. The County may absorb other costs not covered by DMC based on the managed care plan. You do not need to know if you have a diagnosis to ask for help.

Chapter 3: Substance Use Treatment Services Substance Use Treatment Services are part of your managed care benefits. All services are culturally and linguistically appropriate. Treatment is provided by credentialed counselors, licensed therapists and interns in training. You may request a specific type of counselor or therapist if you choose.

Adults All adult treatment programs are for beneficiaries 18 years old and above who have Substance Use Treatment needs, or substance use and mental health treatment needs. All Withdrawal Management (Detox), Residential programs, Outpatient programs, Perinatal programs, Medication Assisted Therapies (MAT), and Recovery Services programs provide intake, assessment, treatment planning, group and individual counseling, crisis intervention counseling, family services, case management and discharge planning.

Outpatient Programs The least intensive Outpatient sites offer services up to a maximum of six hours per week, based on the beneficiary’s needs.

Intensive Outpatient Intensive Outpatient Treatment (IOT) provides individualized treatment services up to 19 hours per week. Typically these services are provided 3-5 hours per day, 3-4 times per week. Beneficiaries who attend are able to go to school or work and may continue to live at home, but are in need of treatment services beyond traditional outpatient programs. Partial Hospitalization - Outpatient (Available 2018) Partial Hospitalization consists of a minimum of 20 or more hours of service per week. Perinatal Outpatient This intensive outpatient treatment is specifically for pregnant and/or parenting women. In addition to the basic services provided by all treatment programs, perinatal-specific programming (pregnant or parenting) may include education on alcohol and drug use during pregnancy, breastfeeding, parenting skills and child development, as well as referrals for prenatal care, primary pediatric care and immunizations for dependent children. Additional services include on-site childcare for children up to age three and transportation to and from treatment sessions. Opioid/Narcotic Treatment Programs: OTP/NTP Outpatient These outpatient services are provided by County NTP licensed facilities to Medi-Cal beneficiaries. You must be evaluated and determined by a licensed physician to have medical necessity for these services. OTP/NTP programs offer and prescribe medications including Methadone, Buprenorphine (Suboxone), Naloxone (Narcan) and Disulfiram (Antabuse). Services include a medical exam and evaluation, lab work, random urinalysis screens, individual and group counseling for a minimum of 50 minutes up to a maximum of 200 minutes per month.

Medication Assisted Treatment Services (MAT): Outpatient Medication Assisted Treatment services are available outside of the OTP clinic. MAT is the use of prescription medications, in combination with counseling and behavioral therapies, to provide a whole-person approach to the treatment of

substance use disorder (SUD). MAT services includes the ordering, prescribing administering and monitoring of all medications for SUD. Opioid and alcohol use, in particular have well established medication options. Physicians and other prescribers may offer medications under Drug Medical including Buprenorphine, Naloxone, Disulfiram, Naltrexone (Vivitrol), Acamprosate (Campral) or any FDA approved medication for the treatment of SUD. Residential Programs Residential treatment consists of 24 hours per day, seven days per week. The severity and dangerous consequences of the beneficiary’s use prevent them from safely accessing care at a lower level. The goal of residential treatment is stabilization; beneficiaries are able to safely transfer to a lower level of care and continue the work that began at residential. Beneficiaries are allowed a maximum of two separate residential episodes per year. Each episode may be authorized for treatment services up to 90 days at a time. One extension of up to another 30 days may be granted for one of the two yearly episodes. This may clarify: IN ONE YEAR: Plus

As stated earlier, length of stay must match the proper criteria for medical necessity. Perinatal Services

Substance use treatment for pregnant and/or parenting women is offered through intensive individual and group counseling. Opiate-dependent women may receive medically supervised methadone maintenance or detoxification treatment. Programs provide women-specific treatment and therapeutic interventions, including intake, assessment, treatment planning, individual treatment, collateral, crisis intervention services, discharge planning and group counseling; case management; education (vocational and life skills resources,

Maximum of 90 day stay


Possible 30 day extension

TB and HIV, alcohol and drug use during pregnancy and breastfeeding, parenting skills and child development); as well as providing or arranging for primary medical care for women in treatment including referrals for prenatal care, primary pediatric care, and immunizations for dependent children. As a service, SUTS provides on-site childcare for children up to age three and transportation to and from treatment sessions. Withdrawal Management This level of care has traditionally been known as Detox. It is for those who are having withdrawal symptoms from substance use and do not require medical care from a doctor or a nurse. This service takes place in a residential facility which provides care 24 hours per day, seven days per week. Staff provides referral to medical care if necessary. Beneficiaries begin treatment when they are physically able to participate. They will be screened and referred to the next appropriate level of care. Case Management Services Case management services are provided by on-site staff, where the person is currently in treatment. Case management involves linking beneficiaries to outside services related to the person’s immediate needs, such as primary care, mental health, legal, vocational and housing resources. Recovery Services Beneficiaries can receive on-going support after treatment, through individual and group counseling, relapse prevention, recovery monitoring or linkage to support groups to assist their recovery.

Adolescents Outpatient Programs Treatment services for adolescents are offered at centrally based clinics, as well as at particular school sites throughout Santa Clara County. Outpatient sites offer services up to six hours per week, based on the beneficiary’s needs. Treatment services are offered to youth without mandated parent involvement. We do however encourage parents to be involved and treatment is more effective when there is family or caregiver involvement.

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Intensive Outpatient Intensive Outpatient Treatment (IOT) is an intensive track which is a minimum of 6 hours per week. IOT is to help a youth focus on positive relapse prevention skills and the effects of substance use in their lives. The Transitional Age Youth program (TAY) is sensitive to the developmental needs of young adults age 18 through 25, coordinating services appropriate for this age group, such as community resources and age appropriate treatment services addressing substance use in their lives. Residential Programs Residential treatment consists of 24 hours per day, seven days per week. The severity and dangerous consequences of the beneficiary’s use prevent them from safely accessing care at a lower level. The goal of residential treatment is stabilization; they are able to safely transfer to a lower level of care and continue the work that began at residential. Beneficiaries are allowed a maximum of two separate residential episodes per year. Each episode may be authorized for treatment services up to 30 days at a time. One extension of up to another 30 days may be granted for one of the two yearly episodes. This may clarify: IN ONE YEAR:

Plus As stated earlier, length of stay must match the proper criteria for medical necessity. Case Management Services Case management services are provided by the primary treatment counselor. Case management involves linking beneficiaries to outside services related to the person’s immediate needs, such as primary care, mental health, legal, vocational and housing resources. Recovery Services Youth and young adults can receive on-going support after treatment, through individual and group counseling, relapse prevention, recovery monitoring or linkage



Possible 30 day extension


to support groups to assist their recovery.

Medi-Cal and Supportive Services If you are having difficulty getting to your medical appointments or your NTP appointments your counselor will help you find resources. As a beneficiary you can get information about local services from County social services. We will work with you and social services for food, housing, employment and transportation services.

Chapter 4: Access to Services

How to Request Substance Use Treatment Services If you, or someone in your family needs Substance Use Treatment Services, call the 24-hour beneficiary access line - Gateway Call Center at (800) 488-9919. The Gateway Call Center will discuss your Substance Use treatment options, based on your current situation and needs. If you are experiencing severe or life-threatening symptoms from use or overuse of drugs and/or alcohol, dial 911 immediately or go to any emergency room. Emergency services are covered 24 hours a day, seven days a week. Prior authorization is not required for emergency services.

The Managed Care Plan (MCP) respects the right for those who wish, to receive faith-based treatment. We do not provide that within our network of providers. If you wish to receive faith-based treatment services, please contact the MCP Beneficiary Membership number at 408-792-5666.

Authorization of Treatment Services To be "authorized" means that you have been approved by the Santa Clara County Substance Use Treatment Services (SUTS), Managed Care Plan (MCP) for substance use treatment. The MCP uses qualified Substance Use Treatment professionals to screen for eligibility. The authorization will occur within 24 business hours of arriving at the provider to which you have been referred. You, your provider and the MCP are all involved in deciding the type of services you will receive.

Language Translation Services The MCP strives to provide sensitivity to culturally and linguistically appropriate


substance use services. Oral and written interpretation services are available free of cost in the threshold languages, English, Spanish, Vietnamese, Mandarin, and Tagalog, free of charge. ACCESS FOR HEARING IMPAIRED BENEFICIARIES If you are hearing impaired, you can use the California Relay Service at 1-800-855-7100 (TTY). For California Relay Service in Spanish call 1-800-855-7200 ACCESS FOR VISION IMPAIRED BENEFICIARIES This booklet and other MCP important materials are available in large print for the vision impaired. For other formats, or for help in reading this booklet and other materials, please ask your provider. If your provider is unable to assist you, call Member Services @ 792-5666.

Chapter 5: Beneficiary Rights and Protections Notice of Privacy Practices

As a part of the Santa Clara Valley Health and Hospital System BHSD/SUTS we know the value of your privacy and want to protect your health information. Your information can only legally be shared with your permission or within the statutes of the law. We will not disclose any health information that is not in accord with the Federal and State and County law. Moreover we want to make sure you have been given a copy of your Notice of Privacy Practices. Any individual identifiable information, either in electronic or physical form, regarding your medical history, mental or physical condition or treatment that includes elements of identifying information or would reveal your identity is protected. You have rights concerning the access, use and disclosure of your personal protected health information (PHI). It is our policy to always have posted the Notice in a public place at each of our sites. We take great effort to maintain your PHI. We follow HIPAA privacy rules that define your right to be informed of your privacy rights and of Code of Federal Regulations (CFR) 42 part 2 – The Confidentiality of Alcohol and Drug Patient Records, about how to exchange of information, with your consent. We offer a statement at the beginning of treatment that provides an explanation of your rights and practices. It is our policy to always have posted the Notice of Privacy Practices in a public place at each of our sites. You may ask for a copy of the privacy notice any


time you wish.

You have a right to receive Substance Use Treatment Services from the Behavioral Health Services Department (BHSD) Substance Use Treatment Services (SUTS) Managed Care Plan (MCP). When accessing these services, you have the right to:

• Be treated with personal respect for your dignity and privacy

• Receive information about available treatment options and alternatives, including the right to select providers

• Participate in decisions regarding your care, including the right to refuse

treatment

• Request and receive a copy of your medical records. You may be charged for the cost of copying your records.

• Upon review of your record, you may request that it be amended or corrected

• Determine who has access to your Personal Health Information (PHI). Your

PHI is confidential and protected within the boundaries of HIPAA and 42 CFR, Part 2 unless you give signed consent to share your information. o Please note: The MCP and its contracted providers are required by law, to

disclose protected health information without your written authorization under these specific circumstances: to report suspected abuse of a child or a vulnerable adult; serious threats to another person; to coordinate and/or provide emergency, life-threatening care.

• Receive information about all covered services, free of charge and in a

language and manner which you can understand. Your Health Plan will provide appropriate materials for people with special needs, related to vision, hearing and learning difficulties.

• To be free from any form of restraint or seclusion

• Receive Substance Use Treatment Services that follow all State requirements


• Exercise your rights, without being adversely affected by your health plan and its providers

• In the event a treatment provider is unable to remain in operation, all

beneficiaries receiving treatment from that program will be notified at least 15 days prior to closure. Staff will assist in making the necessary referrals to ensure a helpful transition.

Advance Directives

An Advance Directive is a legal document that allows you to say, in advance, what your wishes would be, if you become unable to make health care decisions. It is designed to allow you to have control over your own treatment. You have the right to have an Advance Directive. It is also a written instruction about your health care that is recognized under California law stating how you would like health care provided, and outlines what decisions you would like to be made, if or when you are unable to speak for yourself. You may sometimes hear an advance directive described as a living will or durable power of attorney.

We provide any adult who is Medi-Cal eligible with written information on the Advance directive policies if you ask for the information. If you would like to request the information, you should talk to your direct provider. Or you may call MCP’s beneficiary membership number at 408-792-5666. The California Advance Directive consists of two parts:

1. Your appointment of an agent (a person of your choosing) to make decisions about your health care, and

2. Your individual health care instructions.

If you have a complaint about advance directive requirements, you may contact: • California Department of Health Services,

Licensing and Certification Division P.O. Box 997413 Sacramento, California 95899-1413 You may also call (800) 236-9747

You may have additional rights under state laws about Substance Use Treatment and may wish to contact your county's Patients' Rights Advocate (call Behavioral Health Services – Substance Use Treatment Services listed in the local phone book and ask


for the Beneficiary Rights Advocate) with specific questions.

Chapter 6: Resolution Process Notice of Adverse Benefit Determination

A Notice of Adverse Benefit Determination, formerly known as a Notice of Action is a form that will tell you when a decision is made about whether or not you will get Medi-Cal Substance Use Treatment services. A Notice of Adverse Benefit Determination is also used to tell you if the Grievance, Appeal, or expedited Appeal was not resolved in time. Additionally, it will be sent if you did not receive services within the MCP's time frame. When A Notice of Adverse Benefit Determination (NOA) is sent You will receive a NOA Benefit Determination:

• If your MCP or one of their providers decides that you do not qualify to receive any Medi-Cal Substance Use Treatment services because you do not meet the medical necessity criteria

• If your provider thinks you need a Substance Use Treatment service but the MCP does not agree and denies the request, or changes the type or frequency of the service. (Most of the time you will receive a Notice of Adverse Benefit Determination before you receive the service. If you are receiving the service or have already received the service and you get a NOA, you do not have to pay for the unauthorized service)

• If your provider has asked the MCP for approval, but the MCP needs more information to make a decision and doesn't complete the approval process on time

• If the MCP does not provide services within the required timelines. You may call the Santa Clara County MCP to enquire about timeline standards

• If you file a Grievance and the MCP does not get back to you with a written decision on your Grievance within 60 days

• If you file an Appeal with the MCP and they do not respond with a written decision within 30 days or, if you filed an expedited Appeal within three working days

What the Notice of Adverse Benefit Determination Will Say The NOA Benefit Determination will tell you:

• What decisions the MCP made that affects you and your ability to get services • The effective date of the decision and the reason the MCP made its decision • The state or federal rules the MCP was following when it made the decision • What your rights are if you do not agree with the decision • How to file an Appeal with the MCP


• How to request a State Fair Hearing • 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 • If you are eligible to continue to receive services while you wait for a State

Fair Hearing decision • The timeline within which you must file your State Fair Hearing request if you

want the services to continue Reasons a Notice of Adverse Benefit Determination will not be sent You may not receive a NOA Benefit Determination:

• If you and your provider do not agree on the services you need • If you think the MCP is not providing services to you quickly enough, but the

MCP hasn’t set a timeline You may still file an Appeal with the MCP or request a State Fair Hearing when these things happen. Information on how to file an Appeal or request a State Fair Hearing is included in this handbook. Information should also be available in your provider's office. Actions to take when you receive a Notice of Adverse Benefit Determination When you get a NOA Benefit Determination you should read all the information on the form carefully. If you don’t understand the form, your MCP can help you. If the Notice of Adverse Benefit Determination form tells you that you can continue services while you are waiting for a State Fair Hearing decision, you must request the State Fair Hearing within 10 days from the date the Notice of Adverse Benefit Determination was mailed or personally given to you.

Problem Resolution Process Your county's MCP has a way for you to work out a problem about any issue related to the specialty Substance use Treatment services you are receiving. This is called the problem resolution process and it could involve:

1. Appeal Process - review of a decision (denial or changes to services) that was made about your substance use services by the MCP or your provider.

2. State Fair Hearing Process - review to make sure you receive the Alcohol & Drug services which you are entitled to under the Medi-Cal program.

3. Grievance Process - an expression of unhappiness about anything regarding


your Substance Use Treatment services that is not one of the problems covered by the Appeal and State Fair Hearing processes.

SUTS providers will provide Grievance and Appeal process and forms with self-addressed envelopes for you openly at each site. Language interpreting services are available at no charge, along with toll-free numbers to help you during normal business hours. You will not be jeopardized for filing a Grievance, Appeal or State Fair Hearing. When you’re Grievance or Appeal is complete, your county's SUTS will notify you and others involved of the final outcome. When your State Fair Hearing is complete, the State Hearing Office will notify you and others involved of the final outcome. Your MCP is responsible for allowing you to request a review of a decision that was made about your Substance Use Treatment services by the MCP or your providers. There are two ways you can request a review. One way is using the standard Appeals process. The second way is by using the expedited Appeals process. These two forms of Appeals are similar; however, there are specific requirements to qualify for an expedited Appeal. The specific requirements are explained below. How to Receive Help to File an Appeal, Grievance or State Fair Hearing Your county's SUTS will have people available to explain these processes to you and to help you report a problem either as an Appeal, a Grievance, or as a request for a State Fair Hearing. They may also help you know if you qualify for what's called an 'expedited' process, which means it will be reviewed more quickly because your health or stability is at risk. You may also authorize another person to act on your behalf, including your SUTS care provider.

Standard Appeal A Standard Appeal is a request for review of a problem you have with the MCP or your provider that involves denial or changes to services you think you need. If you request a standard Appeal, the MCP may take up to 30 days to review it. If you think waiting 30 days will put your health at risk, you should ask for an 'expedited Appeal.' The Standard Appeals Process will:

• Allow you to file an Appeal in person, on the phone, or in writing. If you submit your Appeal in person or on the phone, you must follow it up with a signed written Appeal. If you do not follow-up with a signed written Appeal,


your Appeal will not be resolved. However, the date that you submitted the oral Appeal is the filing date

• Ensure filing an Appeal will not count against you or your provider in any way

• Allow you to authorize another person to act on your behalf, including a provider If you authorize another person to act on your behalf, the MCP might ask you to sign a form authorizing the MCP to release information to that person

• Ensure that the individuals making the decisions are qualified to do so and not involved in any previous level of review or decision-making

• Allow you or your representative to examine your case file, including your medical record, and any other documents or records considered during the Appeal process, before and during the Appeal process

• Allow you to have a reasonable opportunity to present evidence and allegations of fact or law; in person or in writing

• Allow you, your representative, or the legal representative of a deceased beneficiary estate to be included as parties to the Appeal

• Let you know your Appeal is being reviewed by sending you written confirmation

• Inform you of your right to request a State Fair Hearing anytime during the Appeal process

When to File an Appeal You can file an Appeal with your county's BHSD SUTS MCP:

• If your MCP or one of the MCP's providers decides that you do not qualify to receive any Medi-Cal Substance Use Treatment services because you do not meet the medical necessity criteria

• If your provider thinks you need a Substance Use Treatment service and asks the MCP for approval, but the MCP does not agree and says "no" to your provider's request, or changes the type or frequency of service.

• If your provider has asked the MCP for approval, but the MCP needs more information to make a decision and doesn’t complete the approval process on time

• If the MCP doesn’t provide services to you based on the timelines the MCP has set up

• If you don't think the MCP is providing services soon enough to meet your medical needs


• If the Grievance, Appeal or expedited Appeal wasn't resolved in time • If you and your provider do not agree on the services you need

Notification of the Appeal Decision Your MCP will notify you or your representative in writing about their decision for your Appeal. The notification will have the following information:

• The results of the Appeal resolution process • The date the Appeal decision was made • If the Appeal is not resolved wholly in your favor, the notice will also contain

information regarding your right to a State Fair Hearing and the procedure for filing a State Fair Hearing

Deadline to File an Appeal You must file an Appeal within 60 days of the date of the action you are Appealing when you get a Notice of Adverse Benefit Determination. Keep in mind that you will not always get a 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 at any time. Appeal Decisions Timeline The MCP must decide on your Appeal within 45 calendar days from when the MCP receives your request for the Appeal. Timeframes may be extended by up to 14 calendar days if you request an extension, or if the MCP feels that there is a need for additional information and that the delay is for your benefit. An example of when a delay might be for your benefit is when the MCP thinks it might be able to approve your Appeal if the MCP had a little more time to get information from you or your provider. What If I Can’t Wait 30 Days For My Appeal Decision? The Appeal process may be faster if it qualifies for the expedited Appeals process. (Please see the section on Expedited Appeals below.) You have the right to request a State Fair Hearing at any time during the Appeals process.

Expedited Appeal An expedited Appeal is a faster way to decide an Appeal. The expedited Appeals process follows a process similar to the standard Appeals process. However, your Appeal has to meet certain requirements (see below):


• The expedited Appeals process also follows different deadlines than the standard Appeals process

• You can make a verbal request for an expedited Appeal. You do not have to put your expedited Appeal request in writing

When to File an Expedited Appeal If you think that 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 Appeal. If the MCP agrees that your Appeal meets the requirements for an expedited Appeal, your MCP will resolve your expedited Appeal within 3 working days after the MCP receives the expedited Appeal. Timeframes may be extended by up to 14 calendar days if you request an extension, or if the MCP feels that there is a need for additional information and that the delay is in your interest. If your MCP extends the timeframes, the MCP will give you a written explanation as to why the timeframes were extended. If the MCP decides that your Appeal does not qualify for an expedited Appeal, your MCP will notify you right away orally and will notify you in writing within 2 calendar days. Your Appeal will then follow the standard Appeal timeframes outlined earlier in this section. If you disagree with the MCP's decision that your Appeal doesn't meet the expedited Appeal criteria, you may file a Grievance (see the description of the Grievance process. Once your MHP resolves your expedited Appeal, the MCP will notify you and all affected parties orally and in writing How to Solve a Problem with the MCP Other than Filing a Grievance or Appeal You can get help from the State if you are having trouble finding the right people at the MCP to help you find your way through the SUTS system. The State has Ombudsman Services that can provide you with information on how the MCP system works, explain your rights and choices, help you solve problems with getting the services you need, and refer you to others at the MCP or in your community who may be of help. The DHCS Office of the Ombudsman phone number is: 1-888-452-8609.

State Fair Hearing

A State Fair Hearing is an independent review conducted by the California Department of Social Services to ensure you receive the Substance Use Treatment services to which you are entitled under the Medi-Cal program. State Fair Hearing Rights


You have the right to: • Have a hearing before the California Department of Social Services (also

called a State Fair Hearing) • Be told about how to ask for a State Fair Hearing • Be told about the rules that govern representation at the State Fair Hearing • Have your benefits continued upon your request during the State Fair Hearing

process if you ask for a State Fair Hearing within the required timeframes • Ask for a State Fair Hearing whether or not you use the MCP's Appeal

process and whether or not you have received a Notice of Adverse Benefit Determination as described earlier in this booklet

When to File a State Fair Hearing You can file for a State Fair Hearing:

• If the MCP or one of the MCP's providers decides that you do not qualify to receive any Medi-Cal Substance Use Treatment Services because you do not meet the medical necessity criteria

• If your provider thinks you need a Substance Use Treatment service and asks the MCP for approval, but the MCP does not agree and says "no' to your provider's request, or the MCP changes the type or frequency of service

• If your provider has asked the MCP for approval, but the MCP needs more information to make a decision and doesn't complete the approval process on time

• If the MCP doesn’t provide services to you based on the timelines the MCP has set up

• If you don’t think the MCP is providing services soon enough to meet your medical needs.

• If the Grievance, Appeal or expedited Appeal wasn’t resolved in time • If you and your provider do not agree on the services you need

How to File a State Fair Hearing You can request a State Fair Hearing directly from the California Department of Social Services. You can ask for a State Fair Hearing by writing to:

California Department of Social Services State Hearings Division, ACAB 744 P Street, MS 9-17-97 Sacramento, CA 95814


To request a State Fair Hearing, you may also call

1-800-952-5253, or for hearing impaired who use TDD, 1-800-952-8349, or Send a fax to 1-916-651-2789

The Timeline for Filing for a State Fair Hearing If you didn't receive a Notice of Adverse Benefit Determination or file an Appeal with the MCP you may file for a State Fair Hearing at any time. If you get a Notice of Adverse Benefit Determination and decide to file for a State Fair Hearing instead of, or in addition to, filing an Appeal with the MCP you must file for the State Fair Hearing within 120 days of the date your Notice of Adverse Benefit Determination was mailed or personally given to you. If you file an Appeal with the MCP and want to file for a State Fair Hearing after you get the MCP's decision on your Appeal, you must file for the State Fair Hearing within 120 days of the postmark date of the MCP's Appeal decision.

Continue to Receive Services while waiting for the State Fair Hearing Decision You can continue services while you're waiting for a State Fair Hearing decision if your provider thinks the substance use treatment services you are already receiving need to continue. They will ask the MCP for approval to continue. The MCP may or may not agree to your provider's request, or change the type or frequency of service the provider requested. You will always receive a Notice of Adverse Benefit Determination from the MCP when this happens. Additionally, you will not have to pay for services given while the State Fair Hearing is pending. If my request to Continue Services while I'm waiting for a State Fair Hearing decision is denied If you want services to continue during the State Fair Hearing process, you must request a State Fair Hearing within 10 days from the date your Notice of Adverse Benefit Determination was mailed or personally given to you. What If I Can't Wait 90 Days For My State Fair Hearing Decision? You may ask for an expedited (quicker) State Fair Hearing if you think the normal 90-day time frame will cause serious problems with your Substance Use Treatment, including problems with your ability to gain, maintain, or regain important life


functions. The Department of Social Services, State Hearings Division, will review your request for an expedited State Fair Hearing and decide if it qualifies. If your expedited hearing request is approved, a hearing will be held and a hearing decision will be issued within 3 working days of the date your request is received by the State Hearings Division.

Grievance A Grievance is an expression of unhappiness about anything regarding your Substance Use Treatment Services that are not one of the problems covered by the Appeal and State Fair Hearing processes. The Grievance process will:

• Involve simple, and easily understood procedures that allow you to present your Grievance orally or in writing

• Not count against you or your provider in any way • Allow you to authorize another person to act on your behalf, including a

provider. If you authorize another person to act on your behalf, the MCP might ask you to sign a form authorizing the MCP to release information to that person

• Ensure that the individuals making the decisions are qualified to do so and not involved in any previous levels of review or decision-making

• Identify the roles and responsibilities of you, your MCP and your provider • Provide resolution for the Grievance in the required timeframes

Reasons for Filing a Grievance You can file a Grievance with the MCP if you are unhappy with the Substance Use Treatment Services you are receiving from the MCP or have another concern regarding the MCP When to File a Grievance You may file a Grievance at any time. How to File a Grievance You may call your county MCP's telephone number 408-792-5666 to get help with a Grievance. The MCP will provide self-addressed envelopes at all the providers' sites for you to mail in your Grievance. Grievances can be filed orally or in writing. Oral Grievances do not have to be followed up in writing.


How Do I Know If The MCP Received My Grievance? Your MCP will let you know that it received your Grievance by sending you a written confirmation. Timeline for the Grievance Decision The MCP must make a decision about your Grievance within 60 calendar days from the date you filed your Grievance. Timeframes may be extended by up to 14 calendar days if you request more time, or if the MCP feels there is a need for additional information and that the delay was for your benefit. An example of when a delay might be for your benefit is when the MCP thinks it might be able to approve your Grievance if the MCP had a little more time to get information from you or other people involved. Notification of my Grievance Decision When a decision has been made regarding your Grievance, the MCP will notify you or your representative in writing of the decision. If your MCP fails to notify you or any affected parties of the Grievance decision on time, the MCP will provide you with a Notice of Adverse Benefit Determination advising you of your right to request a State Fair Hearing. Your MCP will provide you with a Notice of Adverse Benefit Determination on the date the timeframe expires.


Appendix Adult Provider List

Adult Provider

Address Phone Type of Services

Non –English

Languages Spoken

Alexian Health Center

2101 Alexian Dr. Suites A & B San Jose, CA 95116

408-272-6577

Medication Assisted Outpatient Treatment

English only

Caminar/Family & Children Services

950 W. Julian St. San Jose, CA 95126

408-292-9353

Outpatient Intensive Out patient

Spanish


2218 N. 1st St. San Jose, CA 95131

408-538-0880


German, Hindi, Mandarin, Russian, Spanish


375 Cambridge Ave. Palo Alto, CA 94306

650-326-6576


English only

Gardner-Proyecto Primavera

614 Tully Rd. San Jose, CA 95111

408-977-1591

Outpatient Spanish

Central Valley Clinic

2425 Enborg Ln. San Jose, CA 95128 408-885-5400


Spanish Tagalog Polish (Vietnamese: MD only)

Central Treatment & Recovery

976 Lenzen Ave. San Jose, CA 95126

408-792-5656 Outpatient

Spanish

HealthRight 360 1340 Tully Rd. #304 San Jose, CA 95122


Spanish Tagalog Vietnamese Ilocano,

Horizon South 650 S. Bascom Ave. #C San Jose, CA 95128

408-283-8555

• Residential Men Only

• Withdrawal Management Men only

English only

Indian Health Center

602 E. Santa Clara St. San Jose 95112

408-445-3400 x 240

Outpatient English only

Parisi House on the Hill

9505 Malech Rd. San Jose, CA 95138

408-281-6570 Perinatal Residential for women w/ child

Spanish


up to age 5

Adult

Provider Address Phone

Type of Services

Non –English

Languages Spoken

Pathway Outpatient

16433 Monterey Rd. #140 Morgan Hill, CA 95037


Spanish

Pathway House 102 S. 11th St. San Jose 95112

408-998-5191

Residential Co-ed

Spanish

Pathway Mariposa Lodge

9500 Malech Rd. San Jose 95138

408-281-6555

• Residential Women Only

• Withdrawal Management Women only

Spanis59+++h

Project Ninety 792 S. 3rd St. San José 95112

408-295-3799

Residential Men Only

Spanish

South County Clinic

90 W Highland Ave. San Martin 95046

408-852-2420


Spanish (Vietnamese: MD only)

Adolescent Provider List

Adolescent Provider


Non –English Languages

Spoken

Advent Group Ministries

90 Great Oaks Blvd. #108 San Jose, CA 95119

408-281-0708 Residential All Male and All Female Sites

English only

Advent Group Ministries

90 Great Oaks Blvd. #108 San Jose, CA 95119

408-281-0708 Outpatient, Intensive Outpatient

Cantonese, Spanish

Asian Americans for Community Involvement

2400 Moorpark Ave Suite 300 San Jose, CA 95128

408-975-2730

Outpatient Japanese, Spanish

Children, Families and Community Services

2101 Alexian Dr. San Jose,

408-272-6518 Outpatient and school site

Spanish, Vietnamese


(CFCS) CA 95116 outpatient

Adolescent Provider


Non –English Languages

Spoken

HealthRight 360

1340 Tully Rd. # 304 San Jose, CA 95122


Spanish, Laotian, Ilocano, Japanese

Pathway James Ranch

19050 Malaguerra Ave Morgan Hill, CA 95037

408-201-7600

Juvenile Detention Ranch

Spanish, Vietnamese

beneficiary handbook substance use treatment services b… · the least intensive outpatient sites...

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