california institute for mental health
Healthy Families Update
Welcome to the Healthy
Families Update from CIMH!
Our Goal: Provide brief, practical
updates on HF Mental Health issues for
County Administrators, Health Plan
Liaisons, and Mental Health Workers.
We hope this will improve
communication and expand access to the
HF Mental Health benefit. Please share
this newsletter with Access Teams,
mental health staff, and others!
This Month’s Topic: A Summary of
Responsibilities—Who is Supposed to
do What, When for HF members with
mental health needs?
Upcoming Topics: Billing Questions,
Hospitalization…and more.
Other Great Sources of
Information on HF Mental
Health
This winter, CIMH will produce a
Healthy Families Reference Guide,
containing key policies, contact
information, and a way to store issues of
this newsletter. In the meantime, you
can turn to the following:
HF Mental Health Benefits
in a Nutshell
Healthy Families mental health coverage
includes the diagnosis and medically
necessary treatment of serious mental
illness. Benefits are split into two parts:
Basic and SED.
Basic Benefits (Health Plans Provide)
Outpatient services (20 visits/year w/$5
copay), mental health inpatient hospital
services (up to 30 days/year, no charge),
alcohol and drug abuse inpatient as
medically appropriate to remove toxic
substances from the system (no charge),
alcohol and drug outpatient (20
visits/year w/$5 copay), and prescription
drugs.
Seriously Emotionally Disturbed
(SED) Benefit (Counties Provide)
Supplemental mental health benefit for
children with SED that is managed by
County Mental Health Plans. Children
who are determined by the Department
to be SED will be provided the full range
of medically necessary services to the
extent resources are available.
The CIMH Healthy Families SED
benefit Brochure:
http://www.cimh.org/healthy_families.html
Overall program information, including
lists of certified application assistants
who assist families with the application:
http://healthyfamilies.ca.gov/
In This Issue:
Welcome! HF Mental Health
benefits at a glance
County MH Administrators: Overview of
county responsibilities
Health Plans: Overview of plan
responsibilities
County MH Staff: Healthy Families Basics
Everyone: Healthy Families Enrollment Data
General:
1
3
4
5
6
Healthy Families Update
January 2001 PAGE 1
CIMH Healthy Families Update
Defining “Seriously
Emotionally Disturbed”
In CIMH’s work around the State, we
have learned that some confusion exists
regarding the proper definition of
“Seriously Emotionally Disturbed
(SED)” for purposes of the Healthy
Families Mental Health benefit.
Definitions of SED differ in different
systems and for different funding
sources. For Healthy Families enrollees,
according to WIC 5600.3, in order to
meet the criteria for “seriously
emotionally disturbed,” a youth must:
Have a DSM-IV Diagnosis, excepting
V-codes, substance abuse, or
developmental disorders and meet at
least one of the following criteria:
A. As a result of the mental disorder
have severe impairment in two of the
following areas: self-care, school
functioning, family relationships, or
ability to function in the community
and either of the following occur:
Wait! There’s More!
On the following pages you will find
three sections that will always appear in
this newsletter:
 County Mental Health
Administrators Healthy Families
Update
 Health Plans Healthy Families
Update
 County Mental Health Staff
Healthy Families Update
This month, we focus on responsibilities
under Healthy Families.
Suggestions? Questions?
Contact us with your suggestions for
future newsletter topics, comments on
this issue, and questions: email Mary
Jane Alumbaugh, Ph.D., at
mjalumbaugh@cimh.org.
 The child is at risk of removal
from home or has already been
removed from the home.
 The mental disorder and
impairments have been present
for more than six months or are
likely to continue for more than
one year without treatment.
B. The child displays one of the
following: psychotic features, risk of
suicide, or risk of violence due to a
mental disorder.
C. The child meets special education
requirements.
Healthy Families Update
January 2001 PAGE 2
County MH Admin
County Responsibilities
Under Healthy Families
According to the Memorandum of
Understanding (MOU), promulgated by
the Managed Risk Medical Insurance
Board (MRMIB) and signed by most
counties and Health Plans, both Counties
and Health Plans have a number of
specific responsibilities under Healthy
Families. This page summarizes the
MOU’s content regarding County
responsibilities in the areas of
assessment, benefits, coordination, and
medical necessity.
Assessment
The County will assess or arrange to
assess children referred for a mental
health evaluation and will determine if
the child meets SED criteria (WIC Code
5600.3).
 Evaluations will be performed
within five (5) days of referral if the
child is receiving inpatient services.
CIMH Healthy Families Update
Benefits
Children accepted for treatment by the
County Mental Health Department as
SED will be eligible for:
 Medically necessary outpatient
services for treatment of the child’s
serious emotional disturbance.
 Medically necessary outpatient
medication and laboratory services
that are part of the child’s outpatient
treatment plan with the Mental
Health Department.
 Inpatient services including
professional and ancillary services
associated with inpatient days, when
Plan inpatient benefits are
exhausted and such services meet
Short-Doyle Medi-Cal medical
necessity.
Coordination
The County Mental Health Department
will:
 Evaluations will be performed
within thirty (30) days in all other
cases (providing all necessary
information is included in the
referral).
 Consult with the plan as they
determine when non-inpatient care
may be substituted for inpatient
benefits to shorten inpatient stays.
 Counties will be liable for inpatient
costs incurred by the Plan when the
child’s discharge is delayed by
County failure to meet these
timelines.
When the County Mental Health
Department is responsible for inpatient
care, it will utilize the Short-Doyle
Medi-Cal medical necessity and
emergency admission to an acute
psychiatric hospital.
The County shall develop a procedure
for identifying Plan beneficiaries
already receiving SED services.
Medical Necessity
Healthy Families Update
January 2001 PAGE 3
Health Plans
Health Plan Responsibilities
for Children with SED Under
Healthy Families
Health Plans, like counties, have clearly
defined responsibilities as a result of the
MOU in the areas of assessment,
benefits, coordination, and medical
necessity.
Assessment
The Health Plan will obtain or arrange
to obtain a mental health screening
and assessment of any enrollee they
suspect may have a serious emotional
disturbance. The Health Plan will then
refer the child to the County Mental
Health Department for evaluation if the
Health Plan has reason to believe the
following:
A. The child has a serious emotional
disturbance as defined in WIC
5600.3.
B. The disorder cannot be effectively
managed with relatively short-term
therapy.
Benefits
As noted on Page 1, Health Plans
provide basic mental health benefits to
all children. However, they also retain
responsibility for certain benefits to
children with SED.
According to the MOU, children [with
SED] being treated by the County
Mental Health Department will retain
eligibility for Plan benefits including:
CIMH Healthy Families Update
Coordination and
Medical Necessity
The referral for an evaluation for SED to
County Mental Health shall be in
writing and may include a locally
agreed upon referral packet that includes
material the Health Plan and the County
Mental Health Department believe will
facilitate timely, thorough referrals.
The Health Plan may identify procedures
for referral from primary care
physicians.
The Health Plan will provide inpatient
services within the following
parameters. The Health Plan will:
A. When considering admission of SED
children to an inpatient facility
utilize inpatient benefit approval
criteria that are the same as Health
Plan processes for inpatient benefit
approval for non-SED/HF children.
B. Determine with the County Mental
Health Department how ongoing
care for SED children can be
coordinated when inpatient services
are required.
C. The Health Plan, in consultation with
the County Mental Health
Department, will determine when
non-inpatient care may be substituted
for inpatient benefits to shorten
inpatient stays.
A. Inpatient treatment of an acute phase
of a mental health condition in a
participating hospital for up to 30
days per benefit year as per benefits
under this Health Plan, including
professional and ancillary benefits
associated with inpatient days.
Healthy Families Update
January 2001 PAGE 4
County MH Staff
What is Healthy Families?
The Healthy Families Program is a state
and federally funded health coverage
program for children with family
incomes above the level eligible for no
cost Medi-Cal and below 250% of the
federal income guidelines ($35,376 for a
family of three). Healthy Families
provides health (including mental
health), dental, and vision benefits.
Healthy Families members pay a small
premium (which can also be paid by
other community organizations) and
some copayments. Healthy Families is a
key part of California’s effort to reduce
the number of children without health
insurance.
How Does Healthy Families
Affect Mental Health
Services?
Children enrolled in Healthy Families
can get basic mental health services
through their Healthy Families Health
Plan. However, if they have SED, they
will be referred to the County Mental
Health Department. Sometimes, a child
and family will enter the County system
for services and the County will
determine that they are already enrolled
in Healthy Families. Counties can then
bill for these services through the
SD/MC claims processing.
What Rules Affect Healthy
Families?
CIMH Healthy Families Update
There are also certain forms and
protocols for coordination designed to
ensure continuity of care. Contact your
County’s Healthy Families Liaison or
Children’s System of Care (CSOC)
Coordinator for additional information.
Many of the procedures and rules
affecting Healthy Families Mental
Health will be summarized in the
upcoming Healthy Families Mental
Health Reference Guide from CIMH.
How Can I Tell if Someone is
Enrolled in Healthy Families?
 Your County Mental Health
Department’s administrative staff
may have noted their Healthy
Families Program enrollment when
they first came to the County for
service.
 They may have a Card from their
Health Plan. Some cards will say
“Healthy Families,” but others will
not. If someone presents a Health
Plan card, make sure to check
carefully to determine if they are in
the Healthy Families Program. (An
upcoming issue of this newsletter
will review Healthy Families Health
Plan cards for easier identification.)
 They may have been referred by
their Health Plan for SED services.
If you get a referral, contact your
Healthy Families Liaison or CSOC
coordinator for information
regarding the proper referral forms.
Healthy Families members have specific
rights to services. If your County
Mental Health Department receives a
referral from a Health Plan, the County
must evaluate the child within 5 days if
he or she is hospitalized, and within 30
days otherwise.
Healthy Families Update
January 2001 PAGE 5
Everyone
CIMH Healthy Families Update
What’s Next in This
Newsletter?
How Can I Refer an
Uninsured Family to the
Healthy Families Program?
In upcoming issues, this newsletter will
provide additional detail for mental
health staff on:
The Healthy Families Program can
provide important benefits to uninsured
families, including health, dental, and
vision coverage. Your County Mental
Health Department’s intake office may
have people trained to assist clients who
wish to enroll in Healthy Families. If
they do not, a wide range of community
agencies in each County also can assist
people with the Healthy Families
enrollment process.
 Healthy Families referral procedures;
 How to identify a Healthy Families
enrollment card;
 Explaining Healthy Families benefits
to clients…
…and more. If you would like to
suggest a topic, please email:
mjalumbaugh@cimh.org.
For an up-to-date list in your County,
you can visit the Healthy Families web
site at: http://healthyfamilies.ca.gov/
SED Healthy Family Plan (9H) and Medi-Cal Bridge to HFP (7X) Approved Claims By County Fiscal Year 1999-2000
HFP Aid Code
Statewide
Alameda
Butte
Contra Costa
El Dorado
Fresno
Humboldt
Kern
Kings
Los Angeles
Marin
Mariposa
Mendocino
Nevada
Orange
Riverside
Sacramento
San Bernardino
San Diego
San Francisco
San Joaquin
San Luis Obispo
Santa Barbara
Santa Clara
Santa Cruz
Sonoma
Stanislaus
Tulare
Sutter/Yuba
Medi-Cal Bridge to HFP
Approved Amount
1,554,795
8,746
88,022
1,336
13,901
Unduplicated Clients
644
1
29
1
9
3,733
256,421
2
89
88,076
98
4,577
4
6,547
7
111,868
183,753
120,247
49
49
70
114,860
34,559
2,692
198,388
68
34
2
37
115,202
108,359
36,697
56,697
115
15
22
27
30
1
Approved Amount
57,623
447
3,024
5,306
Unduplicated Clients
94
1
1
5
74
2
94
3,407
467
1
8
1
1,219
1
14,959
557
383
792
2,769
907
740
13,459
2,552
1,526
1,164
30
3
2
2
8
3
3
5
2
3
4
3,374
402
6
3
Healthy Families Update
January 2001 PAGE 6