Medi-Cal, California’s Medicaid program, covers a range of mental health services, including therapy, in alignment with state and federal mental health parity laws. These laws ensure that mental health care is treated comparably to physical health care regarding coverage and financial requirements. Access to specific therapy services depends entirely on the severity of a person’s mental health condition and how much it impacts their daily life. The state utilizes two distinct systems to deliver this coverage, meaning beneficiaries must first identify their level of need to know where to seek treatment.
Understanding How Medi-Cal Separates Care
The delivery of mental health services under Medi-Cal is divided into two primary systems based on the required intensity of care. This separation, often called a “carve-out,” directs beneficiaries to different providers depending on the severity of their symptoms and functional impairment.
The first system is for Specialty Mental Health Services (SMHS), which are managed by County Mental Health Plans (MHPs), typically part of the county’s behavioral health department. These services are reserved for individuals with severe mental illnesses that cause significant impairment in major life activities. The second system covers mild-to-moderate mental health conditions and is managed by the patient’s physical health Managed Care Plan (MCP). The distinction between “mild-to-moderate” and “specialty” is based on the level of functional impairment, not simply the diagnosis.
Specialty Mental Health Services for Severe Conditions
Specialty Mental Health Services are designed for individuals whose mental health condition results in significant impairment or a reasonable probability of significant deterioration in important areas of life functioning. The goal is to provide intensive, comprehensive support to those with the most complex and severe needs, such as individuals with schizophrenia, bipolar disorder, or severe major depression. These services are provided through the county Mental Health Plan, which may contract with various community agencies to deliver care.
Covered SMHS are extensive and include individual and group therapy, psychiatric services, and medication support. They also encompass higher levels of care, such as crisis intervention, crisis stabilization, and psychiatric inpatient hospital services. Furthermore, beneficiaries may receive rehabilitative mental health services to help improve daily living or social skills, as well as targeted case management to assist with accessing other necessary community services. Accessing this system begins with requesting an assessment from the county MHP’s access line, where staff will determine if the individual meets the medical necessity criteria for specialty care.
Accessing Mild to Moderate Counseling
Mental health services for mild to moderate conditions are managed by the beneficiary’s Medi-Cal Managed Care Plan, which is the same plan that covers their physical health. This coverage generally applies to conditions like mild anxiety, situational depression, or stress-related issues that do not cause significant functional impairment. The services provided are often referred to as non-specialty mental health services.
These non-specialty services typically include short-term individual and group therapy sessions, outpatient services, and basic psychiatric services like medication management. To find a provider for these services, a patient should start by contacting their Managed Care Plan directly, usually by calling the member services number listed on their health plan card. The MCP is responsible for providing these services through its network of licensed providers, which can include psychologists, licensed clinical social workers, and marriage and family therapists.
Patient Costs and Rights to Appeal
A significant benefit of Medi-Cal is that covered mental health services, including therapy, generally have no financial requirements for the beneficiary. This means there are typically no co-payments, deductibles, or out-of-pocket maximums for medically necessary services provided through either the County Mental Health Plan or the Managed Care Plan. This financial structure aligns with federal rules to ensure that cost is not a barrier to accessing mental health care.
If a beneficiary is denied coverage for a service, or if the services they are receiving are reduced or stopped, they have the right to file a grievance or appeal the decision. The specific process depends on which system is denying the care: the County Mental Health Plan or the Managed Care Plan. For denials of Specialty Mental Health Services, the appeal process involves the MHP and can proceed to a State Fair Hearing. Patients can also seek assistance from advocacy groups or the Department of Managed Health Care if they believe their plan is violating mental health parity laws.