Helping FQHCs Fund Behavioral Health Services in SBHCs
good morning everyone welcome my name is tracy mendez i’m the executive director at csha and i’m really excited to welcome you to this workshop we have a great panel presenting for you this morning and we’re all excited to help you learn and think about strategies you can use to help ensure that you can financially support behavioral health services for children and adolescents in your school-based health centers it’s a really important topic right now this workshop is focused on federally qualified health centers which we call fqhcs or fqhc look-alikes and i’m suspecting there are others in the room today that don’t come from an fqhc setting so you may find this this workshop is not as relevant to you and we apologize for that we hope you’ll find some something worthwhile and also want to offer that if you have questions that aren’t met today or suggestions for future trainings or workshops for your setting please let us know through the chat or other any other way and we’ll try to accommodate that at future sessions so today we are very fortunate to have partners at the state level including csha and the california primary care association and also the oakland-based native american health center i want to thank our speakers for the last minute lineup changes and especially to emily shipman and jessica dyer for their game day pitch hitting so some of you probably already know that school mental health is a really complicated field and funding for it is especially challenging we have a lot to cover this morning so our plan is to take one or two questions after each presenter for any of those really burning topics and then at the end we hope we’ll have time for more questions so i don’t think we’ll spend a lot of time framing the problem this morning because all of you know this and that’s why you’re here and that’s why you’re in this field but um suffice it to say that we are in an acute children’s mental health crisis right now and even before kobed only 30 35 of the youth who reported needing mental health services actually received them and most of those students most of those young people who received services did so through their schools either through school mental health personnel or his school lifestyle center and then we’ve got this perfect storm right with covid and the heightened social economic uh health and racial inequalities that that has brought both through the disease and through the subsequent lockdown and not to mention our country’s centuries of institutional racism actively continuing to this day so for example some new data show that one in four young adults have seriously considered suicide in the past year and this rate continues to be about 40 for lgbtq adolescents and youth rates of anxiety and depression have more than tripled since the start of the pandemic calls to suicide hotlines are way up intimate partner violence is increasing and many of these trends are more pronounced among black youth and other children of color so how do services these critical services get paid for historically two of the most common sources of funding for school mental health services overall have been epsdt and firms e-r-m-h-s ali from cpca is going to talk a little bit about epsdt in a few moments but i just wanted to share a little bit of information about firms because i think it’s helpful for those of us in the health and mental health side of things to understand the education environment that we’re operating in so irm stands for educationally related mental health services this is an education funded service um and it’s not a medi-cal program so a lot of us in healthcare tend to think of medi-cal as kind of the go-to funding source for a lot of services especially for low-income children um firms is all sometimes been called ab-114 or ab-3632 in california because of past legislation and it’s a program required by the federal department of education for all local school districts for students in special education who have an iep or ifsp and if there’s questions about these terminologies you can chat them to us and who have a behavioral health need that impacts their learning so something like an adhd or an anxiety disorder the funding comes from federal and state education dollars carved out specifically for mental health services and just to get really technical for a moment that money flows through something called selfas that are often associated with county offices of education those services can then be provided directly by local educational agencies like school districts or often they’re provided through contracts with community-based mental health organizations that place therapists on school sites so just wanted to share some of those background that’s not what we’ll be focused on today and in fact there are many many other potential funding streams and sources for child children and school mental health and just some of those are shown in this picture in fact mental health financing for children and youth is really a very complicated set of separate programs some run through health care some through mental health and others through education or social services some of them are based on family and student income and some aren’t and each one has its own set of eligibility service coverage rules contracting rates and provider networks and yet as you probably know we still find ourselves struggling to pay for clinician time especially time spent providing certain types of services like prevention the best administrators in school-based mental health will blend and braid many of these funding much of this funding together which can be hard so today we’re going to focus mostly on two medi-cal funding streams that are accessible for many school-aged children and youth um and that most fqhcs should be able to access for their populations these are both a really good fit with the integrated school-based health model and they’re shown here if you’re already providing behavioral health services in a school-based health center you probably know how hard it is you know that it’s not enough to set up a school-based health center and offer behavioral health services and expect that you’ll be able to recoup the costs of your clinician time much less all the management and support staff for all the reasons listed here that we won’t go into detail right now in many ways in many ways the reason this is so difficult is because the school-based health center delivery model is really set up to expand access and to welcome in people young people at an early stage in their difficulties whereas our financing systems for mental health are much more established to sort of keep people out in their until they’re more acute and to manage care and what we call gatekeep so that’s a fundamental dilemma but it is possible to create great set of services and mental health interventions and that’s what katie and jessica will be bringing us today some tips and tricks for viable programs and paths for your behavioral health services using these two medical funding streams so without further ado i would like to introduce two brilliant and fabulous colleagues from the california primary care association if you don’t know cpca please look them up and familiarize yourselves with their all their resources they’re at least 20 times bigger than csha and they have a ton of resources for community clinics i’m going to turn it over to ali boudel’s ally and i’m stopping my share as soon as i can thanks so much for that background and introduction tracy really appreciate it so my colleague emily shipman is going to get set up with the slides here and we’ll just give a moment for that transition but we’re really excited to be here with you today thank you so much for having us um we’re going to talk a little bit more about the behavioral health delivery system in california how it’s structured and then we’ll dive into the really important role that health centers play as providers in this care continuum and how they work to ensure access in quality to integrated physical behavioral and social determinants of health and we’re really pleased to kick off this morning great so uh again my name is ali budenz i’m the assistant director of quality improvement at the california primary care association i’m joined by my colleague emily shipman who’s the associate director of health center operations and you have our email addresses on the slide there in case you need to reach out with any questions um post presentation we’re always happy to hear from you great so let’s preview a little bit of our section for this morning’s content we’re going to start with a really high level 30 000 foot overview of california’s behavioral health care continuum for medical beneficiaries and in that section we’ll talk about some of the challenges that that this system poses to beneficiaries needing care and certainly some of the challenges that providers navigate in trying to offer these integrated services and then we’ll preview a little bit about what’s on the horizon in terms of policy changes to support a more integrated environment and finally we’ll dive deeper into the micro level of what an fqhc actually is and the work they do within the mild to moderate behavioral health system next slide great and so just a couple minutes about cpca and the health center members that we represent if you’re not familiar with the california primary care association we are the statewide association that represents community clinics and health centers we provide advocacy training and technical assistance on a number of different issue areas that support health centers to be the most effective and the most efficient at serving the health needs of their communities which absolutely includes behavioral health and the social determinants of health we have a varied membership you can go back really quick i just wanted to call out a couple of our different member types so we have a varied membership but they’re all listed right there on the right um and their community health centers of one variation or another and we’ll get into a little bit of the nuances of the different types of health centers and we also are very pleased to have our partner regional associations of california as members of cpca2 i wanted to call them out specifically in this space because given california’s size and complexity we have a really special structure that relies on the regional consortia to work with cpca at the local level sometimes that’s one county sometimes it’s a combination of counties and what the rack do is really offer that localized advocacy training and technical assistance which is really important because as you know the behavioral health delivery system is extremely localized it’s really dependent on the resources and the structure of your county and so the rack with their hyper local focus are really critical partners in this space now you can go to the next slide great so let’s dive into the behavioral health delivery system in california everybody take a deep breath ready okay um because it’s a little bit complicated right so i just want to call out that this slide is from the california healthcare foundation who’s been pouring a lot of thought a lot of action and resources into the case for behavioral health integration recently and just by this visual you can see that so california’s public insurance product has a divided behavioral health system it’s trifurcated really and let’s get into those three different parts so on the one hand you have medi-cal managed care plans administering the physical health and the mild to moderate mental health services within their network of contracted providers of which fqhcs are a huge part of this network then you have county specialty mental health plans administering the specialty mental health benefit for people people with serious mental illness and finally you have about 95 percent of medical beneficiaries with substance use disorder receiving substance use disorder services through county administered drug medical organized delivery systems often referred to as ods systems and i just want to say before we move on that prior to coming to cpca i used to actually work in a health center in sacramento and i can tell you as i’m sure you already know this system is incredibly hard to navigate from an administrative a financial and operational there are so many provider networks so many different payers and providers often don’t really know what’s happening in different parts of the system and remember at the center of this system is supposed to be the patient but right now we’re pairing the most vulnerable and at risk patients with the most complex system and so we’re going to talk a little bit about what we hope to see change to make the system a little bit easier and more user-friendly and effective okay next slide um so we just previewed the trifurcated system and now i want to talk a little bit more about how fqhcs as providers live within this model so the graphic on the right hand side is from cpca is leveraging fqhcs in the behavioral healthcare continuum report and we published this in 2018 it’s still on our website if you would like to go take a look at it it also has a lot of really good background about the trifurcated system so i highly recommend this report um and so what this graphic shows is how an scope of service may overlap with mild to moderate severe and specialty mental health services just because a different part of the system technically administers a program doesn’t mean that the health center doesn’t offer those services within their scope of service there may be many different reasons why a patient chooses to receive their specialty mental health or their substance use disorder services within their fqhc health home maybe they trust their care team they’ve been established with the health center for a long time or they can’t access the county behavioral health services maybe the fqhc is closer to their home or it’s on their direct bus route many different reasons all of that said the bulk of fqhcs behavioral health services are considered mild to moderate um and i use air quotations because mild to moderate in and of itself is a little bit difficult to define and a person can sort of weave in and out for all the clinicians in the room you know you can sort of weave in and out between being well managed um in different parts of uh your yeah your behavioral health uh diagnosis so again the bulk of behavioral health services are considered mild to moderate um and health centers like i said are primary are one of the primary contracted providers for medi-cal managed care plans um and over their years they’ve built up a ton of clinical capacity and expertise in the space so much so that about 85 percent of health centers are at least co-located or fully integrated with behavioral health on their primary care teams which means that a behavioral health provider and a primary care provider are both equally involved in diagnosing and treating the patients in the primary care setting which is really true integration some health centers also have contracts with their county specialty mental health plans or their county drug medical organized delivery systems to participate as providers contracted providers within those systems it’s important to know that fqhcs have a really important and unique role in the delivery system because they innately offer an integrated care model a person can come in for a diabetes exam and because the primary care team screens for depression and screens for toxic stress the patient you know could have a brief interview to address their acute needs with the behavioral health provider in primary care and then they can leave um with an appointment with an lcsw for a more thorough assessment and some sort of regular treatment behavioral health therapy um starting later in the week for example and my colleague emily is going to touch a little bit more on the billing guidance that health centers live under but i did want to say that it’s it’s tricky and it’s not always conducive to an integrated environment the biggest challenge that health centers face is that they aren’t paid for primary care and behavioral health visits that happen in the same day even if they’re two distinct and unique visits you can only bill for one of those visits primary care or behavioral health in a single day additionally health centers are really hamstrung by certain provider types being billable and all pps services and pps is the way that health centers get paid all pps services have to be within the four walls of the health center and there’s been some exceptions made for the public health emergency that allow for telehealth environments um but generally everything has to be within the four walls next slide okay so um that was a lot of information now we’re going to move in to a little bit of the policy environment and i realize um that this is probably eliciting a little bit of tiny font fear but don’t worry because you don’t need to know all of this information what i really wanted to get across to you right now is that is this title right integration is inevitable providers have known it for years that an integrated environment leads to better care outcomes and based on everything all the signals that we’re getting from the state and from the administration they’re starting to come around to this idea too which is very exciting and so the four columns here represent programs and different funding opportunities that the state is prioritized starting in 2019 and moving forward indefinitely and the common thread among all of these is that state agencies managed care plans and providers are all engaged in efforts to address comprehensive medical behavioral and social needs within an integrated delivery platform in pursuit of the whole person care prior to covid the state started an initiative that would fundamentally redesign medi-cal in support of a more coordinated integrated and standardized care this was called the cal aim initiative california advancing and innovative medi-cal in case you want to look it up it’s a pretty long document with a lot of proposals but you can find it on the dhcs website if you’re interested what’s the most important that i really want to call out in the calais is that it’s not necessarily the content which i think is really interesting um and and has a lot of implications but rather just the concept that the state is willing to redline the status quo and re-envision medi-cal designed around integration that’s huge it hasn’t been done before in california and it’s a really great opportunity and the other big final takeaway from this slide is that the state could have very easily cut any of these programs um in face of the billions of dollars of deficit that we’re seeing due to the economic crisis from the pandemic but instead they’re still investing you know 100 million dollars in the value-based behavioral health integration pilots which are going to test some integrated care model models largely within fqhcs um and that’s huge that really shouldn’t be ignored and uh just so you all know i this i see that in the comments that the slides blurry totally understand it’s really tiny font and these slides will be available if you need to see them later you can blow them up no problem okay so great we talked a little bit about the behavioral health care continuum we talked about how fqhcs work in that we talked a little bit about the policy let’s take a step back and just review what an fqhc is and where they come from i’m always really proud and love to talk about fqhcs because i really believe in this model um so i wanted to talk about the origin stories of fqhcs and i don’t know about you all but um in this safer at-home environment i’ve been spending a lot of time with my four-year-old who is really into superheroes and so i am learning so much about the origin stories of all of these great superheroes i know more about spider-man and iron man than you would care to know um and i was like yes every great superhero has an origin story so let’s talk about the fqhc origin story um fqhcs originate in the merging of the civil rights and the social justice movements of the 1960s when community organizers saw that poorer communities had adverse health outcomes due to poor access and so physician leaders doctors jack geiger and count d gibson jr pioneered a south african model of care in which you bring care to the people novel idea right show up where the people need you and so in 1965 the first neighborhood health centers were established in dorchester massachusetts mountain bayou mississippi and denver colorado and then 10 years later in 1975 the community health center program was authorized for the first time as a permanent program within section 330 of the u.s public health services act and from that we have the distinction federally qualified health center or fqhc next slide and so diving a little bit more into what an fqhc is and what their scope of service is um the fqhc is like i said the distinction authorized in statute that acknowledges that a clinic serves a specific population that is either an underserved population or in a medically underserved area excuse me and they do this either through direct services or through contract agreements so fqhcs also receive a yearly grant from the health resource services administration that supports some of the uncompensated care that they provide there are also a couple of other distinctions that i wanted to touch upon like the fqhc look alike and fqhc lookalikes do also meet all of the section 330 requirements but they don’t receive the federal funding under the section 330 grant and i didn’t want to exclude either some of the important categories of health centers or clinics that aren’t fqhcs like rural health centers urban indian and tribal clinics and free clinics in california alone there are over 1300 licensed community health centers in the state the majority of those are federally qualified health centers and so that sort of wraps it up for my piece i’m going to hand things over to my colleague emily shipman who’s going to talk a little bit more about establishing school-based health center sites and dive deeper into the mild to moderate space of um how fqh sees sort of the requirements that they have in mild to moderate behavioral health yep thanks ali hi everyone i’m emily shipman also with cpca i’m an associate director in cbc’s health center operations team um and i’m very happy to be here with you virtually today um and as ali mentioned i’ll be presenting on sort of the nuts and bolts of how to actually uh operational excuse me operationalize a new clinic site specifically at a school so we know many health centers are responding to the needs of their communities by bringing healthcare services into communities um excuse me into community-based sites such as schools there are several important factors though that fqhcs specifically need to consider when expanding services into school sites so we’re going to look at those that’s her scoop excuse me her says scope of project licensing requirements um enrolling the location into medi-cal and setting a pps rate so before we talk about actually billing uh at a school-based health center let’s touch on each of these critical steps so not versus scoop but her scope of project approval so anytime a health center adds a new service or a new location they must apply to hersa for a change in scope of project in order to have the new location and or services included in their existing scope so the approval is important because the health center’s scope identifies the services the sites that are eligible for pps reimbursement uh extends ftca medical malpractice insurance for health centers and employees and provides the site information which enables health centers to purchase discounted drugs under the 340v program and defines the approved sites for dhcs to calculate reimbursement rates under pps and medicare to do that on the federal side so scope changes are requested via ehb so that’s electronic handbook submission and should be requested at least 60 days prior to the intended change that gives time for rehearsal to review and ask for any additional information needed to approve that change and hersa does have a number of resources available on their scope change webpage if you’re not familiar with the process um that’ll help you walk through so i went ahead and included those on the slide okay so licensing um i don’t know how many uh watching the webinar are familiar with licensing a primary care clinic in california but um as ali did earlier it might be time for collective deep breath um licensing can be a complicated it can be a drawn out process it doesn’t necessarily have to be but let’s talk a little bit about what the requirements are so fqhcs can provide care to patients at school sites that are designated as either a licensed clinic an intermittent clinic or a mobile unit that is also designated as a licensed or an intermittent clinic licensing is done through the california department of public health’s licensing and certification division so to apply for a license health center is applied through the centralized applications branch or cab sometimes called cab of licensing and certification and the licensing process can vary greatly in terms of processing time so a good rule of thumb if you can swing it is to submit at least a few months in advance of your intended start or open date um and that ensures time for application review by the state and a site survey if it’s needed for your particular type of license so clinics must meet requirements that are verified through this application process as well as through subsequent site surveys by cdph so that’s licensed clinics intermittent clinics are a little different from licensed locations in that they must be operated by an existing licensed what we call parent location and intermittent clinics are only eligible to operate up to 40 hours per week but they’re exempt from licensure requirements so they have to meet fire and life safety but all the whole host of chapter of health and safety code that applies to licensed clinics does not apply to intermittent clinics as they’re operated by this parent clinic i will add too that there is an existing uh all facilities letter and that went out to all licensed clinics or should have been received if your license clinic and you didn’t see it please contact me i’m happy to share that but what it does is it waves a number of clinic licensing requirements due to the ongoing state of emergency in california due to copin 19. so some of those requirements would impact opening a new clinic or an intermittent clinic so if you’re thinking about doing that or you are doing that you should be aware the all facilities letter does waive the requirement that license sites actually wait for the licensing approval before they begin operating so as soon as you submit your um your completed licensing application to cab and because of this afl that waves the requirements you can go ahead and begin operating while cab works on reviewing that application um the same is true for intermittent sites and also the 40 hour per week maximum for intermittent is currently waived due to that afl um and i think it’s through i believe end of march at this point it has been extended once already so good thing to keep in mind okay so medi-cal enrollment and pps rate setting um licensed clinics not only receive their licenses through cdph but their medi-cal enrollment application process begins with cab or the centralized applications branch as well so simultaneously with the licensing application clinics who are wishing to enroll in medi-cal also submit their certification or enrollment documentation so cab processes the license and then they pass the certification or enrollment documentation along to medi-cal medi-cal ultimately ensures that the new location is uploaded into their system and enrolled as a medi-cal provider and then they send the welcome to medical letter which says you know hello here’s the npi you’re enrolled under go ahead and start submitting claims so fqhcs must also go through the rate setting process for their new location so license locations set their pps rate either utilizing a cost report method or by selecting three comparable clinics whose rates are averaged um my understanding is that that’s significantly harder to do with the school-based clinic uh you know given the amount of of comparable clinics you might find non-school-based versus school-based um however i believe that’s still an option i don’t know if folks are able to actually utilize it um intermittent mobile locations are a little different they’re not eligible for their own pps rates um so they’re assigned the pps rate of a parent location and that’s determined by the fqhc so at this point um dhcs the state there are no specific requirements around um the parent location that an fqhc chooses um they have they being dhcs has indicated um that they would like there to be some parameters there so um the general guidance we give folks is that when choosing a parent site for your intermittent um you should choose a site that is similar in proximity and in patient mix and services offered so um so geographically nearby um you know it doesn’t really make sense to choose a clinic much further away if you have closer clinics um and anyway as for now there aren’t those requirements in place but good thing to consider if you’re looking at opening up the site as an intermittent clinic so and if you’re shaking your head and saying hey lady we have a mobile unit it does have its own pps rate um yes in the past that was um that was the practice that the state allowed so mobile units were able to set their own pps rate based on the services being provided but that’s no longer the case um so some mobile units will still have grandfathered in that old pps rate but new mobile units don’t have that option um and a resource on this slide here is the website from cab that has licensure forms and guidance they have checklists to help walk you through that process okay so getting into actually billing and what reimbursement looks like for fqhc’s in medical so being able to obtain reimbursement from payers is vital to a health center’s ability to keep their doors open continue providing a high quality affordable care i’m sure we’re all on the same page there but to that end it really is to the benefit of the health center to fully understand the billing and reimbursement policies for each of their payers um as noted here we’re only going to be covering medi-cal billing and reimbursement today oh i’m sorry i just saw a chat question around pps so what does pbs stand for pps stands for prospective payment system and it refers to the way that sqhcs get paid in a single payment um that is meant to include all of the costs for providing their services so as i was mentioning um we’re only going to get into medi-cal billing and reimbursement today sorry just making sure i’m catching the chat questions as i go i don’t want you guys scratching your heads about what i’m talking about um okay so for fqhcs to build medical the visit must be a face-to-face encounter between a medical beneficiary and a billable provider in which the provider is rendering medically necessary services so fqhcs can bill for behavioral health services that are provided by licensed psychologists licensed clinical social workers or marriage and family therapists so of no health centers must submit a pps change in scope of services requests so if you’re not familiar at changing the scope of services requests is how you augment or change your pps rate based on a change in providers or services at your health centers um so if you do want to get reimbursed for services that are being provided by mfts you need to file a change in scope of services request um in order to make those mft’s billable providers for your health center if an fqhc does submit a claim for mfts that will automatically trigger that requirement to submit a change in scope um to dhcs so that doesn’t mean the first time that you submit a claim dhcs is going to call you and say hey where’s your change in scope it just means that it’s going to be on their radar and eventually you will need to file that change in scope so as most of you already know fqhcs are reimbursed at the pps rate again that’s prospective payment system and it’s inclusive of all the services provided during a visit so this means that encounters with more than one health professional or multiple encounters with the same health professional that take place on the same day at a single location constitute a single visit and ali touched a little bit on that um and it definitely makes things challenging in terms of integration so while there are instances in which fqhcs can bill for more than one visit on the same day medi-cal doesn’t allow fqhcs to bill for medical and behavioral health visits on the same day unfortunately additionally uh sorry um give me just one moment actually if i could do a quick pause here sorry about that guys perks of being live so um i was just gonna get into talking about intermittence so intermittent clinics bill medical under the parent sites npi for reimbursement at the parent site’s pbs rate so i did just talk a little bit about how both intermittent and mobiles aren’t eligible for their own pps rate so that’s that’s why um but this is just specific to medi-cal so intermittent do need to separately enroll into medical sub programs like family pact um and they do need to separately enroll into medicare if you’re a medicare provider so when a health center has a contract with a medi-cal managed care plan the fqhc bills the health plan separately and then they bill a rap claim to the state the rap payment provides the difference between the health plan payment and what the fqhc’s actual pps rate is so in that way the fqhc is made whole it’s common for managed care plans to subcontract with beacon to manage behavioral health services in this case you would follow the same billing process by submitting a claim to beacon um and then that rap claim to the state each managed care plan has their own billing requirements um so please check with your contracted plans for their specific information um about how they want those claims submitted so lastly if a medi-cal managed care patient is seen out of network uh the fqhc can still build a rat claim to medi-cal for the visit however the fqhc must refer the patient back to their assigned provider for future visits they have to document that referral in the patient’s medical records and maintain proof of payment or denial from the managed care plan um if the plan ultimately does deny the claim that fqhc will be made hold of their full pps rate during the annual reconciliation process that they go through with the hcs audits and investigations okay so actually looking at some billing now that we better understand the billing and reimbursement policies let’s briefly discuss the billing code sets for fqhcs so listed here are a few hipaa compliant billing code sets um please note this is not a comprehensive list what you see on this slide is the billing code sets that are relevant to our discussion today which is billing for behavioral health services in a school-based community clinic um and i know we got some feedback earlier that slides were a little blurry um so hopefully um if you can’t see them right now you’ll be able to access them after the fact so sorry about that um so listed in row one is the billing code set for a visit with a patient enrolled in fee for service or straight medi-cal and row two is the billing code set for the rap claim for a patient enrolled in managed care okay just getting a note that slides are okay that’s good so for behavioral health services not covered by a patient’s managed care plan fqhc’s bill using one of the billing code sets as seen in rows three through five so those claims would go straight to medical okay so let’s look oops let’s look at some actual examples of what a claim might look like um what you see on this slide are two billing examples excuse me um for fqhcs the first example is for a claim to medi-cal for a visit with a patient enrolled in straight fee for service medical um and for our purposes today let’s say this is the behavioral health visit um as noted in this example the claim is billed with revenue code 0521 and hc pcs code t1015 now moving down to example two this shows a rap claim to medical since the patient is enrolled in medical managed care plan the fqhc would also need to submit a claim to the managed care plan so this would be just the portion that goes to medi-cal for the wrap okay so that wraps up my portion talking about sort of the nuts and bolts for getting a site enrolled and doing um the basic billing um let’s move into i believe space i think we have space for a couple questions so okay and i’m looking at the chat here it looks like i think our best bet for folks is if you chat your questions in um i don’t know if folks have done that yet jessica let me know if you see any questions come in through the chat we’ll hang out here for a minute before we move on to the next presentation yes so i have one question that has come through the claim indicated it would be for a service not covered by the managed care plan do you need to have any letter or on or other information from the mcp okay so the question is if the if the managed care plan is saying that they won’t pay and so you want to build medi-cal what documentation do you need from the plan great question um i don’t know the answer offhand but i can look into it and i can follow up after the webinar great i think i think i know the answer um emily all you would need actually is just the denial from the managed care plan in order to build um the state for to make yourself whole in the wreck great thank you um and there is uh one more question and there was mention that services need to be within the four walls but is there exceptions with that with telehealth do you want me to take that one emily yeah go ahead yeah so typically um services would need to be within the four walls of the health center for that site right um there have been exceptions made due to the public health emergency declaration that allows for telehealth services typically outside of the public health emergency the state would consider telehealth outside of the four walls so we have that small allowance for right now and we’re doing our darndest to to keep it indefinitely um through a lot of advocacy at cpca our regional consortia health centers themselves and other stakeholders um there seems to be a broad coalition support that we need to keep that access point but for right now it’s only for the public health emergency thank you and another another question and our most school-based fqhc services provided through mobile units intermittent clinics or full licensed locations i don’t know the answer to that i’m curious what yeah um yeah i don’t know i would think maybe i i don’t know if that’s something that you you guys have a pulse on at the alliance or um maybe focus on the live one yeah i think my understanding is about two-thirds of school-based services are all fqhc um i don’t think mobile units is the most common but and i believe most of them are in intermittent clinics um but tracy if i’m wrong on that you can correct me no that sounds right and i am not aware of any behavioral health services being provided in mobile units and yeah school-based connections yes mostly dental right auto dental and some medical great okay thank you thank you guys um and now we will move on to katie and me hi everyone um my name is katie lampe i am part of native american health center i’m the program manager for our skyline site which is a school-based health center let me go ahead and share the screen so today we’re going to talk about medi-cal behavioral and mental health pairs um so like i said my name is katie um i’m the program manager for the skyline site jessica dyer lcsw she’s the behavioral health project director for csha she’s going to talk about more of the provider side the billing side of this so for medical mental health uh behavioral health services these are the common student insurances that we see at our health center um emily went into most of them so we see medi-cal managed care under that we have full scope alameda alliance with as they mentioned beacon as the payer we have anthem blue cross and kaiser as a pcp all under managed care then we see kaiser as private insurance we have scenarios where students come in with no insurance and then we also have minor consent medi-cal mental health which will be the focus of uh jessica’s side of the presentation so the mental health services enrollment scenarios by insurance so a student has been referred to the health center or request behavioral health services once in the clinic they’re going to fill out the registration forms and the program coordinator does an insurance assessment typically what can happen with this is that our paperwork asks for the insurance but a lot of times our students don’t know what their insurance is they will um so the program coordinator will ask them questions they’ll say hey when you go to the doctor do you go to kaiser do you go to the clinic um the program coordinator position is a very important position they are the front person the you know the contact between the student and the rest of the health center so the scenario for medi-cal full scope alameda alliance and anthem blue cross these are our main major pairs for our behavioral health mental health services so a student has medi-cal alameda alliance anthem blue cross with the pcp other than kaiser or the student may come in with medi-cal full scope so the first thing that we’ll do is we will typically check to see that we have a parent consent on file if we don’t then we send the patient home with a parent consent they come back and then we go ahead and schedule them with the behavioral health clinician for about a 60-minute intake appointment so when we’re dealing with kaiser either private or through medi-cal managed care the program coordinator needs to assess the level of difficulty the student has getting to kaiser for their appointment um so with a low difficulty level the program coordinator will offer resources to connect the student with kaiser mental health so the students may say that they can go to kaiser but the clinic is just more convenient the pc may let them know that kaiser doesn’t reimburse our health clinic they may not say that that’s just depending on their level of comfort but that they’re happy to provide resources so that may look like giving the student the kaiser mental health phone number in some cases the student will have an appointment with the program manager so that the student can call like in their office sometimes students often just either don’t get around to it or it’s not that important so um connecting them with the program manager can help facilitate that connection if the student has a high difficulty level getting to kaiser the program coordinator typically will make a 30-minute appointment with the behavioral health clinician to assess for minor consent mental health eligibility if the student is eligible we will use minor consent mental health as a payer great that’s fantastic scenario if the student is ineligible we would enact a protocol for temporary services which we will go over more of that later so if a student comes in and has no insurance the student doesn’t have any insurance the pc will schedule a 30-minute appointment with the behavioral health clinician to assess for minor consent mental health eligibility so if the student is eligible again we will the pc will enroll the student in minor consent medi-cal with the mental health box checked if the student is ineligible our pcs typically enroll the patient in medi-cal temporary insurance also known as gateway and then they will need to schedule a well child check with the medical provider as well child check is necessary to enroll in temporary medical and obtain parental consent in that scenario the gateway insurance so according to cdhp which is the child health and disparity prevention program states that if we’re going to use this temporary insurance for our students we must do a well-child check and then schedule for other services such as behavioral health or dental or something like that so in this scenario what we would do is we would give the student a one-page application with a parent consent they would take that home bring it back we’ll schedule the well child check for one day and then we have to schedule the behavioral health appointment on another day because as was mentioned we cannot schedule mental health and medical on the same day so here’s a little bit about the more important pieces of the minor consent medi-cal mental health application process here we have our mc4026 form and i do apologize ours is a really used form and so we it’s this is the best we got right now so once the student has been assessed by the behavioral health clinician to meet eligibility for the criteria for minor consent mental health the minor consent mental health application must be filled out at that time if it hasn’t already been filled out earlier in the school year a lot of times our patients will come in for sensitive services they’ll sign up with medi-cal minor consent we will usually check box pregnancy and or family planning and also sexually transmitted diseases at the beginning if they come in later and want mental health services and they’re you know assessed by the provider and they’re deemed eligible we will go ahead and check box five outpatient mental health this is extremely important this is for billing this is to let the county know that we have added a service so what needs to accompany the mc4026 forms and application is the uh clinician the clinician letter basically so a behavioral clinician fills out a template letter your clinic information will be here the behavioral health uh provider will fill out the student name the date of birth the case number will only be there if they have a previous uh minor consent application if they don’t and you’re doing this for the first time don’t worry about the case number it’s not as important you can always go back and fill it out later then the clinician will fill out the rest of the information and make sure that the make sure to state that these services will continue treatment for up to one year then your clinic information will go there they will sign a date and it’ll be all good so the letter like i said must accompany the application and or all monthly mc26 forms again if the application has been done already earlier in the school year it is extremely important then to fill out and check box five on the succeeding mc4026 forms and i’ll tell you about that in a minute this right here is a sample of the minor consent id card which indicates activation this is important um because this is important for updating the minor consent tracking sheet if a student already has a minor consent or an active minor consent case then the pcp will go ahead and check box five on the succeeding forms and attach the letter to each one this right here is what you’ll receive from your liaison after she has activated all of the minor consent so once the liaison so this is the sort of the billing section or the change this is not exactly the billing this is the change in the ehr that our clinic does and that billing will need to do so the liaison adds the mental health services to the county case once that has been activated and usually you know that when they return the next month to pick up new applications or mc4026 forms they will let you know at that time yes we processed it yes we went ahead and um added it to the case then you’re going to go ahead and alert your billing department of the change in status when it’s activated so what we do in our clinic is that we go ahead and we change the payer aid code right here a typical minor consent sensitive service application will have a 7m right here in the pair aid code and i do apologize for that pop-up that keeps happening um when the mental health gets added to the case that payer code will go from 7m to 7p the reason that this is so important is because if you put in claims if the behavioral health clinician puts in claims for minor consent mental health we will not be reimbursed unless that aid code has changed to indicate that we have added that service so this is the minor consent medical outpatient mental health checklist so we’re going to have the behavioral health clinician they must assess eligibility the program managers can’t do it medic the medical team can’t do it they can suggest they can confer with the behavioral health clinician and say hey i think this student might qualify for this and in that case we would make them a 30-minute assessment appointment and go from there then we will have the student fill out the application and we will make sure to have to put mark all of the correct boxes on the mc4026 forms these forms we’re going to make monthly copies of for either the rest of the months in the school year or for the one calendar year because minor consent has is activated the activation card shows that it’s active for one year however in reality it is only good month to month depending on the mc4020 forms that are turned in so we’ll have the mc4026 forms and then the letter filled out and signed by the clinician we’re going to attach to we’re going to attach the letter either to the new application or to the mc4026 forms it is very very important that once you have added this service that when the county liaison comes in and they usually come in about once a month they should be coming in to your clinic once a month we have our liaison come two times a month because we process a lot of minor consent as we are high school and we deal a lot with teenagers um so when the county liaison comes in to pick up her information and all of the paperwork we’re gonna say hey this student has a mental health option and so they are aware when they go back to activate the case or resubmit activation for a following month that they make sure to change the case to include mental health services when they come back the next month as i said then they should usually let you know that yes we’ve changed the case then at that point you’re going to go ahead and you’re going to alert your billing department of the change and then you’re either going to change the ehr pair code aid code from 7m to 7p or the billing department will go ahead and do that this is where you’re going to need a really secure relationship with your billing department so that we can make sure that we are able to bill for the services that we are providing in our health center then we’re going to go ahead and we’re going to track all of our minor consent applications i can’t stress i can’t stress this enough how important it is that you track all of your minor consent applications uh this way you can i mean i can’t tell you how many times i’ve had to go back and check and see you know who who’s already active who’s pending who needs a new application so some things to remember about this process minor consent medi-cal mental health may be used once a sense by the health clinician and determined to meet eligibility requirements unfortunately minors under the age of 12 may not use minor consent mental health again stress this immensely continuation of coverage and to make sure that you are being reimbursed for all your services is a monthly commitment the pc needs to submit application and or the mc4026 forms with that letter on a monthly basis then you’re going to go ahead and track all your minor consent applications in a database we use an excel spreadsheet sometimes they’re smart sheets whatever it is it it’s a very important part of this whole process ultimately if the student does not have any eligible insurance please be sure to create a protocol for short-term care for students that do not qualify for minor consent they have um kaiser and have high difficulty level um or they just don’t qualify for the gateway because their household makes too much money whatever the case may be we’ll go into the protocol a little bit more with jessica but just to give you a general idea the protocol that we have at our health center is that we are able to see patients one to four sessions for non-reimbursement this is gonna depend on how comfortable your health center is with that um they may there may be grants like emily uh was talking about that will reimburse that at the end of the year it just it really depends so the most that we can do typically is one to four um we also refer those patients sometimes to our cost team or our coordination of services team because that team has a lot of other resources that the student might be able to utilize after they have used up their one to four services with us so now i’m gonna go ahead and stop sharing the screen and turn it over to jessica and if you have any questions about this we’ll be happy to answer them after uh her part of the presentation thank you katie yeah and feel free to chat the questions in the chat box um as they come up for you and we will get to them um at the end uh i am going to start my share while you’re doing that jessica i just wanted to make sure that you share that even though you work at csha now that you’re exp where your experience was working thank you yes um i’m just pulling up the uh this on my screen as well so um hi everyone yes so i currently am the behavioral health director at california school-based health alliance health alliance um and to in this part of the presentation and today i’m going to be um talking a lot from my experience when i was the behavioral health provider at native american health center um and i’m just checking that you all can see the slide and not the presentations part great um thank you katie for all the um pieces about the uh front of the house um for minor consent i’m going to be talking about um the perspective from the clinician side and and starting out with what the clinician needs to be including for billing and for all of the insurances and so i’m not going to talk about everything that the clinician needs to include in their assessments and each clinic is going to have their own policies and procedures that dictate some of those things ehrs do a really great job of helping to make sure clinicians are documenting all the details such as when the session begins and session ends but i’m going to talk more about what we need to document as far as the diagnosis how to demonstrate medical necessity how the diagnosis impacts um clients daily functioning and the diagnostic formulation and and then what needs to be included in the treatment plan and so more of the storytelling side of the clinician’s piece what they need to show to demonstrate that this what the need is for the child and how to best meet the need and and so uh to start um the clinician needs to um be able to demonstrate that the client does have a dsm 5 diagnosis and um as ali mentioned in her presentation integration is really important and really helpful and so when there are integrated behavioral health clinics and ehrs and those are really using the icd-10 code and the medical code so there needs to be a dsm-5 diagnosis and then the related icd-10 code is what needs to be used in the ehr and and so i just have a little chart here that shows what category df codes the icd-10-f codes are and so for example um for a single episode of major depression disorder and that f code is 32.9 um so you can see mood disorders are going to be in f30 to 39. and there are many crosswalks you can google between dsm-5 and icd-10 to help you get the right code a lot of ehrs themselves have them built in which is really nice um so it’s not usually too hard to find but it’s just important that we use the correct icd-10 codes and icd-10 codes are more specific than dsm codes so they’ve got a percentage or decimal points that you go out to get more and more specific around what a student is experiencing and it’s really important that if there is more than one diagnosis that the student or client is experiencing that you include all of what they are experiencing so sometimes uh it can happen or some a clinician will only put one diagnosis but that doesn’t tell the whole story and for reimbursement and for payers they want to know what are they actually funding and so it’s really important that as clinicians we are documenting all of what a person is experiencing and whatever the focus is or is most uh salient for that client at the time will be the top diagnosis but say they’ve got depression and anxiety or ptsd and depression you want to make sure that you’re listing out both of those or say there’s a substance use problem you want to also make sure that that is included and that um whatever is at the the first one you list is what you’re really um focusing on in that treatment but that the whole story is being told uh for um the pairs and to be able to know what’s actually going on and and so then that brings me to not only is it important to document and what the student is experiencing as far as what their what diagnosis they qualify for but also it’s important to document medical necessity medic and and sometimes this can feel like it puts up barriers to treatment and there are actually right now many advocates working on removing this as the necessary criteria for school-based health services um and having some other criteria such as an aces score or um some social determinants um of health to be criteria and um i think it’s also important to understand that an intention of medical necessity is to actually protect the student and the client and to make sure that um clients aren’t receiving services that are more intention intensive than what is actually um needed so for example not keeping a client in inpatient treatment when really what they’re going to be benefiting from is outpatient um one-on-one individual services it’s and so the idea and part of why it’s important is that it really is to protect certain students and clients and i think in school-based services one way that it’s helpful to think about this is that it can be helpful in thinking about triaging the limited services we all know that behavioral health services are so needed in schools and a lot of times very hard to find and there just are not enough clinicians and there aren’t enough services and so um using the medical necessity criteria can help to triage so for example if a student is experiencing some mild anxiety or stress symptoms but overall they’re really functioning very well they’re still able to make it to class and do their homework and socially there’s they have some friends they feel comfortable with what they may really benefit from is a like a group setting where there’s a stress management group or a beginning high school managing anxiety group um or some of those dynamic uh mindfulness um breathing groups but they don’t necessarily need uh individual therapy services where they’re meeting with the clinician one-on-one for an hour every week so looking at the medical necessity criteria the things that are important to remember are that there is a dsm diagnosis and that the symptoms the person is experiencing are consistent with that and that you’re documenting that that you’re documenting the moderate to severe symptomatic distress or impairment in functioning due to psychiatric symptoms and at least one area of functioning such as self-care occupational school or social function so in this situation you know it’s not if a student is really struggling and having struggles with ptsd or depression or anxiety they generally will have some struggles with taking care of themselves which can be not sleeping enough sleeping too much not eating enough eating too much not being able to get to school on time missing a lot of their classes not attending a lot of their classes socially it can look like not having any real good friends nobody they feel connected to and so these are all things that the clinician needs to be mindful of documenting in the chart and like i said telling the story of how the diagnosis is really impacting the student’s overall well-being and so that’s what pairs are looking for how is the diagnosis impacting the student’s well-being and ability to function um and then you also want to document that the student has the capacity to make progress towards treatment um goals and or and or that the retr the treatment is required to maintain or get back to a baseline level of functioning and so this is just ensuring that um that therapy is the appropriate uh treatment for the for the student and that you also want to document the member does not require a more intensive level of treatment and and so that they are able to function at a moderate enough level but that there are some impairments and not that they are at immediate risk of harm to themselves or something like that where they would need a more higher level of care so we always do risk and safety assessments and that’s documented every time you see them um and so that is the medical necessity um and yeah i think it’s just helpful to remember and think about it as a way of telling the story of how what the student is experiencing is impacting their day-to-day life and why treatment is beneficial and there is some exemption exclusionary criteria and and this is um something that advocates are really working on um so exclusionary criteria currently that the primary problem is the social is social occupational or economic um or one of physical health without a concurrent psychiatric episode meeting criteria for this level of care or and or the it is not okay to use uh this therapy as an alternative to incarceration um [Music] and so right now there is actually some movement in the field where family therapy um is covered as a treatment for a social determinant of health and so and i don’t fully understand that yet i think it’s new and coming out um so that’s something to be on the lookout for that family therapy is um actually going to be more available and covered and i think tracy may be able to speak a little bit to that at the end and the other exclusionary criteria is that the treatment plan um needs to be designed to address the goals of the active symptoms that the client is experiencing that go along with their diagnosis so for example self-actualization is not something that a payer is interested in continuing to pay for therapy for they want to really see that what you’re working on in therapy is to alleviate the symptoms that are getting in the way of the student’s daily life um [Music] and the so the next part um is to talk about from how the diagnosis impacts the functioning so this is something that the clinician needs to have documented um in the assessment a lot of ehrs um make this pretty easy by having it in the um putting this in the diagnostic formulation at the end of this biopsychosocial assessment is where you can find this um but it’s really you want to make a clear picture of how the client and student is being impacted by their mental health concerns and so this is an example template of how to write a diagnostic formulation and i highly recommend um for anybody who wants more support on this um stan taubman from the berkeley training associates has written a treatment planning guide and and in there he talks all about how to do the diagnostic formulation and how to create treatment plans that justify all of the payer’s requests so this is taken from the berkeley training associates uh book on the treatment planning guide um and so this is just a generic uh formula that anybody could use so you really want to start out with the client’s strengths and available resources and then you say due to the specific diagnosis that you have determined the client is struggling with the client experiences and you want to talk about the symptoms that the client has experienced that are related to the diagnosis and then which lead to um what the client and that the impacts on the functioning and and how it is impacting their goals in their life um and so just a simple example of this one uh and is for somebody who’s experiencing general anxiety um and it’s you know the client starting out with their strengths they value physical activity and knowledgeable about their health and nutrition and and then due to generalized anxiety disorder the client experiences generalized anxiety as evidenced by so it’s listed out the diagnosis and then the symptoms that they experience per base of worry apprehensive anticipation of future events restlessness difficulty concentrating irritability muscle tension and sleep disturbance so we’re painting the picture of what the client is experiencing on a day-to-day basis and then how it’s impacting them as a result their concentration and ill and ability to complete and turn in homework and other duties at home are impaired due to hyper vigilance and preoccupation with apprehensive anticipation threatened with removal from the basketball team and failing grades due to impaired productivity the client says he’s unable to stop worrying and says it is hard to make decisions so i think um it can be intimidating to think about um justifying medical necessity and things like that for payers but it can be helpful to remember that we’re just painting the story of what um the client is experiencing and how their mental health struggles are making things challenging for them and then in the treatment plan it’s important to document that uh the goals and the objectives that we’re working on are related to the functional impairments that we described in the diagnostic formulation so it’s just really that it’s all connected and uh telling the same story uh it’s also very important to make sure that the client is completely involved and bought into the treatment plan right it’s their treatment it’s their goals that they’re working towards clients don’t always have the wording or you know don’t come with these are the goals that i’m working on but they know how they want their lives to be better and how they want to feel better and as clinicians it’s our job to translate that into these um the the forms that the payers are going to accept and so uh payers are really wanting and goals related to functional impairments they also want objectives you know we’ve all heard smart goals that are observable and measurable related to a time frame and related to a sense of um progression and so um for an example for the last diagnostic formulation um i said one objective could be client is able to identify two thoughts that increase anxiety within four weeks as measured by client report um so we’re really just helping everything tied together and showing the payer that everything we’re doing is connected and um in service of the client and that you know the overall client goal here is to be able to stop worrying and to be able to continue playing basketball and get his grades up and two resources for treatment plans that i recommend i mentioned the berkeley training associates treatment planning guide and then i also recommend the adolescent psychotherapy treatment planner um these books are really helpful and give examples of um objectives and goals and um are written in a way that payers uh agree with and so it can be helpful to have some examples of things as clinicians you know we’re trying to do all these all of these treatment plans and so much on your plate and having some examples already laid out that you can pull from and then you know getting client feedback like hey is this something it sounds like you would want to work on does that feel doable um but and that we’re really getting client involvement in the treatment plans another thing i want to say about treatment plans is that they’re really a living breathing document it’s not that the client comes in we do the treatment plan that’s it we know we’re working with real people things change for them goals change situations change context changes and so the treatment plan is really something that is meant to be evolving as the treatment progresses you know clients can come in with one thing and then a couple weeks later there can be a crisis that happens and maybe the treatment goal is adjusted to stabilization or um maybe things start to feel better right away and maybe they don’t need to be coming in every week i mean so many different things can happen and it’s really important that clients are really involved in what their treatment plan is and that it’s evolving with the treatment it’s going to move on to minor consent so can a minor consent to their own uh mental health treatment in california we actually have two laws regarding minors and mental health the first one listed here is family code 6924 and health and safety code 124260 and this law says minors ages 12 and over are eligible to consent to their own mental health care if they are mature enough to participate intelligently in their own care so if a mind if the clinician deems that the minor is intelligent and mature enough to participate in their own care 12 years and older they are able to there’s another law an older law in california that says a minor who meets all of the following requirements to consent for mental health outpatient care that they have to be 12 and older they have to be mature enough to participate intelligently and the miner would be in danger of serious physical or mental harm to him or herself or others without treatment or the minor is the alleged victim of incest or child abuse so there is a more restrictive law about who can consent to their own mental health treatment and as katie was talking about the payer minor consent medical for mental health that funding stream uses the more restrictive law for minors to consent to their own treatment now it’s determined by each county which law that they’re going to use and so we are actively advocating that um counties use the less restrictive ma less restrictive law and as of right now many counties use the more restrictive law so miners in order to be eligible to use the minor consent medical paying funder the clinician must determine that the child is at risk of causing serious physical or mental harm to themselves or another without treatment or they’ve been allowed an alleged victim of child abuse or incest and this must be documented in the client’s chart and the clinician must sign a letter that indicates the client meets this criteria and this is the letter that katie was talking about gets submitted with the application for the minor consent paying string and as katie was talking about what if a student does not qualify for any insurances that are accepted by the health clinic so at native american they have uh put into place a protocol because you know a kid will be referred from say cost or a really concerned person and then the student comes in and they either have kaiser and it’s really difficult for them to access um care or they don’t qualify for any of the insurances but they’ve come in and they’ve got this they’ve had this assessment and they’re struggling so a native american has the protocol that they will give the student four sessions of counseling um and then connected with others connect them with other sources of support peer support groups mentor and whatever is available at that the site that this um the student is at um but those four sessions are paid for by the clinic’s budget and there is not a funding stream to pay for them and so it doesn’t allow them to see the student for more than that um so we really recommend that if you are um getting kids in and you are going to be considering using minor consent medical they may not qualify and so then it’s important to have a protocol for what you’re going to do if they do not qualify so some challenges for and to using the minor consent medical payer is that like we talked about there are limitations to who gets served and they use the more restrictive california law and ideally we see that mental health treatment um is preventative and would um you know be put into place before someone’s going to be a harm to themselves or others and they don’t need to wait for that to be occurring to qualify but currently that is what needs to happen in a lot of places you know and in many clinics assessments are one or two meetings and the eligibility criteria may not come to light in those one or two sessions um thus restricting students from needed services even if they do qualify i mean the information needed to show that they’re eligible is very sensitive information and as clinicians we know students will come in and they may not be ready or able to talk about abuse that they’ve experienced or the fact that they are considering harming themselves until they’ve met with somebody a number of times and feel really comfortable so that really sensitive information is challenging to get in just one 30-minute session or you know if you have longer assessments available at your clinic but they’re not paid in this a lot of cases they’re not being paid for and so um it’s a barrier to kids getting services even if they do qualify for the more restrictive criteria and at risk of harm to sell for others this is subjective clinician determination um there’s it’s not clear what it’s not written as to very strict guidelines as to what that means and this also means that mental health stigma can create real barriers um for treatment so you know in at native there are some sites where uh kaiser is a popular insurance or there are private insurances and yet parents are not necessarily supportive of therapy and and the student doesn’t meet the restrictive criteria for minor consent um the minor consent payer and so the parents aren’t going to be taking them to therapy outside of school but there’s no pain funding stream for them to get services in school and there there’s a real gap there as to who can actually receive um receive services um and so that is the uh end of that portion and now i will be pulling up another slide unless there are any questions oh i see there are some questions for uh this section one moment let me go back and look through um okay if you want i can collect your last slides while you look at the chat box thank you that would be great um so i see one here which students would not be eligible for minor consent also is parental consent just too difficult or how has your clinic tried to seek parental consent great so and thank you for bringing that up lisa i realized i did not cover parental consent so yes parent i’ll start first which students would not be eligible for minor consent in order to be eligible for the minor consent para model the stude the clinician has to determine that the student has experienced incest or abuse or that they are at risk of harming themselves or others so any student that does not fall under that is not eligible for the minor consent mental health funding parental consent so parental consent we need to get for any of the other funding streams so for uh all of them any other funding stream we need to have parental consent on file for a student to be able to access the services sometimes students register at the beginning of the school year and the parents sign consent that they can receive any of the services at the health center at that time so when that happens um parental consent is already done and then the clinician it’s best practice that the clinician then gets parental consent for the specific mental health treatment and gets the parent parent involved in the treatment plan and that they sign on to that sometimes a student is referred for services and the parent has not filled out the um parental consent at the beginning of the school year and they’re not an enrolled student in the clinic and so then yes the clinician and the program coordinator work together to get parental consent before the student is able to access mental health treatment katie you can correct me if i’m wrong yeah no you’re you’re absolutely right um if it happens later on in the school year and we need parent consent we’ll send it home with the student uh sometimes what happens is that during that meeting with behavioral health clinician to assess the behavioral clinician will often call the parent uh if the student feels like that is a viable thing to do they’ll sit with the student call the parent they will get verbal consent and they will go ahead and document that in the ehr so that’s another that’s just an initial sometimes that happens yes um and hold on i’m gonna stop my sh so and another question is are there limitations on what mental health services can be billed with parental consent as with minor consent limitations mental health services so if at school-based clinics we’re doing individual therapy and assessment and so that and that could be the 45 minute to 30 minute 60 minute um sessions um if there’s parental consent i don’t believe there are limitations on what mental health services and then so under minor consent would you be able to justify excessive use of marijuana as serious physical or mental harm and how would you integrate substance use treatment great question so i don’t believe that is uh what they meant when they wrote excessive or at risk of physical or mental harm um excessive use of marijuana but like i said it is subject subjective to the clinician and so if the clinician is determining that they document that in their chart and they can um argue that how another thing to talk about is that substance use counseling is covered under minor consent it’s another um one of the minor consent pair it’s another option and so if a student is um having excessive use of marijuana and needs substance use treatment and that qualifies for as one of the paying streams so um you can uh use that and there’s another ques so i hope that makes sense there’s another little box so just as there’s outpatient mental health there’s also one that says substance use so you can um use it for use it for substance use treatment um which you know many students so it minor con it is a paying source that can be used with a lot of um students and how are you defining serious mental or physical harm talk about that as one of the challenges it is clinician determination um and so yes i think that they it’s intended to be cutting oneself risk of suicide but you know mental or physical harm it’s a subjective criteria are there any other questions i think i got the ones that i could see okay then i will move on to the next portion um and tracy do you want to just advance the slide since you have it up yep okay um and i’m okay great so now i’m gonna talk a little bit um about uh school mental health in general and um the importance of integration so as school mental health uh providers it’s a big job you wear a lot of hats and in order for school mental health services to be the very best that they can be it’s really important that the clinician is really integrated into the school-wide culture and climate and so teachers admin staff they see you as a partner in this work and they see you as a resource and somebody that they can go to and get support when they’re have they’re noticing struggles come up for students um in their classroom and that you can provide social and emotional learning support in a in a classroom-wide setting or school-wide being able to provide training and support on how a school can be more centered um and so uh really as much as a mental school mental health clinician can be a part of professional development can be a part of uh school meetings and just really integrated to the school-wide culture and climate the more um the clinician is going to be seen as a resource and a way that they um a resource and and a value part of the um community and and on another level there uh many schools have a a type of coordination of services team and so this is where different service providers uh doing all different services for students are able to come together and meet and to have the mental health providers as a part of that team is so vital because like we talked about mental health services are limited and it’s important that we’re using multi-tiered systems of support and sometimes support is going to be something that the whole school needs a group of student needs or just a few kids are really struggling with and and as a coordination of services team that you all get to meet together and see what sort of struggles are coming up for students and who and what service is going to be the best fit for the student sometimes it’s individual therapy sometimes it’s group sometimes it’s mentoring sometimes it’s being part of a culturally specific group that’s gonna really speak to the client um and so being a part of whatever sort of coordination of services teams but where you are working with all of the other service providers at the school site to make sure that the correct services are being provided to the students and the better and then as ali talked about as much as possible doing integrated behavioral health and that’s complicated when there are different um agencies providing medical and behavioral health at the site different behavioral health providers um and as much as possible coming together so that there are shared referral pathways and that medical providers and behavioral health providers are really working as a team to provide the best services to the students and and it can be really important to set up regular meetings if it’s not possible every week bi-weekly monthly where medical providers and behavioral health providers are coming together um to talk about what they’re seeing and who can provide the uh supportive services to the students and and really be as integrated as possible it’s so easy as mental health providers to get siloed and but it you know because that’s where our our billable services are at in the the one-on-one services um and so that’s the challenge that all of these things we’re talking about meeting on with other service providers providing supports to teachers and staff and admin and school-wide and classroom-wide supports those things aren’t billable and so they take away from the billable hours but they’re so important in um providing mental health services on on a school campus so that’s integration is very important uh tracy i think we’re ready for the next slide um so another thing um wanted to talk about is the um aces uh screening so this is just wanted to bring this up because we’re talking about sustainability and funding many of you may know that uh the aces that eligible medical providers and if you work in an fqhc and that they’re eligible and you’ve taken the training and you’ve attested that you’ve taken the training and medical is going to be reimbursing 29 for um combin conducting the aces screening so in school-based services work that’s with children and adolescents so i linked the perl screening tool on here and that’s the one that is approved right now through aces the tool that they will reimburse and so i wanted to also bring this up that we mentioned that there’s advocacy around uh medical necessity criteria um changing and one of the things that there’s advocacy around is that a high aces score will uh determine eligibility for um treatment um so something to be keeping um aware of uh next slide and in today’s world uh you know doing aces via telehealth is something that is still um it can be done um and these are you need to make sure that you’re documenting all these things listed on here on in your charts um and so but it’s really something to be thoughtful about whether it can be done in a clinically appropriate manner and so at your clinics and your sites that’s something to really um be thinking about you know we the using the de-identified aces um seems to be a great way to go and but that’s really hard to do via telehealth and so it’s really something to just keep thinking about how it’s going to be done at your site and for any of you who really want to dive more into aces and whether you’re going to do it at your site how to do it well we will be having a two-hour session on this this afternoon from 12 to 2 where the first part will be on training and then the second hour is really going to be talking to providers about challenges limitations successes and how to do aces and in the best way possible how to screen for aces um so anybody and all of you welcome to come to the next to 12 from 12 to 2. where we talk about yes thank you tracy next slide uh and as we’ve talked about a little bit telehealth um you know has been a great way for fqhcs and school-based clinics to be able to continue to provide services and to provide billable services during this time there is not no guarantee and that it is going to continue but there are advocates really working towards this and because as we’ve all been able to see telehealth decreases the no-show rate that allows for providers to be more flexible in how they meet the needs of the students um you know a lot of clients are actually reporting that they prefer telehealth we don’t have to depend on a student being in their seat in their classroom where they’re supposed to be at the time of their appointment but we can make their appointment even if they’re not even at school so there are a lot of benefits to telehealth and we’re really pushing that it gets something that we’re able to continue using even after the emergency criteria has been put today next slide that is all for me thank you everybody so much for joining today and please if you have any questions type them in the chat and we will get to them as best we can and i we really appreciate all of you staying on with us yeah i wanted to say a few things too jessica yes that’s all right yes so first of all thank you so much to the speakers this morning um a very talented and experienced group so i’m so grateful and i especially want to thank jessica who took on multiple roles at the last minute is toggling between being a presenter and a moderator which is quite tricky because there’s multiple platforms working in the background and who was receiving erroneous messages from me at the same time so that’s my personal apology and i’m sorry also for some noise and other technical difficulties that were really human difficulties so deep breath again several of our presenters stated i think this was a lot of information to pack into a fairly tight session and it covered a lot of different aspects of school funding school-based behavioral health services so you know we acknowledge that this is a lot i think really we could make this more almost a full day for with breakouts and different groups and practicing so that’s something that we’re going to take under consideration and welcome your suggestions and also as you can see there’s a lot of room for important advocacy to help ensure that children and youth can get access to behavioral health services through their schools that are going to keep them from escalating into a higher level of need which is really i think what everybody wants right now so having said all that we have some time we have actually about 15 minutes for questions so um hopefully you’re madly typing them in and jessica’s going to read them and pick someone to respond so there’s a question from uh about the substance use can school-based clinicians utilize the substance use treatment option for minor consent medical or would this be more for a specific substance use treatment program um and so my understanding is if the clinician has documented that substance use is part of what they are treating and it’s again in the whole story it’s one of the diagnoses and it’s in the treatment plan along with a mental health diagnosis so it needs to be co-occurring yes the um substance use treatment option for minor consent medical can be used in school-based health clinics i’m sorry sorry i’ll just say again again on that note um if you’re going to be using that option that definitely you want to bring that to the liaison’s attention as well as there could be another change in the aid code it just it really depends so you just want to make sure that that is added to their case and there’s another question that’s so uh so mental health providers can use the aces screenings despite using um the cans and so um and when i says despite using the cans i’m not sure i think you still need to use the cans but the ace of screening that can be is something that can be used in addition to that to get the uh reimbursement for it yeah and jessica i just wanted to add one thing about the aces screening if you don’t mind um please so mental health providers are eligible um to screen and then bill a supplemental payment if you’re a mental health provider within an fqhc you have to be one of those licensed provider types so a psychologist um a an lcsw or a lmft if your scope has mfts in it so small caveat there thank you and tracy did you have something you wanted to add earlier i was only going to add that csha is very interested in trying to bring greater clarity around the minor consent medical program including areas like substance use treatment so we are working with other allies and partners and with the department of health care services at the state so we hope that we’re going to bring you additional information about this program in the next several months and um someone has a question um i’m not sure cans i cannot remember child it’s a it’s a screener um so what does the can stand for and i don’t remember what the acronym stands for but it is a screener that um assesses that clinicians use to assess child’s strengths and needs um it might be a child assessment of needs and strengths i don’t remember what it stands for i’m sorry child and adolescent needs and strength greater and actually i was going to suggest too maybe jessica if you’re able to put in the chat the resources that you shared for um treatment planning from stan talkman and the other one yes just to give you one more job today no problem and thank you lisa she just typed in the child out of adolescent needs and strengths we still have up to 12 minutes available in this room so if you have any other questions please let us know there is a question and in regards to billing i thought i saw somewhere that lpccs could be included along with mfts and i think yeah i can take that and and emily um back me up if i start to stray off course but within fqhcs lpccs are not a billable provider and they are um not so you cannot include them within your pps rate is that yeah my understanding as well yep so they have there has to be lcsw lmft or a licensed psychologist yes okay um and another question so you have to be a licensed mental health provider to do the aces screening so that’s for the reimbursement um so in order to for medical to reimburse the screening which they also only reimburse one per child per year per clinic so if a medical provider has done the aces screening and then uh you decide to do it because you know the medical provider did it in your clinic they’re not going to reimburse both the behavioral health provider and the medical provider for doing it but yes for the to be reimbursed for doing the screening it has to be a licensed mental health provider and i’ll address if you want oh yeah there are um some health centers that have created you know workflows that work for their environment so it may be that you know it’s a combo screening perhaps a nurse on the primary care side would uh introduce the screening to the patient excuse me walk them through some of the questions that they may have you know sort of give a cursory review of the screening results but then ultimately that screener has to be reviewed and the claim has to be the supplemental payment claim has to be submitted by a licensed billable provider within an fqhc and that’s just with the fqhc i would say you know there’s other scenarios for for other billable providers and non-fqhc settings but within the fqhc it has to be a licensed billable provider actually submitting the claim if there are any other questions feel free to chat them i don’t see any coming in right now so i i actually have a question about the uh the billing um for so if a provider or like a nurse practitioner or maybe not a nurse practitioner but like an m.a does the screening for aces and we need a licensed um mental health provider if the school-based health center is like ours and attached to a main clinic could that assessment be done and then transferred over um to the clinic licensed mental health person and they could submit the claim as long as they reviewed it that’s quite the question and a pretty that’s a that’s a really interesting scenario i would have to ask the state about that scenario specifically the other key caveat to the um person who actually submits the claim is that they must have re taken the two hour mandatory aces aware um provider training which anybody can take i took it i’m a non-clinician um and then the clinicians have to attest with the state that they have taken that training and that attestation piece is like your pasco you know collect your 29 or whatever it is um and the folks that are going to a test are going to be licensed providers with an npi number right um i scenario in your scenario i would say one of the key components is that somebody must have reviewed the the screening results and have enough competency and training and capacity to respond with the patient for positive screeners right so for those positive areas um i mean that’s just like the basic clinical standard that you want to have right in your workflow and then in terms of the billing i would have to ask the state if that’s an allowable method i would i’m hesitant to offer an actual response for the billing piece and there was a question that asked can you talk about reimbursement for screening and i think you just talked about that but yes the license provider has to take the training and attest that they have to have taken the training um and then they can submit the claim and and it says and it all says is aces the way to i’m not sure it’s ace is the way to do this it talks about prior diagnosis and establishment medical necessity so i think aces is one piece of a an overall assessment and could be um a part of establishing medical necessity and i think that is what is one thing that there are advocates in um that are trying to say that yes uh you just need to have a high enough asus score i believe it’s three but i’m not don’t i’m not positive um and then that should be enough to qualify um as a meeting medical necessity criteria um and anybody else i would say for the billing piece too the department of healthcare services has re so it’s a little wonky to do the billing for fqhcs um because it’s not your pps rate and the state’s like i don’t know how to receive a claim that’s not an actual pps right so we had to work with them um to figure out what that system looks like and there is some guidance on the department of healthcare services website um specifically for fqhcs what the claims should look like where you put the information etc um in the codes and things like that um and then i also wanted to add too that you know we’re talking about the screening but really one of the most important and critical pieces is to have the right environment to do the screening right especially in this environment where we have you know the pandemic of coba 19 and structural racism embedded into our systems i mean we want to make sure that we’re not bringing up a bunch of and bringing to light a bunch of issues without having the appropriate responses for patients um and having a trauma informed and resilience oriented lens and so i highly encourage you to take the or to attend the session with leo wolfe prasan who is one of my new favorite people she’s been doing a trauma informed and resilience oriented health centers seminar series which is uh taking place right now they’re nine minutes in of their like fourth session for cpca um so she’s been leading that she’s presenting at this conference today so i really want to plug that session and then also check out the cpca website um and we have some some great resources there you’re more than welcome to watch some of the recordings that she has completed um for this seminar series which is really all about like creating a healing environment which will enable you to then screen in a safe way for your patients and for your staff right because our staff some of some of our staff come from the community i think in one session uh behavioral health provider was like just because i’m a behaviorist doesn’t mean i’m inoculated from from trauma or from having anxiety um as it relates to the pandemic or other things happening so i really just really want to plug and encourage folks to make sure you’re focusing on those systems of care that really support trauma screenings yeah and if to just piggyback on that that is what we will be discussing um this afternoon um from 12 to two uh and really talking about all of the concerns that people have around um administering an asus screen um and what it what it takes to do it in an ethically uh client-centered way that’s actually um healing and not um just bringing up um triggers um and and we’re also going so we’re gonna have the training today and listening session and where we’re talking about what are people’s challenges around this how do you do this in a good way um and then we’re going to be selecting from people who apply eight um sites where they actually want to do implementing the asus greener in the next year and we’re going to meet monthly throughout the next year and talk about how is it going what are you facing um as challenges and how can we support doing this in the best way possible as ali talked about to be trauma informed and healing centered and that the whole system is supporting and the students um in that way and so anybody who’s interested in really diving very deep into aces and how to do it well please join us this afternoon and then consider um if you want to be a part of our learning collaborative throughout this next year i’m inclined to stop there so that folks can get to the 11 15 brain break which um i’m not looking at the program but i know we have a great break for you coming up so if there’s nothing else burning in the q a or chat jessica thank you everyone for coming we’re so glad that you are working on this difficult and so important set of services for our youth and thank you very much presenters take care everyone you
We know that the mental health needs of children and youth were growing rapidly even before the COVID-19 pandemic and latest wave of racial injustices. This workshop is aimed at FQHCs and other community health centers that provide or want to provide integrated behavioral health (BH) services to students in SBHCs. It includes an overview of how the mental health system in California is organized and financed, and how school-based health providers fit into this structure. The workshop briefly reviews some common funding sources for BH services in SBHCs, including EPSDT; the Medi-Cal managed care benefit for mild to moderate mental health concerns, Minor Consent Medi-Cal; MHSA grants; and reimbursement for ACEs screening. Advocates and practitioners highlight their experience and practices related to referral streams, eligibility and enrollment, provider credentialing, billing, coding, documentation, and consent for treatment in school-based health settings.
Presenters: Allie Budenz and Emily Shipman, California Primary Care Association
Catherine Lampi, Native American Health Center
Jessica Dyer and Tracy Mendez, California School-Based Health Alliance