New Children’s Medi-Cal Behavioral Health Benefits 101: Family Therapy and Dyadic Services

By Kathryn Margolis

Associate Clinical Professor, UCSF Departments of Psychiatry and Pediatrics; Director, ZSFG Division of Integrated Behavioral Health; Associate Director, ZSFG Primary Care Behavioral Health, Pediatrics

Recent policy shifts in California have changed the landscape of mental health services available for children. The changes have been rolled out over the last two years, with more slated to go into effect in January. Together, these changes will allow for prevention-oriented, whole-family care for children who qualify for Medi-Cal coverage.

The first change came in June 2020 when the Department of Health Care Services launched a family therapy benefit, retroactive to January 2020. Through this benefit, psychologists and other California Board of Behavioral Science licensed or license-eligible providers can bill Medi-Cal for family therapy and treat a caregiver and child together. Instead of needing a diagnosis, families are eligible for family therapy if they are experiencing certain risk factors. These risk factors are broad and include both child-oriented variables, such as exposure to interpersonal or community-level adversity, and caregiver-oriented variables, such as maternal mental health concerns or substance use disorder.

Then, in December 2021, the Department of Health Care Services updated its provider manual for all non-specialty mental health services. Non-specialty mental health services are delivered via Medi-Cal managed care and fee-for-service delivery systems and are separate from the specialty services delivered through county mental health plans. Non-specialty mental health services include family therapy, but also other mental health supports including group and individual psychotherapy. This update makes children eligible for non-specialty services if they are experiencing certain health-impacting risk factors such as homelessness, or if they are otherwise eligible for services, regardless of their level of impairment or the presence of a diagnosis. It also allows behavioral health clinicians to use qualifying physical health diagnoses (e.g. fussy baby or colic) as their primary diagnosis for a behavioral health service by billing a “Health and Behavior” assessment or intervention code. In addition, it expanded Family Therapy to include subclinical presentation of mental health concerns (e.g. anxiety symptoms without a diagnosis).

These changes acknowledge that early childhood development and mental health are heavily dependent on family well-being and caregiver mental health and bonding. They are major shifts in the way mental health care can be provided to children. However, they still do not fully allow for behavioral health promotion and prevention in primary care-based services for the caregiver-child dyad in Medi-Cal.

This gap led California to create a dyadic services Medi-Cal benefit effective January 2023. The dyadic services benefit allows Medi-Cal to cover behavioral health wellness visits that focus on the individual child and their surrounding environment, including caregiver wellness, all within the context of the child’s medical appointment. Dyadic services provides reimbursement for evidence-based health promotion and primary prevention supports that can be brief in duration. Covered behavioral health services include screening for behavioral health problems, interpersonal safety, tobacco and substance misuse, and social determinants of health and referrals for appropriate follow-up care. Unlike family therapy, children do not need to exhibit certain concerns or conditions in order to be eligible. This benefit will allow pediatric providers to implement models such as HealthySteps in their clinics and receive Medi-Cal reimbursement for eligible providers.

Care coordination for the child or caregiver in support of the child’s health will also be a covered benefit in the dyadic services package. In addition to direct, face to face or telehealth clinical intervention with children or their families, the dyadic services benefit package provides reimbursement pathways for the care coordination services that are performed by NSMHS providers. This will ensure linkage with external, community-based supports that are critical to ensuring child and family health. Previously not covered care coordination services like following up with families about linkage to a caregiver’s own mental health services or linkage to a child’s early intervention services will now be considered a billable service when delivered by an eligible provider.

In the dyadic services integrated care model, pediatric behavioral health professionals are able to address developmental and behavioral health concerns as soon as they are identified, providing a brief intervention to a caregiver in distress while working alongside a trusted pediatric provider during a naturally occurring pediatric visit. This approach not only reduces mental health stigma while increasing access to care, but is also more effective because it leverages a unique moment in time during natural touchpoints with healthcare systems when the caregiver is open and motivated to engage in care.

Dyadic services also bypass the many obstacles families face when referred to offsite behavioral health services. Although longer, individualized, behavioral health follow-up visits occurring outside of the pediatric visit are critical for families who need and are ready to engage in treatment, intervening in the moment that a caregiver is expressing desire to receive help, like during a pediatric visit, promotes access and timeliness to care. For example, it is well documented that a person's motivation to change fluctuates. Engaging individuals during highly motivated moments is a key promoter to change. Dyadic, same-day services leverage this natural promoter of care engagement by meeting the family during their motivated moments as their child receives care from their pediatrician, a highly trusted individual for families, second only to their own families.

Dyadic services foster access to preventive care for children, improve immunization rates, coordination of care, child social-emotional health and safety, developmentally appropriate parenting, and maternal mental health. It is effective in improving health outcomes, especially when provided over time, such as across the multiple well-child visit touch points during the infant and toddler time period. This means families can learn to develop their own and their child’s mental health and well-being from the time their baby’s newborn visit even without the presence of individual or environmental risks.

There is a long road ahead for the state and local communities to implement these new benefits, especially dyadic care. We will need to grow a much larger mental health workforce including those with the expertise to serve children. There is also awareness building that must happen among providers and families about early childhood mental health and the new benefits. Furthermore, clinics will need to adjust their operations to embed and implement dyadic care. This includes developing infrastructure to leverage new benefits and train providers to use them, but also to transform the way in which clinics practice so that true team-based care is provided in the context of naturally occurring pediatric visits. Additionally, FQHCs will need support to ensure they are leveraging dyadic services in a way that upholds the gold standard of dyadic care in conducting same-day visits, while also ensuring adequate revenue generation in spite of the same day billing exclusions for behavioral and physical health. Finally, it is critical that providers and health plans are incentivized to create broad access to dyadic services. This can be supported by aligning healthcare metrics with the needs of children, such as ensuring that their caregivers are screened for mental health concerns and that a same day assessment is conducted.

That’s why we have launched a pediatric practice technical assistance center at the University of California San Francisco. This innovative center supports pediatric practices in building evidence-based models into their standards of care, and provides technical expertise to high-impact practices across the state on providing early childhood behavioral health and developmental care and receiving reimbursement.

As we grow our capacity, there is a role for the Department of Health Care Services, philanthropy, and Medi-Cal Managed Care Plans in making sure that providers and communities across the state have sufficient resources and TA to engage in these new benefits. Careful attention and oversight of implementation is an essential part of making these benefits a success and ensuring all young children and families in Medi-Cal get the care they need.

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