AAP-CA Expresses Concern over CalAIM Section 1115 

May 6, 2021 Letter on CalAIM Section 1115

May 6, 2021

Will Lightbourne, Director
California Department of Health Care Services PO Box 997413, MS 0000
Sacramento, CA 95899-7413

RE: CalAIM Section 1115 & 1915(b) Waivers

Dear Director Lightbourne,

The American Academy of Pediatrics, California (AAP-CA) representing over 3,000 pediatrician members appreciates the broad goals of DHCS’ proposed 5-year CMS Waiver. However, we are deeply concerned that the proposal in its current form may unintentionally limit, rather than expand, access to behavioral health care for children and youth in California.

Eligibility for Behavioral Health Services

The draft proposal uses unclear criteria to define which children and youth should receive behavioral health services. Federal Early and Periodic Screening, Diagnostic and Treatment (EPSDT) regulations state that children and youth are eligible for services if an “appropriate” clinical provider determines services are needed, but it is not clear who is an “appropriate” clinical provider. EPSDT rulings have determined that if a competent medical provider finds specific care to be “medically necessary” to improve or ameliorate a child’s condition, services must be covered. Without clarifying who is or isn’t an “appropriate” provider, children and youth may not qualify for services until they undergo a secondary assessment of the need for care. The guidelines should clearly state that when a primary care provider or licensed behavioral health provider determines that services are necessary and submits or makes available documentation that substantiates that eligibility, the child or youth is eligible for behavioral health services.

Timeliness of Behavioral Health Services

The draft proposal does not clarify the process for receiving behavioral health services within the DHCS-required timely access to care standard of 10 business days from the date of the request for a non-urgent appointment and 48 hours for an urgent appointment. Past policies and practices, lack of workforce capacity, and unclear responsibilities of the behavioral health systems upon referral have resulted in substantial delays in receipt of care. Medi-Cal Managed Care Plans (MCP) should be responsible for assuring that the timely access standard is met for all referrals for service unless the patient has previously received services in the County Mental Health Plan’s (MHP) specialty mental health system. The MHP is responsible for assuring access to timely care for previous enrollees who received specialty mental health care in any County mental health plan, regardless of location.

Eligibility for Specialty Mental Health Services through County Mental Health Plans

The draft proposal specifies that beneficiaries under age 21 are eligible to receive specialty mental health services if they meet particular criteria, with “scoring in the high-risk range on a DHCS-approved trauma screening tool” as one of the criteria. According to an article by Dr. Robert Anda, author of the ACEs study, “ACE scores are being misappropriated as a screening or diagnostic tool to infer individual client risk and misapplied in treatment algorithms that inappropriately assign population-based risk for health outcomes from epidemiologic studies to individuals.”1 Furthermore, the proposal does not take into account the way ACEs are experienced in the BIPOC population or take into account the systemic

racism and inequality that lie beneath these issues. DHCS should convene an advisory workgroup to consider the

1 https://psycnet.apa.org/record/2020-54827-019
2 https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-020-10091-y

The American Academy of Pediatrics, California is the state-level advocacy organization of California AAP Chapters 1, 3 and 4. Our mission is to promote the health and well-being of all children and youth in California and to support the professional needs of our California Chapter member pediatricians. We are a 501(c)4 nonprofit legally incorporated in California.

American Academy of Pediatrics, California

5000 Campus Drive Newport Beach, CA 92660 Phone (626) 796-1632 Fax(626) 628-3382 Email: support@aap-ca.org |www.AAP-CA.org

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American Academy of Pediatrics, California

5000 Campus Drive Newport Beach, CA 92660 Phone (626) 796-1632 Fax(626) 628-3382 Email: support@aap-ca.org |www.AAP-CA.org

appropriate role of trauma screening in determining mental health access for children and teens.

Initial Intervention services

The CalAIM proposal states there should be “No Wrong Door” for entry to care and that reimbursement and services can be offered before a diagnosis is clearly established, yet how can non-urgent services be provided in a timely manner or which system pays for the interim services is not clear. The behavioral health workforce shortage makes it impossible for MCPs and MHPs to obtain the information needed for a referral and arrange a continuity behavioral health provider within 10 business days, let alone complete a baseline evaluation to determine the needs of the patient. A plan for delivering initial intervention services for non-urgent referrals, either through the primary care provider, the referring behavioral health provider or a member of a pool of behavioral health providers incentivized and available to deliver care to children and youth in a timely manner is needed.

Plans could authorize initial intervention services with the referring behavioral health provider or primary care provider, possibly through contract arrangements with local education agencies and medical providers. Specifications regarding the content of brief initial intervention services, along with credentialing to deliver these services to children and youth would need to be developed.

An appointment for initial intervention services should be provided within 10 business to support the child/youth and complete the evaluation for new non-urgent referrals if a continuity behavioral health provider is not available. The Medi-Cal Managed Care Plans (MCP) are responsible for providing initial intervention services for patients who have not previously received care in the County Mental Health Plan until an evaluation has been completed and an appointment is made with a continuity provider. The MHP is responsible for providing initial intervention services for nonurgent referrals to enrollees who had previously received specialty mental health care in any County mental health plan, regardless of location.

Support of Preventive Services

Federal EPSDT funding covers preventive services as well as therapeutic services for children and youth, however DHCS has not proposed funding services targeted specifically towards behavioral health early intervention and prevention.

Implementation of statewide preventive services could be made available through the EPSDT funding stream, such as enhanced school-based services working in partnership with mental health and primary care providers, enhanced implementation of integrated behavioral health in primary care practices, and enhanced dissemination of dyadic care for parents and young children in need of support.

AAP-CA respectfully opposes the proposed CMS waiver unless amended due its potential clinical impacts. Thank you for your public service and leadership on behalf of the health and wellbeing of children, youth, and families in California.


Jacques-Emmanuel Corriveau, MD, FAAP Chair, State Government Affairs Committee American Academy of Pediatrics, California

cc: AAP Leadership