10.26.01 Behavioral Health Treatment Program Form

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Policy Title: Behavioral Health Treatment Program POLICY #: 10.26.01 Line of business: Medi-Cal Department Name: Behavioral Health Original Date 10/2014 Effective Date: 7/2018 Revision Date: 9/2024, 9/2025 Governing Committee: Medical Services Committee Governing Committee Approval: Jennifer Nuovo, MD, Blue Shield Promise Chief Medical Officer Date: 9/9/25 Vice President (VP) Approval: Tracy Alvarez, VP, Medical Care Solutions Date: 9/9/25

A. PURPOSE The purpose of this document is to outline the program for Behavioral Health Treatment (“BHT”) Services for Medi-Cal Members under Early Periodic Screening, Diagnosis, and Treatment (“EPSDT”).

BACKGROUND On July 7, 2014, the Centers for Medicare and Medicaid Services (CMS) released guidance regarding the coverage of BHT services pursuant federal law. Federal law requires the EPSDT benefit to include a comprehensive array of preventative, diagnostic and treatment services for low-income individuals under 21 years of age, which encompasses BHT services. In accordance with federal EPSDT requirements, Medi-Cal provides coverage for all Medically Necessary BHT services for eligible Members under 21 years of age. This includes children diagnosed with Autism Spectrum Disorder (ASD) and children for whom a licensed physician, or psychologist determines that BHT services for the treatment of ASD are Medically Necessary, regardless of diagnosis.

On March 30, 2016, CMS issued a final rule (CMS-2333-F) that applied certain requirements from the Mental Health Parity and Addiction Equity Act of 2008 (Pub. L.

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110-343, enacted on October 3, 2008) to services covered by Medi-Cal Managed Care Plans (MCPs). The general parity requirement contained in Title 42 of the Code of Federal Regulations section 438.910(b) prohibits treatment limitations for mental health benefits from being more restrictive than the predominant treatment limitations applied to medical or surgical benefits. In accordance with federal law, mental health parity also applies to BHT services. Additionally, as the MCP, Blue Shield Promise Health Plan (Blue Shield Promise) must comply with mental health parity requirements when providing BHT services consistent with APL 22-006 or any superseding APL. Treatment limitations for BHT services may not be more restrictive than the predominant treatment limitations applied to medical or surgical benefits. Additionally, mental health parity requirements stipulate that MCPs must disclose utilization management criteria.

B. DEFINITIONS:

1. Ameliorate: Is to “make more tolerable”.
2. Applied Behavioral Analysis: Applied Behavioral Analysis means the design, implementation, and evaluation of systematic instructional and environmental modifications to promote positive social behaviors and reduce or ameliorate behaviors, which interfere with learning and social interaction.
3. Behavioral Health Treatment Services: Behavioral Health Treatment services are services based on reliable evidence and are not experimental. This includes professional services and treatment programs, including but not limited to: Applied Behavioral Analysis (“ABA”), and other evidence-based behavior intervention programs that develop or restore to the maximum extent practicable, the functioning of a Member, including those with or without ASD. Covered Services, BHT services must be: a. Medically Necessary b. Provided, observed and directed in accordance with an Blue Shield Promise approved behavioral treatment plan that is developed by a BHT service Provider who meets the requirements in California’s Medicaid State Plan; and, c. Provided by a Qualified Autism Service Provider, Qualified Autism Service Professional, or Qualified Autism Service Paraprofessional who meets the requirements contained in California’s Medicaid State Plan or a licensed Provider acting within the scope of their licensure.
4. DSM-V: Diagnostic and Statistical Manual for Mental Disorders (DSM) V
5. EPSDT: Early Periodic Screening, Diagnosis, and Treatment
6. Evidence-based practice: means a decision-making process that integrates the best available scientifically rigorous research, clinical expertise, and individual’s characteristics. Evidence-based practice is an approach to treatment rather than a specific treatment. Evidence-based practice promotes the collection,

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interpretation, integration, and continuous evaluations of valid, important, and applicable individual- or family-reported, clinically observed, and research- supported evidence. The best available evidence, matched to consumer circumstances and preferences, is applied to ensure the quality of clinical judgments and facilitates the most cost-effective care.

7. IOP: Intensive Outpatient Program
8. LEA: Local Educational Agency
9. Maintenance Services: services that sustain or support rather than those that restore functioning or improve health problems.
10. Medically Necessary: a service is Medically Necessary if the service is necessary to correct or ameliorate (see definition above) defects and physical and/or mental illnesses and conditions. A BHT service need not cure a condition in order to be covered. Services that are considered to maintain or improve the Member’s current health condition must be covered to “correct or ameliorate” a Member’s condition.
11. NCQA: National Committee for Quality Assurance
12. Parent Participation: Will include, but will not be limited to, the following meanings: a. Completion of group instruction on the basis of behavioral intervention b. Implementation of intervention strategies, according to the intervention plan c. If needed, collection of data on behavioral strategies and submission of that data to the provider for incorporation into progress reports d. Participation in any needed clinical meetings e. Purchase of suggested behavior modification materials or community involvement if a reward system is used
13. PHP: Partial Hospitalization Program
14. Qualified Autism Service Provider: means either of the following: a. A person that is certified by a national entity, such as the Behavior Analyst Certification Board, that is accredited by the National Commission for Certifying Agencies, and who designs, supervises, or provides treatment for pervasive developmental disorder or autism, provided the services are within the experience and competence of the person, entity, or group that is nationally certified. b. A person licensed as a physician and surgeon, physical therapist, occupational therapist, psychologist, marriage and family therapist, educational psychologist, clinical social worker, professional clinical counselor, speech-language pathologist, or audiologist pursuant to Division 2 (commencing with Section 500) of the Business and Professions Code, who designs, supervises, or provides treatment for pervasive

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developmental disorder or autism, provided the services are within the experience and competence of the licensee.

15. Qualified Autism Service Professional: means an individual who meets all of the following criteria: a. Provides behavioral health treatment. b. Is employed and supervised by a qualified autism service provider. c. Provides treatment pursuant to a treatment plan developed and approved by the qualified autism service provider. d. Is a behavioral service provider approved as a vendor by a California regional center to provide services as an Associate Behavior Analyst, Behavior Analyst, Behavior Management Assistant, Behavior Management Consultant, or Behavior Management Program as defined in Section 54342 of Title 17 of the California Code of Regulations. e. Has training and experience in providing services for pervasive developmental disorder or autism pursuant to Division 4.5 (commencing with Section 4500) of the Welfare and Institutions Code or Title 14 (commencing with Section 95000) of the Government Code.
16. Qualified Autism Service Paraprofessional: means an unlicensed and uncertified individual who meets all of the following criteria: a. Is employed and supervised by a qualified autism service provider. b. Provides treatment and implements services pursuant to a treatment plan developed and approved by the qualified autism service provider. c. Meets the criteria set forth in the regulations adopted pursuant to Section 4686.3 of the Welfare and Institutions Code. d. Has adequate education, training, and experience, as certified by a qualified autism service provider. C. POLICY I. It is the policy of Blue Shield Promise to ensure compliance with state and regulatory guidance as it relates to Behavioral Health Treatment services. Pursuant to the Department of Health Care Services’ (“DHCS”) All Plan Letter 23- 010, MCPs will be responsible for these benefits. These benefits are available to all current and newly eligible Medi-Cal children and adolescent Members 0 to 21 years of age that are in need of Medically Necessary BHT services. Blue Shield Promise, as the MCP, has primary responsibility for ensuring that all of a Member’s needs for Medically Necessary BHT services are met across environments, including on-site at school or during virtual school sessions. Additionally, as the MCP, Bule Shield Promise is responsible for coordinating with other entities and covering any gap in Medically Necessary BHT services for the Member. II. BHT services are based on reliable evidence and are not experimental. BHT services for the treatment of ASD are described in California’s Medicaid State

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Plan, Limitations on Attachment 3.1-A, 13c – Preventive Services, BHT, and Attachment 3.1-A, Supplement 6.7 BHT services include applied behavioral analysis (ABA) and a variety of other behavioral interventions that have been identified as evidence-based approaches that prevent or minimize the adverse effects of behaviors that interfere with learning and social interaction. The goal is to promote, to the maximum extent practicable, the functioning of a Member, including those with or without a diagnosis of ASD. As the MCP, Blue Shield Promise will cover all services that maintain the Member’s health status, prevent a Member’s condition from worsening, or that prevent the development of additional health problems. Additionally, Blue Shield Promise will cover all necessary EPSDT services, including BHT services, when they are covered under Medicaid, regardless of whether California Medicaid State Plan covers such services for adults, when the BHT services have an ameliorative, maintenance purpose. III. BHT is the design, implementation, and evaluation of environmental modification using behavioral stimuli and consequences to produce socially significant improvement in human behavior, including the direct observation, measurement, and functional analysis of the relations between environment and behavior. BHT services teach skills through the use of behavioral observation and reinforcement, or through prompting to teach each step of targeted behavior.

D. PROCEDURE I. Member Notifications: Blue Shield Promise Health Plan will inform Members that Early Periodic Screening, Diagnosis, and Treatment (“EPSDT”) services are available to Members 0 to 21 years of age. II. Screening: Primary Care Physicians are responsible for comprehensive screening and preventative services for said Members, which include but are not limited to the following: a. Health and Development History b. Comprehensive Physical Examination c. Appropriate Immunizations d. Lab Tests e. Lead Toxicity Screening f. Diagnosis and treatment referral for all Medically Necessary services, including but not limited to BHT III. Review for Duplicative Services: while the Member is in the process of an assessment and evaluation, the Blue Shield Promise Behavioral Health Utilization Management (BH UM) clinician will outreach to the Regional Center and other entities (such as Other Health Care Coverage) to ensure what the Member’s status is with BHT Services. IV. Assessment and Evaluation Process: Upon receipt of the referral from the PCP and/or the Professional, the Blue Shield Promise BH UM clinician will provide a referral for services to a Qualified Autism Service (“QAS”) Provider as defined in

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Attachment 3.1A, Supplement 6, California’s Medicaid State Plan.

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a. The Functional Behavior Assessment will be submitted by QAS Provider with a treatment plan and recommendation for services. V. Determination: The Blue Shield Promise BH UM clinician will review the documentation submitted by the QAS Provider and render a formal determination regarding authorization of services. Criteria for BHT Services: a. Be under 21 years of age; b. Have a recommendation from a licensed physician or a licensed psychologist that evidence-based BHT services are Medically Necessary and covered under Medicaid; c. Be medically stable; and d. Be without a need for 24-hour medical/nursing monitoring or procedures provided in a hospital or intermediate care facility for persons with intellectual disabilities (ICF/ID) e. Use current clinical criteria and guidelines when determining what BHT services are Medically Necessary in accordance with EPSDT requirements and medically accepted standards of care. Notification of Determination a. If Approved: Blue Shield Promise BH UM will send a notification to the parent/guardian and requesting provider. b. If Denied or Modified: Blue Shield Promise BH UM will send a notification to the parent/guardian and requesting provider including the specific criteria on which any denial of authorization is based. c. Notification Timeliness follows Medi-Cal Guidelines for Member and provider notifications and is documented in the Blue Shield Promise Policy and Procedure 10.26.2 Authorization Denial, Pending/Deferral, and/or Modification Notification for Behavioral Health Treatment.

VI. Treatment Services: Blue Shield Promise will establish contracts with QAS Providers or Organization(s), which will provide Behavioral Health Treatment services to Members. As the MCP, Blue Shield Promise will permit the Member’s Guardian(s) to be involved in the development, revision, and modification of the behavioral health treatment plan, in order to promote Guardian participation in treatment. The treating QAS Provider will submit a treatment plan which will: a. Be developed and supervised by a qualified autism service provider for the specific Member being treated; b. Identify the Medically Necessary services to be provided in each community setting in which treatment is medically indicated, including on-site at school or during remote school sessions. In cases where the

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approved behavioral treatment plan includes BHT services provided during school hours, Blue Shield Promise will ensure effective coordination with the LEA, as necessary. c. Include a description of patient information, reason for referral, brief background information (e.g., demographics, living situation, home/school/work information), clinical interview, review of recent assessments/reports, assessment procedures and results, and evidence- based BHT services; d. Be person-centered and based upon individualized, measurable goals and objectives over a specific timeline; e. Delineate both the frequency of baseline behaviors and the treatment planned to address the behaviors; f. Identify measurable long-, intermediate-, and short-term goals and objectives that are specific, behaviorally defined, developmentally appropriate, socially significant, and based upon clinical observation; g. Include outcome measurement assessment criteria that will be used to measure achievement of behavior objectives. h. Include the current level (baseline, behavior parent/guardian is expected to demonstrate, including condition under which it must be demonstrated and mastery criteria [the objective goal]), date of introduction, estimated data of mastery, specify plan for generalization and report goal as met, not met, modified (include explanation); i. Utilize evidence-based BHT services with demonstrated clinical efficacy treatment tailored to the Member; j. Clearly identify the service type, number of hours of direct service(s), observation and direction, parent/guardian training, support and participation needed to achieve the goals and objectives, the frequency at which the Member’s progress is measured and reported, transition plan, crisis plan, and each individual BHT service provider responsible for delivering the services; Include care coordination involving the parents or caregiver(s), school, state disability programs, and other as applicable; k. Include care coordination that involves the Guardian, school, state disability programs, and other programs and institutions, as applicable. l. Consider the Member’s age, school attendance requirements, and other daily activities when determining the number of hours of Medically Necessary direct service and supervision. As the MCP, Blue Shield Promise will not reduce the number of Medically Necessary BHT hours that a Member is determined to need by the hours the Member spends at school or participating in other activities;

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m. Deliver BHT services in a home or community-based setting, including clinics. BHT intervention services provided in schools, in the home, or other community settings, must be clinically indicated, Medically Necessary and delivered in the most appropriate setting for the direct benefit of the Member. BHT service hours delivered across settings, including during school, must be proportionate to the Member’s medical need for BHT services in each setting; and Medically Necessary n. Include an exit plan/criteria. However, only a determination that services are no longer Medically Necessary under the EPSDT standard can be used to reduce or eliminate services. VII. Ongoing Treatment: BHT services are provided under a behavioral treatment plan that has measurable goals over a specific timeline for the specific Member being treated has been developed by a BHT Service Provider/QAS Provider. The QAS Provider will be required to submit a progress report based upon an agreed upon timeframe between Blue Shield Promise and the QAS Provider. Initial Treatment plans must be submitted by a QAS Provider and reviewed by a Blue Shield Promise BH UM clinician. At the re-evaluation period (no less than once every 6 months), the treatment of services will be reviewed for medical necessity and a determination will be rendered. The requesting provider and Member guardian will receive notification of the determination. BHT services may be discontinued when the treatment goals are achieved, goals are not met, or services are no longer Medically Necessary. VIII. BHT Service Limitations: a. Services must give consideration to the child’s age, school attendance requirements, and other daily activities as documented in the treatment plan. As the MCP, Blue Shield Promise will not limit BHT services on the basis of school attendance or other categorial exclusions. b. BHT Services will be discontinued when the treatment goals and objectives are achieved or are no longer Medically Necessary.

IX. Services Not Covered. The following services do not meet medically necessity criteria, nor qualify as Medi-Cal covered BHT services for reimbursement: a. Therapy services rendered when continued clinical benefit is not expected unless the services are determined to be Medically Necessary (see above for definition of “Medically Necessary”). b. Provision or coordination of respite, daycare, recreational services or educational services, or reimbursement of a parent, legal guardian, or legally responsible person for costs associated with participation under the behavioral treatment plan; c. Treatment whose sole purpose is vocationally- or recreationally-based;

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d. Custodial care e. For purposes of BHT services, custodial care: f. Is provided primarily for maintaining the recipient’s or anyone else’s safety; and g. Could be provided by persons without professional skills or training. h. Services, supplies, or procedures performed in a non-conventional setting including, but not limited to: i. Resorts; j. Spas; and k. Camps l. Services rendered by a parent, legal guardian, or legally responsible person. m. Services that are not evidence-based behavioral intervention practices As the MCP, Blue Shield Promise is contractually responsible for educationally necessary BHT services covered by a Local Educational Agency (LEA) and provided pursuant to a Member’s Individualized Family Service Plan (IFSP), Individualized Education Program (IEP), or Individualized Health and Support Plan (IHSP). However, if Medically Necessary, Blue Shield Promise will provide supplementary BHT services, and will provide BHT services to address any gap in service caused when the LEA discontinues the provision of BHT services (e.g., during a PHE). If Medically Necessary BHT services are otherwise still needed, but the need is not documented in an IEP or IFSP/IHSP, then the MCP may coordinate any needed BHT services in a school-linked setting.

X. COORDINATION OF CARE Blue Shield Promise has primary responsibility for ensuring that EPSDT Members receive all Medically Necessary BHT services. As the MCP, Blue Shield Promise will establish data and information sharing agreements as necessary to coordinate the provision of services with other entities that may have overlapping responsibility for the provision of BHT services, including but not limited to Regional Centers (RCs), LEAs, and County Mental Health Plans.

When another entity has overlapping responsibility to provide BHT services to the Member, Blue Shield Promise BH UM will: a. Assess the medical needs of the Member for BHT services across community settings, according to the EPSDT standard; b. Determine what BHT services (if any) are actively being provided by other entities; c. Coordinate the provision of all services including Durable Medical Equipment and medication with the other entities to ensure that the MCP and the other entities are not providing duplicative services; and

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d. Ensure that all the Member’s medical needs for BHT services are being met in a timely manner, regardless of payer, and based on the individual needs of the Member. Medically Necessary BHT will not be considered duplicative when Blue Shield Promise has overlapping responsibility with another entity for the provision of BHT services unless the service provided by the other entity is currently being provided, is the same type of service (e.g., ABA), addresses the same deficits, and is directed to equivalent goals.

Blue Shield Promise has the primary responsibility to provide all Medically Necessary BHT services covered under Medicaid. When services provided by a LEA or RC do not fulfill all the Member’s medical needs for BHT services, Blue Shield Promise BH UM will authorize any remaining Medically Necessary services covered under Medicaid. Blue Shield Promise will not rely on LEA programs to be the primary Provider of Medically Necessary BHT services on-site at school or during remote school sessions. Further, Blue Shield Promise will not assume that BHT services included in a Member’s IEP/IHSP/IFSP are actively being provided by the LEA. Blue Shield Promise is responsible for determining whether such services continue to be provided by the LEA and will provide any Medically Necessary BHT services that have been discontinued by the LEA, for example during a PHE. If a Member’s IEP team concludes that MCP-approved BHT services are necessary to the Member’s education, the IEP team must determine that Blue Shield Promise-approved BHT services must be included in the Member’s IEP.

a. Individualized Educational Program: Blue Shield Promise will: i. Not reduce or discontinue services in a Member’s IEP without formal amendment of the IEP. ii. Not use Medi-Cal funding to provide services if the Blue Shield Promise contracted Provider determines that BHT services included in a Member’s IEP are no longer Medically Necessary, iii. Maintain sole financial responsibility for providing, or coordinating with the LEA to provide, any BHT services included in a Member’s IEP until such time that the IEP is amended. iv. Coordinate with the LEA to ensure that BHT services that are determined to be no longer Medically Necessary are removed from the IEP as Blue Shield Promise-provided services upon amendment of the IEP. v. Attempt to obtain written agreement from the LEA to timely take over the provision of any Blue Shield Promise-approved BHT services included in the IEP upon a determination that the services are no

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longer Medically Necessary. vi. Ensure Members have access to and support medication adherence for the carved-out prescription drug benefit. vii. Cover Medically Necessary BHT services that were being provided by the LEA when school was in session. viii. Provide BHT services in accordance with timely access standards, pursuant to WIC Section 14197 and the MCP contracts.

Blue Shield Promise may: ix. Coordinate with the LEA to contract directly with a school-based BHT services practitioner, if the practitioner is enrolled in Medi-Cal and otherwise qualified as required by APL 23-010, to provide any Medically Necessary BHT services included in a Member’s IEP. x. Reimburse the LEA for the school-based Provider's services only to the extent the services continue to meet the EPSDT standard of medical necessity.

XI. CONTINUITY OF CARE Blue Shield Promise will offer Members continued access to out-of-network Providers of BHT services (continuity of care) for up to 12 months, in accordance with existing contract requirements and APL 23-022: Continuity of Care for Medi- Cal Members Who Newly Enroll in Medi-Cal Managed Care from Medi-Cal Fee- For-Service, on or After January 1,2023, or any superseding APL.

E. MONITORING

1. At minimum, The Plan monitors during the quarterly Medical Services Committee meeting the following, but not limited to: utilization of services, network access, appeals and grievances to identify any opportunities for improvement or administer a corrective action plan.

   F. REPORTING

2. Reports from the following departments are reviewed and discussed in the quarterly Medical Services Committee Meeting, which then are reported to the Quality Oversight Committee: • Appeals and Grievances: PHP AGD Appeals and Grievance Log • Utilization Management: ABA Utilization • Behavioral Health Care Management: Behavioral Health Screening & Transition of Care
   • Quality Improvement: Continuity and Coordination Measures and Goals • Enterprise Behavioral Health: Mental Health Services – Outpatient Utilization

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G. ATTACHMENTS

1. UM Policy 10.26.2 Authorization Denial, Pending/Deferral, and/or Modification Notification for Behavioral Health Treatment

2. UM Policy 10.26.13 Continuity and Coordination Between Medical and Behavioral Health Care

   H. REFERENCES

3. APL 23-010: Responsibilities for Behavioral Health Treatment Coverage for Members Under the Age of 21
4. APL 23-022: Continuity of Care for Medi-Cal Members Who Newly Enroll in Medi-Cal Managed Care from Medi-Cal Fee-For-Service, on or After January 1, 2023
5. California Code of Regulations Title 17
6. California Health and Safety Code section 1374.73(c)(3) through (5)
7. California Welfare and Institutions Code Section 4686.2
8. Attachment 3.1-A, Supplement 6, California’s Medicaid State Plan
9. Title 42 of the United States Code (USC), Section 1396d (r)

10. Title 42 of the Code of Federal Regulations (CFR), Section 440.130(c)

    I. REVISION HISTORY

    Date Modification (Reviewed and/or revised) E-Filing Number 9/25
    2025 Annual Review

    9/24 2024 Annual Review • Formatting/grammatical updates • Reviewed regulatory requirements • Updated Reporting section 12/23 Updated per revised APL 23-010 • Added “covered under Medicaid” to several sections • Expanded definition of provider types • Updated reference from APL 22-023 to APL 23-022 4/2023 Moved policy to new template and included minor edits 7/2020 Updated with Minor edits 1/2020 Updated with minor edits 6/2019 Updated per APL 19-014 Moved Policy on to BSC Promise Template 10/2014 Creation of Policy & Procedure