by Sara Lee, Supervising Attorney, Health Unit

Our client Russell (fictitious name) is a recipient of Medi-Cal and received his services from Orange County Mental Health Plan (OC MHP). He had a history of attention deficient hyperactivity disorder, major depressive disorder, anxiety, substance use, and multiple psychiatric hospitalizations.

Russell received dialectical behavior therapy program services from an out-of-network provider (Compass) covered by the OC MHP. However, OC MHP terminated the services with Compass on June 30, 2023, without any notice of termination and appeal rights.

After receiving services from Compass, Russell had established trust and a therapeutic bond with his therapist, had been making significant improvements, and reached milestones. After the termination, Russell’s mental health condition deteriorated, he lost his part-time job, and he was unable to complete the process to attend college.

Despite not receiving any written notice, Russell appealed the termination of service with Compass. However, the OC MHP notified him that since there was not a Notice of Adverse Benefit Determination issued, they treated his appeal as a complaint, which can take up to 90 days for a decision. They also refused to provide his request to Aid Paid Pending (APP), which would have allowed him to continue receiving services after June 30, 2023, service termination date.

Health Unit steps in

After the CLA SoCal Health Unit intervened and represented Russell on his case (also required escalation to the Department of Health Care Services that oversees County Mental Health Plans), the OC MHP agreed to provide APP until the hearing decision.

The OC MHP also sent a notice regarding the termination of services and appeal rights with APP. However, the notice was sent about two months after the termination of service on 6/30/23, violating the law and the Russell’s constitutional right to due process.

We assisted Russell in obtaining APP until the hearing decision and represented him at the state fair hearing. At the hearing, the parties reached an agreement on the record. The agreement states as follows:

  • County will extend Letter of Agreement (LOA) through 6/30/24 for the doctor and Compass to continue treatment of Russell.
  • The doctor shall independently set a clinical benchmark to determine whether Russell has stabilized sufficiently that he is not threat to himself and others and otherwise ready to begin concurrent psychological therapy with the doctor along and together with County designated therapist.
  • The doctors will meet by phone, video, or in person once per month to discuss the coordination of services to be provided to Russell by Pathway Community Services program.
  • When the clinical benchmarks are met by Russell, the doctor will begin concurrent therapy for him together with county designated therapist and begin coordination of transfer of services to pathway.
  • If the doctor determines that all benchmarks are not met before expiration of LOA, they will discuss their clinical finding in writing to the County designated therapist no later than 6/1/24. If LOA is set to expire before satisfaction of all benchmarks as determined by the doctor the County will provide written notice whether to renew LOA with doctor/ Compass by 6/21/23 and provide claimant with state appeal rights.
  • The County will not seek reimbursement for APP in this case.

Furthermore, OC MHP believes that they have a right to collect payment made to providers under APP from Medi-Cal members if they lose at the hearing, which is against state policy; however, the law/CFR does not state as such.

We did extensive research on this matter and escalated the issue to the Department of Healthcare Services (DHCS), who agreed that OC MHP is operating inconsistently with state policy and that their policy is incorrectly stated in their contract, model handbook, and guidance. Thus, DHCS will be updating its guidance, MHP contract, and model handbook.