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Whole-Child Model Program Implementing in Select Counties

August 29, 2018

Senate Bill 586 authorizes the Department of Health Care Services (DHCS) to establish the Whole-Child Model (WCM) program in designated County Organized Health Systems (COHS) or Regional Health Authority counties to incorporate California Children’s Services (CCS) program covered services for Medi-Cal eligible CCS children and youth into a Medi-Cal Managed Care Plan (MCP) contract. Under WCM, MCPs assume full financial responsibility for authorization and payment of CCS program-eligible medical services, including authorization activities, claims payments and processing, case management and quality oversight.

Effective July 1, 2018, Phase 1 of the WCM program is implemented in the following counties:

  • Merced
  • Monterey
  • San Luis Obispo
  • San Mateo
  • Santa Barbara
  • Santa Cruz

As of the transition date, the CCS program-eligible medical services in WCM counties are carved into MCPs’ capitated rate for those counties. In addition, MCPs are required to cover and ensure the provision of screening, preventive and medically necessary diagnostic and treatment services for clients under the age of 21, including Early and Periodic Screening, Diagnosis and Treatment. CCS program State-Only children with other health coverage will continue to receive services the way they do today and remain the responsibility of the counties.

Service Authorization Requests (SARs) received by WCM CCS programs before June 30, 2018, for Phase 1 are the responsibility of the county to complete. All SARs for services after the Phase 1 WCM start date of July 1, 2018, are to be sent to the MCPs. For the purpose of continuity of care, SARs approved before the transition to MCPs shall remain valid until the end date of the authorization or until the MCPs complete an assessment of the client’s needs. Services carved-out of the MCPs contract are the responsibility of DHCS and will be authorized by DHCS. SARs for carve-out services received by CCS programs or MCPs should be routed to DHCS for authorization.

Providers rendering services for WCM clients should submit their claims directly to the MCP for services rendered on or after July 1, 2018, for Phase 1. Carve-out services authorized by DHCS should be billed to DHCS accordingly. Providers not part of the MCP network are encouraged to become part of the MCP’s provider network. MCPs are required to pay physician and surgeon provider services at rates that are at least equal to the applicable CCS fee-for-service rates unless the physician and surgeon enter into an agreement on an alternative payment methodology mutually agreed upon by the physician, surgeon and the MCP.

DHCS issued additional guidance on California Children’s Services Program Whole Child Model Numbered Letter 04-0618 and the Whole Child Model Provider Notice. Both documents are posted on the California Children’s Services (CCS) Whole-Child Model (WCM) page of the DHCS website. Providers can contact their respective COHS plan provider services should they have any claims or billing inquires.

County COHS Phone Number
Merced, Monterey,
Santa Cruz
Central California Alliance for Health 1-800-700-3874 TTY/TDD
San Luis Obispo,
Santa Barbara
CenCal Health 1-877-814-1861 TTY
San Mateo Health Plan of San Mateo (650) 616-2500 TTY
(650) 616-8037