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Whole Child Model Program Implementing in Select Counties

January 8, 2019

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 will 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 January 1, 2019, Phase 2 of the WCM implemented in the following counties:

  • Del Norte
  • Humboldt
  • Lake
  • Lassen
  • Marin
  • Mendocino
  • Modoc
  • Napa
  • Shasta
  • Siskiyou
  • Solano
  • Sonoma
  • Trinity
  • Yolo

As of the transition date, the CCS program-eligible medical services in WCM counties will be 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 beneficiaries under the age of 21, including Early and Periodic Screening, Diagnostic 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 received by WCM CCS programs on or before December 31, 2018, for Phase 2 are the responsibility of the county to complete. All authorization requests for services after the Phase 2 WCM start date of January 1, 2019, must be sent to the MCPs. For the purpose of continuity of care, service authorization requests 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 beneficiary’s needs. Services carved out of the MCPs contract are the responsibility of DHCS and will be authorized by DHCS. Authorization requests for carve-out services received by CCS programs or MCPs should be routed to DHCS for authorization.

Providers rendering services for WCM beneficiaries shall submit their claims directly to the MCP for services rendered on or after January 1, 2019, for Phase 2. 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 through the WCM CCS Numbered Letter 04-0618 and the WCM 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 Provider Services should they have any claims or billing inquiries.

County COHS Phone Number
Del Norte, Humboldt, Lake, Lassen, Marin, Mendocino, Modoc, Napa, Shasta, Siskiyou, Solano, Sonoma, Trinity, Yolo Partnership HealthPlan 1-800-863-4155
1-800-226-2140 TTY/TDD