On January 6, The Centers for Medicare & Medicaid Services (CMS) approved Medicaid State Plan Amendment (SPA) #23-0010. The SPA authorizes the California Department of Health Care Services Service (DHCS) to use an alternative payment methodology (APM) to pay Federally Qualified Health Centers (FQHC), Rural Health Clinics (RHC), and Tribal Health Programs at the Medi-Cal fee-for-service (FFS) rate for dyadic services. FQHCs and RHCs will receive a separate payment for dyadic services in addition to their standard prospective payment system (PPS)/all-inclusive payment rates in certain circumstances. This SPA is retroactively effective to March 15, 2023.
Key provisions are as follows:
- California’s new set of dyadic benefits supports relationship-based caregiver and family surveillance and family-based interventions that bolster child development, recognizing the importance of the parent/caregiver and child dyad to support healthy child development. Dyadic health care services are ideally provided in the context of routine well child care in pediatric settings, meeting families where they regularly receive health care and related services.
- Services are linked to a child’s Medi-Cal coverage, providing a basis for revenue recovery for primary care pediatric settings and for cases in which the parent/caregiver may not be a Medi-Cal beneficiary.
- Services are exempt from the same day exclusion applied to FQHC and RHC settings. If FQHCs or RHCs have met their visit per day limit, then dyadic services provided to Medi-Cal-eligible members (children or parents/caregivers) will be reimbursed at the FFS rate. Any dyadic services that are provided to a non-Medi-Cal-eligible parents/caregivers for the direct benefit of Medi-Cal-eligible children will be reimbursed at the FFS rate.
- Payment for dyadic FQHC and RHC services will be reimbursed at the applicable FFS rate in addition to Medi-Cal member visits, which are reimbursed at the applicable PPS rate.
In addition, the dyadic care benefit provides a pathway for families to access additional supports via the new family therapy benefit. Family therapy is a psychotherapy service that managed care plans provide under Medi-Cal’s Non-Specialty Mental Health Services benefits. Family therapy services support members younger than age 21 to receive up to five family therapy sessions before a mental health diagnosis is required. More importantly, children and youth (younger than age 21) may receive family therapy without the five-visit limitation if they (or their parents/caregivers) demonstrate certain risk factors, including separation from a parent/caregiver because of incarceration, immigration status, or death; foster care placement; food insecurity; housing instability; exposure to domestic violence or trauma; maltreatment; severe/persistent bullying; and discrimination.
Health Management Associates (HMA) has been proud to partner with HealthySteps, as a DHCS-recognized model, to provide an evidence-based (APL 22-029 (ca.gov) approach to implementing the new dyadic care benefits. Contact our experts below to learn more.
