Improving Care for Medi-Cal Enrollees with Substance Use Disorders

By Molly Brassil, Director, Behavioral Health Policy
and Courtney Kashiwagi, Senior Policy Consultant

This month, two California counties began delivering substance use disorder (SUD) treatment services to Medi-Cal enrollees under the state’s pilot program testing a new delivery system for enrollees with SUDs. The pilot, known as the Drug Medi-Cal Organized Delivery System (DMC-ODS), was authorized in 2015 by the Centers for Medicare & Medicaid Services (CMS) under California’s Medicaid Section 1115 waiver.

Harbage Consulting has been working closely with the California Department of Health Care Services (DHCS) since 2015, with support from the California Health Care Foundation, to support the state and counties in implementing the pilot.

San Mateo and Riverside counties are the first two systems in the country to implement a comprehensive continuum of care for enrollees with SUDs under the new federal Medicaid 1115 waiver opportunity. Seventeen other California counties have submitted proposals to implement the pilot in the coming months. The DMC-ODS pilot program is authorized through December 31, 2020.

The need to provide comprehensive care for individuals with SUDs is rapidly increasing. According to the Centers for Disease Control and Prevention (CDC), the growing prevalence of abuse and addiction to opioids (including heroin), prescription pain medication, and morphine is a national epidemic that significantly impacts rural and urban communities alike. An estimated 91 Americans die from an opioid-related overdose every day and California is no exception. In 2014, California had over 2,000 opioid overdose deaths, accounting for 7.1% of the total opioid overdose deaths in the United States that year.

The DMC-ODS aims to improve access to necessary SUD treatment for Medi-Cal enrollees, including those with opioid addition, by:

  • Expanding the continuum of care to model benefits on national practice standards as specified in the American Society of Addiction Medicine (ASAM) Criteria;
  • Expanding local networks of high-quality providers through selective provider contracting;
  • Permitting counties to propose interim payment rates to support care delivery and incentivize provider participation;
  • Requiring the use of evidence-based practices in SUD treatment;
  • Increasing coordination with other systems of care, including physical and mental health;
  • Increasing state and local oversight and accountability; and
  • Creating structures to promote quality improvement and quality assurance.

Of particular significance, residential treatment services under the DMC-ODS are available to all enrollees that meet the medical necessity criteria in facilities of any size. Outside of the pilot program, California’s state Medicaid plan restricts residential SUD treatment to pregnant women or women who just gave birth in facilities with 16 beds or less. This expansion will help increase access for Medi-Cal enrollees who are particularly vulnerable and in need of intensive services.