1. (a) “Out-of-Plan Services” means specialty mental health services covered by this Subchapter, other than psychiatric nursing facility services, provided to a beneficiary by providers other than the MHP of the beneficiary or a provider contracting with the MHP of the beneficiary.

2. (b) The MHP shall be required to provide out-of-plan services, when the services are also available through the MHP of the beneficiary or a provider contracting with the MHP of the beneficiary, only under the following circumstances:

   1. (1) When a beneficiary with an emergency psychiatric condition is admitted for psychiatric inpatient hospital services as described in Section 1820.225 to the extent provided in Section 1830.230.
   2. (2) When a beneficiary with an emergency psychiatric condition is admitted for psychiatric health facility services under the conditions described in Section 1830.245.
   3. (3) When a beneficiary is out of county and develops an urgent condition and there are no providers contracting with the MHP reasonably available to the beneficiary based on the MHP's evaluation of the needs of the beneficiary, especially in terms of timeliness of service.

   4. (4) When there are no providers contracting with the MHP reasonably available to the beneficiary based on the MHP's evaluation of the needs of the beneficiary, the geographic availability of providers, and community standards for availability of providers in the county in which the beneficiary is placed and the beneficiary is placed out of county by:

      1. (A) The Foster Care Program as described in Article 5 (commencing with Section 11400), Chapter 2, Part 3, Division 9 of the Welfare and Institutions Code, the Adoption Assistance Program as described in Chapter 2.1 (commencing with Section 16115), Part 4, Division 9 of the Welfare and Institutions Code, or other foster care arrangement.

         1. (1) If the beneficiary is a child or youth of either the Foster Care Program, Adoption Assistance Program, or other type of foster care arrangement such as Kin-GAP, and is placed outside his/her county of origin, the MHP of the county of origin must make an authorization decision and notify the host county and the requesting provider, if applicable of that decision within three working days following the date of receipt of the request for service by the MHP of origin. If the MHP of the county of origin documents a need for additional information to evaluate the beneficiary's need for the service, an extension may be granted up to three working days from the date the additional information is received, or 14 calendar days from the receipt of the original Treatment Authorization Request, whichever is less.
         2. (2) Within 30 calendar days of the date of authorization of service, the MHP of the county of origin shall arrange for reimbursement for the service provided to the child or youth through the host county or the requesting provider.
         3. (3) If there is a disagreement between the MHP of the county of origin and the MHP of the host county, the MHPs shall resolve their differences through the arbitration process provided in Section 1850.405.
      2. (B) A Lanterman-Petris-Short or Probate Conservator or other legal involuntary placement.

Note: Authority cited: Sections 14680 and 14684, Welfare and Institutions Code. Reference: Sections 5777, 5777.6, 11400, 14684 and 16115, Welfare and Institutions Code; and Section 438.210, Title 42, Code of Federal Regulations.

History

1. New section filed 10-31-97 as an emergency; operative 11-1-97 (Register 97, No. 44). A Certificate of Compliance must be transmitted to OAL by 3-2-98 or emergency language will be repealed by operation of law on the following day.

2. New section refiled 3-2-98 as an emergency; operative 3-2-98 (Register 98, No. 10). A Certificate of Compliance must be transmitted to OAL by 6-30-98 or emergency language will be repealed by operation of law on the following day.

3. New section refiled 6-17-98 as an emergency; operative 6-30-98 (Register 98, No. 25). Pursuant to Chapter 324 (Statutes of 1998) Item 4440-103-0001(4), a Certificate of Compliance must be transmitted to OAL by 7-1-99 or emergency language will be repealed by operation of law on the following day.

4. Editorial correction of History 3 (Register 98, No. 39).

5. Editorial correction extending Certificate of Compliance date to 7-1-2001 pursuant to Chapter 50 (Statutes of 1999) Item 4440-103-0001(4) (Register 99, No. 33). Notwithstanding any other provision of law, emergency regulations adopted pursuant to Welfare and Institutions Code section 14680 to implement the second phase of mental health managed care as provided in this part shall remain in effect until permanent regulations are adopted, or June 30, 2006, whichever occurs first.

6. Editorial correction of History 5 (Register 2000, No. 42).

7. Editorial correction of History 5 and repealer and new section filed 5-19-2006; operative 6-18-2006 (Register 2006, No. 20).

8. New subsections (b)(4)(A)(1)-(3) and amendment of Note filed 7-11-2008; operative 8-10-2008 (Register 2008, No. 28).