CHILDREN AND YOUTH 

Children and Youth At Risk for Avoidable Hospital or ED Utilization

Children and youth who meet one or more of the following conditions:

• • • Three or more ED visits in a 12-month period that could have been avoided with appropriate outpatient care or improved treatment adherence
    • Two or more unplanned hospital and/or short-term SNF stays in a 12-month period that could have been avoided with appropriate outpatient care or improved treatment adherence.

Kings County

Children and Youth with Serious Mental Health and/or Substance Use Disorder (SUD) Needs

Medi-Cal managed care members with serious mental health and SUD needs, as defined below, have disproportionately high rates of chronic physical health conditions as well as complex social needs. For children and youth, a number of social conditions and risk factors (e.g., exposure to trauma or other adverse childhood experiences (ACEs)) often present as behavioral health needs. Enrolling this child and youth Population of Focus into ECM is critical to addressing risk early and averting long-term chronic illness.

Children and youth who:

• • • Meet the eligibility criteria for participation in, or obtaining services through one or more of:
      • Specialty mental health services (SMHS) delivered by county mental health plans (MHPs);
      • The Drug Medi-Cal Organization Delivery System (DMC-ODS) OR the Drug Medi- Cal (DMC) program 

Further information on access criteria for the specialty mental health services for adults and children can be found in BHIN  21-073 and for the DMC-ODS delivery system in BHIN 24-001. The medical necessity criteria for DMC services can be found in California Code of Regulations, Title 22, § 51341.1 and BHIN 21-071. 

Kings County

Children and Youth Enrolled in California Children’s Services (CCS) or CCS Whole Child Model (WCM) with Additional Needs Beyond the CCS Condition

CCS and CCS WCM serve some of Medi-Cal’s most vulnerable children. In addition to their physical health condition qualifying them for CCS/CCS WCM – such as cancer, cerebral palsy, and cystic fibrosis (see full eligibility criteria on the DHCS website) – these children often experience a high co-occurrence of social and behavioral health challenges beyond their CCS/CCS WCM qualifying condition. As a result, many children in CCS/CCS WCM work with multiple care/case managers to navigate many delivery systems, creating a need for the child’s guardian or other advocate to navigate a variety of fragmented care delivery systems and discordant care plans. 

Eligibility

Children and youth who:

• • • •  Are enrolled in CCS OR CCS WCM; 
      • AND are experiencing at least one complex social factor influencing their health. Examples include (but are not limited to) lack of access to food; lack of access to stable housing; difficulty accessing transportation; high measure (four or more) of adverse childhood experiences screening; history of recent contacts with law enforcement; or crisis intervention services related to mental health and/or substance use symptoms.

Kings County

Children and Youth Involved in Child Welfare

Children and youth in California who are currently or were previously involved in Child Welfare Services provided through the California Department of Social Services (CDSS) often experience an extraordinary amount of transition and fragmentation of health care, social support services, and adult advocates in their childhoods.

Eligibility:

Children and youth who meet one or more of the following conditions:

• • • Are under age 21 and are currently receiving foster care in California; and/or are under age 21 and previously received foster care in California or another state within the last 12 months;
      • Have aged out of foster care up to age 26 (having been in foster care on their 18th birthday or later) in California or another state;
      • Are under age 18 and are eligible for and/or in California’s Adoption Assistance Program;
      • Are under age 18 and are currently receiving or have received services from California’s Family Maintenance program within the last 12 months.