We know that a lot of people with Medi-Cal coverage have difficulty finding and/or accessing treatment programs that fit their needs. This is often because of long wait lists or availability for desired levels of care in their areas.

If you have Medi-Cal and are looking for treatment options, our treatment advocates may be able to help.

About Medi-Cal

Medi-Cal must cover SUD services as part of mental health and substance use disorder “essential health benefits,” but the actual menu of services depends on whether the member lives in a DMC‑ODS “opt‑in” county. In DMC‑ODS counties, the covered SUD benefit is much broader than in non‑participating counties.

In a DMC‑ODS county, medically necessary covered SUD services can include:

Outpatient and intensive outpatient treatment
Multiple levels of residential treatment (ASAM level 3.x), with no federal bed cap
Withdrawal management (detox) at various ASAM levels
Narcotic treatment programs (methadone and other medications for OUD)
Recovery services, case management, physician consultation
Medication‑assisted treatment (MAT) and sometimes partial hospitalization

In a non‑DMC‑ODS county, Drug Medi-Cal still covers a more limited set of SUD services, typically:

Outpatient
Intensive outpatient
Perinatal residential treatment
Narcotic treatment program services

Medi-Cal SUD treatment is financed under the Short-Doyle/Medi-Cal (SD/MC) system, where counties submit claims and get reimbursed at set rates, and the cost is shared across federal, state, and county dollars.

Providers must be Drug Medi-Cal enrolled and certified to bill. They bill the county (or county’s ASO/plan) using HCPCS/CPT and local codes tied to specific covered services and ASAM levels. The SD/MC system processes claims and calculates federal financial participation (FFP), with the remainder funded by state and county.

Some services (e.g., certain residential and inpatient ASAM 3.7–4.0) are billed as institutional claims, while others are billed as professional/clinic claims.

For members with a “share of cost,” Medi-Cal only pays once the member’s share has been met, as with other Medi-Cal services.
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For example, residential services under ASAM levels 3.1, 3.3, 3.5 in DMC‑ODS are reimbursed by daily rates, while outpatient and intensive outpatient services are typically reimbursed on a visit or time‑based unit. Narcotic treatment programs have their own bundled payment rules and must provide at least a minimum amount of counseling time per month.

Role of ASAM levels and medical necessity
Medi-Cal uses ASAM criteria and medical necessity standards to determine what level of care it will pay for. Counties must authorize higher‑intensity services like residential or inpatient levels, often within 24 hours of a prior authorization request, and there are defined maximum lengths of stay (for adults, typically up to 90 days per residential episode, with possible extensions for medical necessity or special populations such as perinatal).

Examples:
ASAM 1.0/2.1: Standard outpatient / intensive outpatient – billed as regular SUD clinic visits.
ASAM 3.1, 3.3, 3.5: Clinically managed residential services – paid per‑diem with specific service requirements and documentation.
ASAM 3.7, 4.0: Medically managed/inpatient withdrawal or residential – can be covered through DMC‑ODS in inpatient hospital‑type settings, billed as institutional claims.

CalAIM and recent updates
Under CalAIM, California has moved DMC‑ODS into its broader Medicaid waiver structure (1915(b) and 1115) and is refining payment, quality, and integration with physical and mental health care. Recent policy includes piloting coverage of contingency management (CM) for stimulant use disorder in some DMC‑ODS counties, with specific new billing codes and reimbursement guidance.