[{"_1":2,"_88":-5,"_89":-5},"loaderData",{"_3":4,"_26":27},"root",{"_5":6,"_17":10,"_18":19,"_20":21,"_22":10,"_23":-5,"_24":-5,"_25":10},"user",{"_7":8,"_9":10,"_11":10,"_12":-5,"_13":-5,"_14":15,"_16":-5},"roles",[],"isAuthenticated",false,"isPremium","planName","subscriptionStatus","featureFlags",{},"insightsBudget","isDevelopmentHost","userPreferences",{},"recaptchaSiteKey","6LcvOJcUAAAAAHsB-gPGfGktcRlKpH7OTIU_dMTD","isImpersonating","impersonation","affiliateStatus","isFreedomPortal","routes/v2/article/layout",{"_28":29,"_30":31},"notFound",true,"relatedArticles",[32,76],{"_33":34,"_35":36,"_37":38,"_39":40,"_41":42,"_43":44,"_45":46,"_47":48,"_49":50,"_51":52,"_53":54,"_55":56,"_57":58,"_59":60,"_61":62,"_63":64,"_65":66,"_67":68,"_69":70,"_71":72,"_73":74,"_75":74},"mediaId",6185107,"mediaKeyId","5083521-75dc5f8328db5eda7d4297280d1d67d4","parentId",5083521,"title","OCA refines behavioral health claims code set; clinicians press to include traumatic brain injury, members debate crisis‑care grouping","audioSeconds",666,"startMs",2294000,"endMs",2960000,"viewUrl","/Search/View?dp=1&key=5083521-75dc5f8328db5eda7d4297280d1d67d4&start=2294&end=2960","thumbnailUrl","https://assets.pipeline.soar.com/5083521-75dc5f8328db5eda7d4297280d1d67d4/thumbnail_2294000.jpg","articleUrl","/articles/6185107/California/OCA-refines-behavioral-health-claims-code-set-clinicians-press-to-include-traumatic-brain-injury-members-debate-crisiscare-grouping","mediaUrl","https://secure.pipeline.soar.com/6185107-6c611e97d184c66036422d0b4579e92f/orig.mp4?Expires=1771134678&Signature=KSnKqHYgcQAbd1RjMEy-rsm67wc5qeAFj3~RoVbdvC7bGAa~AcdiRtBE5PD70SPRx81JCdbcbkfCnrPj5KnOn~jglgwZB5g3~PC1BBoIxqRGYnuMn2THGuIlUNWMrIuJAU4k1zStd4uqC-31KRoYHCV~TmUI1u0daKu6quioRfZzoPwre0C2zoMkxDzshwghtVWZXTUhVzsfwh4xDw2UIU7Cf9DlK8CAVSkxYyUMuj61OdQWQERxqTX2mGqD2TDC8nUCDRAvABmXgeJW306kizh8hsvowpFLEkgYhCDU6E8nNcFgxWG-LimJn0R4c~9DxiLPduVfAD5Jdsznf~pQSA__&Key-Pair-Id=KUT5TJCACFTXG","author","Department of Health Care Access and Information","date","2025-06-27T04:33:04.78Z","article","The Office of California (OCA) presented a revised claims code set to measure behavioral health spending and asked its investment and payment work group for feedback on two contested issues: whether to include traumatic brain injury (TBI) diagnoses and whether to replace a community‑based mobile clinic category with a broader crisis care category.

Debbie Lindes, manager of the Healthcare Delivery System Group at the Office of Healthcare Affordability, reviewed the code‑set approach and explained the measurement will span three modules: claims‑paid behavioral health care, non‑claims spending, and a behavioral‑health‑in‑primary‑care module. Lindes said the primary care module exists so integrated primary care behavioral health services can be counted in both primary care and behavioral health without double counting.

Key proposed rules and clarifications

Lindes said OCA will: keep drugs on the code set if at least one approved indication is for a behavioral health condition (while acknowledging some over‑counting of drug spending will occur), and exclude pharmacy spending from the behavioral health benchmark. The code set relies on primary diagnosis plus combinations of service, place‑of‑service and revenue codes to define subcategories. OCA will expand the primary‑care provider taxonomy used for module assignment so services provided by behavioral health clinicians in integrated primary care settings can be captured in both modules.

Two issues drew extended discussion

Traumatic brain injury (TBI): OCA staff noted TBI is not included in Milbank or other states’ behavioral health code sets and warned inclusion would capture non‑behavioral spending (for example, neuroimaging and acute neurosurgical care). Clinicians in the group argued that much of TBI treatment today is behavioral and that excluding TBI would omit neurobehavioral sequelae managed by mental health clinicians. Karnika Saxena, a geriatric psychiatrist representing the California State Association of Psychiatrists, said TBI sequelae are often managed with behavioral interventions and supported including TBI in the code set so those services are not missed. Others cautioned the diagnosis could pull in high‑cost nonbehavioral services if measured only by diagnosis.

Crisis care vs. mobile clinic categorization: OCA proposed replacing a Community‑Based Mobile Clinic Services subcategory with a broader Crisis Care subcategory to reflect state and federal priorities on crisis systems. Lindes cited Substance Abuse and Mental Health Services Administration (SAMHSA) guidance on coordinated crisis care and a March 2025 Department of Managed Health Care all‑plan letter reminding plans of coverage obligations under AB 988 (2022). Several participants, including Vicky and Hector, urged OCA to preserve the ability to distinguish mobile, community‑based crisis teams from facility‑based emergency department crisis care so analysts can compare cost and effectiveness by delivery model. OCA staff said many crisis codes are used for telephone/988 or mobile settings while ED claims often use diagnosis codes rather than crisis service codes, and they will investigate how claims usage patterns map to settings.

Other clarifications

Lindes said inclusion of diagnoses such as autism spectrum and dementia will be refined to include relevant subtypes (including Alzheimer’s disease). OCA will review provider taxonomy expansions to identify provider types that commonly deliver integrated behavioral health in primary care. The staff also noted they will consult clinical experts on specific codes flagged by members and that some codes not uniformly covered by payers are being retained to encourage coverage and ensure comprehensive measurement.

Next steps

OCA will take the work group’s feedback back to staff, continue consultation with clinical experts and HPD analysts, and return in July with more detailed definitions and a finalized code set. OCA plans to begin collecting behavioral health spending reports from payers in fall 2026 and to continue complementary HPD analyses for more granular questions about models of care and where services occur.

No formal vote or board action occurred at this meeting; discussion produced staff commitments to refine definitions, examine how crisis and mobile services appear in claims, and assess whether and how TBI should be included without materially overcounting nonbehavioral medical care.","mediaType","Video","parentTitle","June 2025 | OHCA Investment Payment and Workgroup Meeting","oneSentenceSummary","The Office of California presented a revised claims code set to measure behavioral health spending and asked the work group for feedback on whether to include traumatic brain injury and how to categorize crisis and mobile services.","taxTitle","Department of Health Care Access and Information, Agencies under Office of the Governor, Executive, California","taxId",16207,"location","California","headline","","shortSummary",{"_33":77,"_35":36,"_37":38,"_39":78,"_41":79,"_43":80,"_45":81,"_47":82,"_49":83,"_51":84,"_53":85,"_55":56,"_57":58,"_59":86,"_61":62,"_63":64,"_65":87,"_67":68,"_69":70,"_71":72,"_73":74,"_75":74},6185115,"OCA to delay setting behavioral health investment benchmark to gather more payer data, board suggests revisiting in 2026",960,0,960000,"/Search/View?dp=1&key=5083521-75dc5f8328db5eda7d4297280d1d67d4&start=0&end=960","https://assets.pipeline.soar.com/5083521-75dc5f8328db5eda7d4297280d1d67d4/thumbnail_0.jpg","/articles/6185115/California/OCA-to-delay-setting-behavioral-health-investment-benchmark-to-gather-more-payer-data-board-suggests-revisiting-in-2026","https://secure.pipeline.soar.com/6185115-8f747b91ef04f79331f638f43246ef77/orig.mp4?Expires=1771134678&Signature=e7mF5o2-XED2ga7bPa682o1G70Yt6JP0-bwXxVBU1kTeULNSP-Z3nIzMGor~kIw5llejjfSLo47v6ZczZNklidFlzE1nm9GXHivWheOHIe1Bh89QnwiEPE59Hif2UvtZzmniKmUUj~Cxf-w3Yoj2jVMbDGKBsrhcn~VAAeAOvuAZlaFQNamwE5ZOC~J8Da~LxMN3eMZyNiBhDrQaT-x3Pf1~tF4qp2izHe7SyLXUmiO9ZgxezDI2hfF6zjy~eniXlJEsYsIXFV7h0bmux6FhuDQmA9b0taQsYWCdwzvd9mVZOWofMv4vmwHsL1oM7XxOksIyoeNb5GP2LYegQCFOrw__&Key-Pair-Id=KUT5TJCACFTXG","The Office of California (OCA) told its investment and payment work group that it will delay setting a statewide behavioral health investment benchmark and instead collect additional payer data and perform further analyses before proposing a formal benchmark.

OCA Assistant Deputy Director Margaret Abbrandt said the agency revised its approach after work group input and recent board and advisory committee discussion, explaining the new plan is to collect payer submissions for performance years 2024–2026 and use that analysis to inform any benchmark set in spring 2028 for performance year 2029. Abbrandt said the delay would allow staff to “identify and resolve challenges with the data submission process” before setting a multiyear target.

Why this matters: A formal benchmark would have directed payers to increase in‑network outpatient and community‑based behavioral health spending by a set percentage each year. Advocates and clinicians said a benchmark could accelerate access to outpatient care and integration with primary care; payers and some board members urged caution without more detailed data on payer variation, capitated payments and county specialty mental health spending.

What the data shows so far

OCA summarized analyses from three sources—Health Care Payments Database (HPD), Covered California and CalPERS—showing commercial payer behavioral health spending rising from about 5% to about 8% of total claims between 2021 and 2023, depending on the source. OCA staff reported that outpatient, community‑based spending has grown faster than other subcategories and that outpatient professional non‑primary‑care services represented roughly 43% of commercial payers’ behavioral health spending in 2023. The share for residential facility services rose from about 4% in 2018 to about 9% in 2023, OCA said.

Board and advisory committee feedback

Board members broadly supported delaying a benchmark until more data were available, but some said waiting until 2028 would be too long. The board recommended that OCA and HPD conduct additional HPD analysis and consider revisiting whether a benchmark can be set in 2026; if the evidence remains insufficient in 2026, the board asked OCA to reassess again in 2027. The board also urged OCA to incorporate county‑based specialty mental health services in its measurement as soon as feasible and requested a summary of current programs and funding that could influence spending trends.

Advisory committee members generally endorsed a measurement‑first approach and suggested the benchmark explicitly promote integration of behavioral health into primary care. They also recommended separating mental health and substance use disorder spending for some analyses and asked for greater clarity on how capitated payments and non‑claim spending would be accounted for.

Participant views

Karnika Saxena, a geriatric psychiatrist representing the California State Association of Psychiatrists, told the group she expected spending to continue rising and urged OCA and the board to consider workforce constraints: “I would not be surprised if the spending continues to increase,” she said, adding that provider burnout and shortages affect the state’s ability to scale services.

Kirsten Barlow of the California Hospital Association asked for clarification about next steps and whether the board had taken formal action; OCA staff said the recommendation to delay was a staff proposal that the board and advisory committee discussed but did not formally adopt at the meeting and that OCA will return in July with a formal plan for next steps.

Data scope and next steps

OCA indicated HPD contains data beyond commercial claims—HPD includes commercial, Medicare Advantage and Medi‑Cal submissions, and HPD staff noted county specialty mental health data from county mental health plans are present in HPD but have not yet been analyzed. OCA said it will coordinate with HPD and the Department of Health Care Access and Information (HCAI) and with the Department of Health Care Services (DHCS) to assess how to include Medi‑Cal specialty mental health and other non‑claim spending in measurement.

OCA staff signaled they are leaning toward pausing a benchmark decision for at least a year, performing additional HPD analyses, working with payers and state partners on data submissions, and returning to the work group with a formal next‑steps proposal in July. The timeline presented shows OCA aiming to finalize definitions and code sets this year and to begin collecting behavioral health spending reports from payers in fall 2026.

Discussion vs. action

The work group’s discussion produced no formal board motion or vote. The substantive outputs from the meeting are OCA’s recommended pause to collect further data, the board’s request to evaluate the option of revisiting a benchmark in 2026, and the advisory committee’s endorsement of a measurement‑first approach. OCA will proceed to: (1) collect payer submissions for 2024–2026, (2) run additional HPD analyses including Medi‑Cal and county specialty mental health where feasible, and (3) return with a detailed proposal and timeline to the work group in July.

What remains unresolved

Work group members and committee participants flagged open questions: how to measure capitated payments without double counting, how to capture behavioral health delivered in primary care when the primary diagnosis on a claim is not behavioral health, and how to incorporate county specialty mental health and non‑claim spending into a single measurement framework. OCA said it will use the next year to address these technical issues rather than adopt a benchmark this year.

Looking ahead

OCA plans to post proposed definitions and code sets for public comment after further internal work and to return to the board and advisory committee as the HPD analyses and payer data submissions progress. The work group will reconvene in July to review a formal set of next steps.","The Office of California (OCA) told its investment and payment work group that it will delay setting a statewide behavioral health investment benchmark and instead collect additional payer data and perform further analyses before proposing a formal benchmark.","actionData","errors"]

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OCA refines behavioral health claims code set; clinicians press to include traumatic brain injury, members debate crisis‑care grouping

OCA to delay setting behavioral health investment benchmark to gather more payer data, board suggests revisiting in 2026