May is Mental Health Awareness Month. For reimbursement directors, the development worth tracking this month is that trauma screening has become a claim-level payment issue, and the payment mechanism that started in California now operates in two more states with different administrative architectures.

For reimbursement directors outside California, this matters in three specific ways: recurring revenue your affiliated providers may already be eligible for, contract implications when your state follows, and commercial payer ripple effects that historically arrive ahead of analogous federal action. The rest of this piece works through the evidence, then returns to those implications and what to do about them.

What California built

In January 2020, California’s Medicaid program (Medi-Cal) began paying providers $29 per screen for screening children and adults for Adverse Childhood Experiences using a standardized tool. Two HCPCS codes — G9919 for a screen indicating high risk for toxic stress (ACE score of 4 or greater) and G9920 for lower risk (ACE score of 0–3) — handle the billing. Providers complete a two-hour training, self-attest, and become eligible to bill.

Twenty-one months later, California went further. In October 2021, the state enacted SB 428, the ACEs Equity Act, mandating that commercial insurance plans regulated by California cover ACE screening for adults and children. The commercial mandate took effect in 2022. California became the first state to require both Medicaid and commercial payers to cover ACE screening as a distinct service.

The program is operating at scale. According to ACEs Aware’s March 2026 data report, Medi-Cal clinicians had conducted more than 5.23 million ACE screenings of approximately 2.88 million unique Medi-Cal members from January 2020 through March 2025. By January 2026, 53,580 individuals had completed the required ACEs Aware training, including 24,970 Medi-Cal clinicians certified to receive payment for ACE screenings. The $66 million paid to clinics through March 2023 is now outdated as a measure of program scale. Independent evaluation by RAND has documented both the progress and the headwinds: screening uptake has plateaued in some clinic settings, several implementation barriers remain, and sustained investment is needed to continue scaling.

Whatever one thinks of California’s broader Medicaid model, this payment mechanism now has more than five years of operational history, claims data, and independent evaluation.

One tension running underneath this conversation deserves to be named directly. The clinical evidence that ACE screening as an intervention reliably improves health outcomes is not yet settled. The California Health Benefits Review Program’s analysis of SB 428 found limited or insufficient evidence on whether ACE screening changes health care utilization or outcomes. RAND’s 2025 evaluation describes substantial early progress but not conclusive effectiveness. The reimbursement question and the clinical-effectiveness question are separable, and they are being answered by different institutions on different timelines. This piece is about the reimbursement question; it does not depend on the clinical debate being settled, and it should not be read as a clinical endorsement.

The spread is documented

For most of the program’s first four years, the question of whether the California payment mechanism would migrate was a leading indicator. As of 2025, the picture is more textured. One state has replicated the payment architecture directly. One state has adopted a narrower version of it. A third state has built an adjacent mechanism that uses ACE-related logic to expand coverage through different Medicaid authority. The pattern is not “California is being copied.” It is “ACE-related Medicaid policy is spreading through multiple architectures, with the California payment mechanism as the most prominent of them.”

New York launched its version effective January 1, 2025. The New York State Department of Health Medicaid program now reimburses providers $29 per screen — the same rate California uses — with the same two HCPCS codes (G9919 and G9920) and the same general structure. Annual screening is covered for Medicaid members up to age 21; one lifetime screening is covered for members ages 21 through 65. Provider training is required. The September 2024 Medicaid Update distinguished effective dates for fee-for-service and managed care implementation. The February 2025 Dear Colleague letter from the State Health Commissioner makes explicit the connection between ACE screening and downstream mental health outcomes that the rest of this piece will return to.

The fact that this is New York specifically matters. New York runs the second-largest state Medicaid program in the country, and it is a large, administratively complex Medicaid program outside California. Its Department of Health adopted the core elements of California’s payment architecture: the $29 payment amount, the same two HCPCS codes, provider training as a billing prerequisite, and the same basic age and frequency structure. The screening tools required are also the same (PEARLS for pediatric patients and the ACE Questionnaire for Adults). New York’s adoption demonstrates that the California payment mechanism is replicable in a Medicaid program operating under significantly different administrative conditions.

Wyoming represents a narrower form of the same approach. Wyoming opened Medicaid reimbursement for ACE screening at $29 per screen, effective March 1, 2023, in a narrower fee-for-service model for children with full Medicaid eligibility. Wyoming’s version is more limited than California’s or New York’s — coverage is for children rather than the broader child-and-adult scope California built, and qualifying payments flow through fee-for-service rather than the full fee-for-service-and-managed-care scope. Wyoming nonetheless represents a working replication of the payment-code mechanism, and it indicates that the model is portable to a state with very different demographics, political composition, and Medicaid administrative architecture than California.

Alaska represents an adjacent pathway. Through its Section 1115 behavioral health demonstration, Alaska has used Medicaid waiver authority to expand community-based behavioral health services in a way that reflects the same upstream logic California’s program operates on: childhood adversity and trauma exposure can have reimbursable downstream consequences worth structuring Medicaid policy around. This is not replication of California’s screening-payment architecture; it is a different Medicaid mechanism operating in the same policy family.

The California Health Benefits Review Program’s 2022 analysis of SB 428 noted that “more than 35 states introduced similar legislation in 2020.” Most of those bills did not pass. The honest read of that data is that legislative introduction in roughly three dozen states going back to 2020 indicates the issue is not confined to California, though the rate and form of subsequent enactment has varied considerably. New York validates the payment mechanism’s replicability; Wyoming demonstrates a narrower version of the same approach; Alaska shows the policy direction extending through different Medicaid authority. The pattern is a category of policy spreading, and reimbursement directors should treat further state activity as the base case, not the upside scenario.

Why this matters for hospital and health system reimbursement strategy

The $29 per-screen payment, taken on its own, is provider revenue rather than hospital DRG revenue. Hospital CFOs whose facilities don’t operate affiliated primary care practices may read the dollar amount and conclude the precedent is irrelevant to them. That conclusion is incomplete.

There are three implications worth tracking, in increasing order of strategic weight.

Revenue your providers may already be eligible for. If your system operates in California or New York and includes affiliated primary care, behavioral health, or pediatric practices, your providers may already be eligible to bill for ACE screenings and may not be doing so. The reasons vary: training attestation hasn’t been completed, workflow integration hasn’t happened, the screening tool isn’t in the EHR template, or no one has translated the eligibility into a billing workflow. ACEs Aware’s own evaluation data shows that uptake plateaus partly because of operational friction, not lack of clinical need. At $29 per screen across an eligible patient panel, this is recurring revenue. Modest per encounter, but compounding when added to existing well-visit and behavioral health workflows.

Contract implications when your state follows California or New York. When a state Medicaid program adds an ACE screening benefit, several questions cascade into existing managed care contracts. How does the directed payment flow from the managed care plan to the network provider? What training requirements does the plan impose, and who covers the cost of compliance? How is screening integrated with existing well-visit codes and behavioral health workflows? What documentation standard must be met for the payment to be defensible against audit? California’s All Plan Letter 23-017, dated June 13, 2023, is the operational template that has now been functionally replicated in New York. Health systems that have done this contract work in advance of state adoption are in a stronger negotiating position than those that respond after the fact.

Commercial payer follow-through. This is the harder strategic question. California’s SB 428 is the more disruptive precedent because it set up the pattern of state-mandated commercial coverage years ahead of any analogous federal action. The dynamic to track is not only whether commercial mandates spread, but how they are structured if they do. California’s bill required commercial coverage but left latitude on whether the screening is separately reimbursed or bundled into the office visit. That latitude is where the contract negotiation happens, and reimbursement directors who haven’t surfaced the question with their commercial payers are likely to discover the answer in the form of a contract amendment they didn’t negotiate.

There is also a related implication for value-based contracts that this piece will note briefly and return to in a future article. When ACE screening leads to clinically supported identification and documentation of active conditions that drive HCC risk adjustment — major depressive disorder, PTSD, substance use disorder — the documentation may have independent reimbursement consequences under Medicare Advantage and ACO arrangements. That is a separate argument with its own mechanics, and it deserves its own analysis.

What to do now

Six concrete actions worth considering before the next contracting cycle.

1. If your system operates in California or New York, audit whether your eligible network providers are trained, attested, and billing for ACE screenings. Specifically: have they completed the required training, and are they submitting G9919/G9920 with the correct modifiers on eligible encounters? In New York, the relevant modifiers are U1 and U9.
2. Review your Medicaid managed care contracts for language addressing new screening benefits and how directed payments flow from the plan to the provider. The California APL 23-017 structure is the operational template that other states are now adopting. If your contracts don’t anticipate this pattern, they will be silent on it when your state moves.
3. Map your patient population by state of residence if you operate across state lines. The state with the most aggressive payment mechanism may not be your largest patient state, but commercial contracts often follow the most aggressive state’s rules for that book of business.
4. Track state legislative activity on ACE-related Medicaid and commercial coverage. Government affairs and reimbursement teams should be in the same room on this; the pattern of state activity moves faster than annual contracting cycles.
5. Engage your behavioral health and primary care service lines on training infrastructure. Both California and New York require provider-level training attestation before billing eligibility. If your state adopts the same model, providers who completed training early begin billing earlier. The training itself is two hours and free.
6. Coordinate with your contracting team on commercial payer language. California’s SB 428 left latitude on whether screening is separately reimbursed or bundled. Your network agreements either address this question or they don’t. The negotiation is easier before the mandate than after.

Closing

May is Mental Health Awareness Month because the public health argument for paying attention to mental health is well-established. The reimbursement argument has been quieter. What California started in 2020, what Wyoming adopted in a narrower form in 2023, and what New York adopted in 2025 is a payment mechanism that operationalizes the upstream-mental-health conversation at the claim level — one screening code, one training attestation, one paid encounter at a time.

The question for hospital and health system reimbursement directors is not whether to support trauma screening as a clinical matter. That conversation belongs to clinicians and to public health, and it is genuinely unsettled. The question is whether your reimbursement infrastructure — your contracts, your training compliance, your coding workflows, your commercial payer language — is positioned to absorb a payment mechanism that is no longer hypothetical and no longer confined to a single state.

The precedent is operating at scale. The spread is documented through multiple architectures. The infrastructure work is the part you control.

Sources and resources

Operational and payment guidance

• ACEs Aware Billing & Payment guidance (acesaware.org/learn-about-screening/billing-payment/)
• California All Plan Letter 23-017, Directed Payments for ACE Screening Services (DHCS, June 13, 2023)
• New York State Department of Health, Medicaid Update on expanded ACE screening reimbursement (September 2024); Dear Colleague letter from Commissioner James V. McDonald, M.D., M.P.H. (February 5, 2025)
• Wyoming Medicaid ACE screening reimbursement, effective March 1, 2023

Program data and evaluation

• ACEs Aware March 2026 Quarterly Progress Report and prior quarterly reports (acesaware.org)
• RAND Corporation, California’s ACEs Aware Initiative Has Made Substantial Early Progress, but Sustained Investment Is Needed (RBA2152-2, 2025)
• National Governors Association, State Actions to Prevent and Mitigate Adverse Childhood Experiences

Policy and legislative analysis

• California SB 428, the ACEs Equity Act (October 2021)
• California Health Benefits Review Program, analysis of SB 428 (2021–2022)
• Shimkhada R., et al., “Policy Considerations for Routine Screening for Adverse Childhood Events (ACEs),” Journal of the American Board of Family Medicine, 35(4): 862–866, 2022

Background

• Peterson C., et al., “Economic Burden of Health Conditions Associated With Adverse Childhood Experiences Among US Adults,” JAMA Network Open 6(12), 2023
• Alaska Section 1115 behavioral health demonstration (Alaska Department of Health)