BILL ANALYSIS Ó
SB 614
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Date of Hearing: August 26, 2015
ASSEMBLY COMMITTEE ON APPROPRIATIONS
Jimmy Gomez, Chair
SB 614
(Leno) - As Amended July 16, 2015
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Urgency: No State Mandated Local Program: NoReimbursable: No
SUMMARY:
This bill requires the Department of Health Care Services (DHCS)
to establish a certification program for peer and family support
specialists (PFSS), for purposes of assisting clients with
mental health and substance use disorders, and adds peer support
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services as a Medi-Cal service, subject to federal approval.
Specifically, this bill:
1) Defines four categories of PFSS, including: Adult,
transition-age youth, family, and parent peer support
specialists.
2) Requires DHCS, not later than July 1, 2017, to establish
a certification program that establishes a certifying body,
either within the department, through contract, or through
interagency agreement, to provide certification for the
four categories of PFSS.
3) Defines other duties of DHCS with regard to the
certification program, including: defining the range of
responsibilities and practice guidelines, determining
curriculum and core competencies, specifying training and
continuing education (CE) requirements, determining
clinical supervision requirements, establishing a code of
ethics, determining processes for certification revocation
and renewal, and determining a process to allow existing
personnel employed as a PFSS to obtain certification at
their option (which appears to be a requirement to
"grandfather" in individuals already doing this work).
4) Specifies requirements individuals must meet to obtain
certification.
5) Requires DHCS to amend its state plan to include PFSS as
Medi-Cal providers, and peer support services as a distinct
covered Medi-Cal service type.
6) Requires DHCS to collaborate with specified entities,
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including the Office of Statewide Health Planning and
Development (OSHPD), in developing, implementing, and
administering the certification program. Requires
bi-monthly stakeholder meetings and allows DHCS to seek
private funds for this purpose.
7) Allows DHCS to use Mental Health Services Act (MHSA)
funds, as specified, and any designated Workforce Education
and Training (WET) Program resources, including funding, as
administered by OSHPD as specified, to develop and
administer the certification program. Allows MHSA funds to
serve as the state's share of funding to develop and
administer certification program, and specifies the funds
shall be available for purposes of claiming FFP once
federal approvals have been obtained.
8) Finds and declares it clarifies procedures and terms of
the MHSA (a voter-approved initiative).
9) Allows the use of exclusive or nonexclusive contracts on
a bid or negotiated basis, including those for technical
assistance.
10) Allows DHCS to issue guidance to implement this bill
without issuing regulations, but requires regulations to be
issued by January 1, 2019. Requires semiannual status
reports to the Legislature until regulations are adopted.
FISCAL EFFECT:
1)Assuming federal approval and availability of federal
financial participation (FFP), approximately $1.5 million in
administrative staff costs for the first year of
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implementation, and conservatively in the range of $1 million
ongoing for DHCS state staff costs for investigation,
discipline, and contract oversight (state/federal).
The state share could potentially be MHSA 5% state
administrative set-aside funds or OSHPD WET funds, as
authorized in the bill, or GF, depending on availability of
funds and subsequent budget decisions. Implementation of this
bill is contingent on federal approval and FFP. DHCS
indicates that there are significant claims on MHSA state
administrative dollars, but budget documents were not
available at the time of this analysis.
Similarly, OSHPD indicates there is approximately $5 million
in WET funds that were set aside for expenditure in the
2015-16 fiscal year that could potentially be used for
purposes of this bill, but that there are significant
expectations among stakeholders that ongoing funding will be
used for currently funded activities. With respect to the
allocation of WET funds, OSPHD currently recommends a funding
plan, which must be approved by the Mental Health Planning
Council. However, subject to legislative appropriation and
redirection of MHSA 5% state administrative set-aside funds or
OSHPD WET funds from other planned or potential uses, it
appears these funding sources could support the ongoing
certification program costs.
2)Contract costs, likely in the hundreds of thousands of dollars
(state/federal, as above).
3)Increased federal Medi-Cal reimbursement, and possibly
increased local funding, for peer support services
(local/federal). Currently, some peer services are funded
through existing Medi-Cal service classification such as
targeted case management, but the explicit recognition would
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facilitate reimbursement. This is not likely to increase
overall local cost pressure on counties for delivery of mental
health and substance abuse services in Medi-Cal.
COMMENTS:
1)Purpose. The purpose of this bill is to create a certification
program for PFSS. The author notes a substantial body of
research shows peer support services improve outcomes and
quality of life for clients of the mental health and substance
abuse (behavioral health) system and their families, and save
money by reducing acute incidents such as hospitalization.
Stakeholders in the behavioral health community, based on
years of discussion and research, have strongly recommended
creating a state certification program in order to standardize
training and core competencies, as well as to allow counties
who deliver behavioral health services to leverage federal
financial participation (FFP) in Medi-Cal.
2)Peer specialists and certification. Peer support specialists
are persons who used lived experience from mental illness or
substance abuse, plus formal training, to deliver services in
a behavioral health setting to promote recovery. The federal
Substance Abuse and Mental Health Services Administration
(SAMHSA) notes peer services are varied and can in include the
following activity types: (1) peer mentoring or coaching, (2)
recovery resource connecting, (3) facilitating and leading
recovery groups, and (4) building community. A 2007 Center
for Medicare and Medicaid Services (CMS) letter to state
health officials clarifies states can seek federal approval to
receive Medicaid (Medi-Cal in California) reimbursement for
peer support services, but notes state-defined training and
certification is required in order to receive reimbursement.
County behavioral health directors note these services are
often provided to Medi-Cal enrollees but, unlike other
behavioral health services they provide, they are not eligible
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federal reimbursement because the state does not recognize
peer support services as distinct services, nor certify PFSS
providers. Behavioral health services for serious mental
illnesses and addiction in Medi-Cal are delivered and paid for
by counties pursuant to 2011 Realignment.
3)Related State and Stakeholder Activities. Substantial work is
ongoing in the behavioral health community to formally
recognize and promote PFSS as part of a continuum of care for
behavioral health services, including the following:
a) DHCS has included the PFSS as a workforce expansion
strategy in the recent 1115 Waiver Renewal "Medi-Cal
2020", which it submitted to the federal Centers for
Medicare and Medicaid Services (CMS) on March 27, 2015.
b) A report by the California Mental Health Planning
Council notes California is lagging behind in
implementing a peer support specialist certification
program, and in the inclusion of these valuable services
within Medi-Cal. The report notes U.S. Department of
Veterans Affairs and more than 34 states have already
established programs for certification of peers and have
included peer services as a component of their Medicaid
plans.
c) The Working Well Together Statewide Technical
Assistance Center, a collaborative of peer and
client-oriented organizations, produced a final report
including a recommendation to proceed with peer
certification. This effort identified key issues for
laying the foundation of certification in California,
including training recommendations and core components
for a statewide certification program.
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4)DHCS Existing Certification Programs. DHCS currently licenses
or certifies drug and alcohol rehabilitation facilities,
programs, and counselors. A Center for Investigative Reporting
and a CNN series exposed widespread fraud in the Drug Medi-Cal
program in 2013. The California State Auditor also concluded
that DHCS as well as the prior entity, DADP, failed to
implement an effective provider certification process for the
Drug Medi-Cal Program. With respect to certified counselors,
DHCS oversees counselors indirectly via oversight of three
designated certifying entities. This mechanism has been
criticized in recent years for being ineffective and providing
insufficient consumer protection. For example, a 2013 report
by the California Senate Office of Oversight and Outcomes
noted the state makes no attempt to review counselors'
criminal backgrounds, as well as the existence of loopholes
allowing individuals to be employed in facilities as
registered counselors even if their certification had been
revoked by a different certifying agency. Since this time,
DHCS has attempted to address the identified issues through
suspension and recertification, and improved oversight.
5)Comments. Though a strong case exists that California should
recognize certification for peer counselors in order to claim
FFP, the bill's approach raises some specific questions
relating to lack of specificity and delegation of authority,
as well as fees, that should be resolved. Other technical
notes and a comment about applicability to non-Medi-Cal
populations are listed below.
a) Delegation of Authority. As compared to the detailed
specifications in statute of other licensed and certified
health care providers, this bill appears to delegate a high
level of legislative authority to a state department. The
day-to-day work of certification raises significant
practical issues and decisions- for example: what
disqualifies someone from certification? What standards are
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is in place to guard against arbitrary disciplinary action?
How will decisions be made? Will there be a board or task
force vested with decision-making authority? If so, who
will comprise the board or task force? How can the state
ensure individuals with adequate expertise are responsible
for making decisions related to curricula, exams, and
continuing education requirements? Under what
circumstances and how can existing PFSS providers receive
certification through an expedited path? The bill
delegates such policy issues to DHCS. For other licensed
or certified professions, such policy issues appear to be
more clearly resolved in statute. On the other hand, there
is also statutory precedent for delegating broader
authority. The question is, what level of delegation is
desirable for this program?
This bill delegates even the definition of the services, as
well as the scope of competency and practice for a peer
support specialist, to DHCS. The author and sponsor of
this bill point to significant workload that has been
conducted by existing entities, including the Mental Health
Planning Council, OSHPD's workforce development efforts,
and the Working Well Coalition, with respect to training,
curricula, and identification of various components of a
certification program. However, none of the specific
material the author suggests should be relied on is
referenced in the bill. If it is the intention of the
author that the department rely heavily on resources that
have already been created, the bill should direct them to
do so in a clear and specific manner.
The level of specificity provided is a policy issue with
fiscal implications. There is lower cost and risk if some
of these issues are vetted through the legislative process
and simply carried out through the administrative process
based on clear statutory direction. Greater specificity
may also provide greater certainty to all parties about the
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scope, intent, and operations of certification.
b) Fees? Unlike most state certification programs, this
bill has no provisions for certification fees. Ideally, a
certification program is entirely and appropriately
supported by fees. If a fee-supported program is
inappropriate in this case, the burden should be to
demonstrate why, instead of defaulting to the certification
program being state-funded. For example, is fee collection
practically unworkable or overly burdensome for the
population to be certified? Similarly, if it is the intent
that fees may be charged by a non-state certifying entity
under contract with DHCS to perform certification, this
should be clarified. If it the intent not to allow fees to
be charged, this should be specified as well.
c) Specific to Medi-Cal? Unlike most other licensed and
certified professionals, certification as created in this
bill is specific to the Medi-Cal program, but substance
abuse and mental health issues are not exclusive to the
Medi-Cal program. If this is indeed a highly promising
model of service delivery, it is unclear that it should be
limited to the Medi-Cal program. At the same time, the
establishment of state certification appears urgently
needed in order to allow counties, who are in many cases
already delivering these services, to leverage federal
dollars the state is otherwise leaving on the table. Not
receiving federal funds available for these services is a
missed opportunity to use local funds more efficiently and
effectively. Thus, a focus on fulfilling Medi-Cal
requirements seems appropriate at this time in order to
leverage federal funding, but the author might consider
either modifying the bill to allow flexibility for a
broader recognition by removing some references that appear
to restrict certification to those providers participating
in Medi-Cal-or following up at a later time to ensure the
implementation of state certification supports the adoption
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of the peer support model outside Medi-Cal if appropriate.
d) Technical Notes. Section 14045.22 requires FFP and
federal approval in order to implement the bill. However,
the bill does not specify whether FFP is required for the
services or for the DHCS administrative or contract costs
of a certification program, or both. Additionally, DHCS
notes "while the bill assumes the program would secure
federal funds through FFP, those funds cannot be used for
the program until it receives federal approval. Once the
program is approved, FFP would be at a 50/50 matching
level, meaning additional state funds would still be needed
to pay for ongoing obligations. Thus, it would be necessary
to use State General Fund seed funding to start the program
for an indeterminate amount of time." This section should
be clarified in order to allow DHCS to move forward with
certification program activities prior to federal approval
and FFP, if that is the intent.
Analysis Prepared by:Lisa Murawski / APPR. / (916)
319-2081