BILL ANALYSIS                                                                                                                                                                                                    Ó



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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