BILL ANALYSIS Ó
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Date of Hearing: June 21, 2016
ASSEMBLY COMMITTEE ON HEALTH
Jim Wood, Chair
SB
1113 (Beall) - As Amended June 8, 2016
AS PROPOSED TO BE AMENDED
SENATE VOTE: 39-0
SUBJECT: Pupil health: mental health.
SUMMARY: Permits local educational agencies (LEAs) and county
mental health plans (MHP) to enter into partnerships for the
provision of Early and Periodic Screening, Diagnosis, and
Treatment (EPSDT) program mental health services, as specified.
Specifically, this bill:
1)Permits a county or a qualified provider operating as part of
the county MHP network and a LEA to enter into a partnership
that includes all of the following:
a) An agreement between the county MHP or the qualified
provider and the LEA that establishes a Medi-Cal mental
health provider that is county operated or county
contracted for the provision of mental health services to
pupils of the LEA. Allows the agreement to include
provisions for the delivery of campus-based mental health
services through qualified providers or qualified
professionals to provide on-campus support to identify
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pupils not in special education who a teacher believes may
require those services and, with parental consent, to
provide mental health services to those pupils;
b) The county MHP or the qualified provider and the LEA use
designated governmental funds for eligible Medi-Cal EPSDT
program services provided to students enrolled in Medi-Cal,
for mental health service costs for non-Medi-Cal enrolled
students in special education with individualized education
programs (IEPs), and for students not part of special
education if the services are provided by a provider
pursuant to the agreement described in a) above;
c) The LEA, with permission of the pupil's parent, provides
the county MHP provider with the information of the health
insurance carrier for each pupil;
d) The agreement between the county MHP or the qualified
provider and the LEA addresses how to cover the costs of
mental health provider services not covered by governmental
funds, in the event that mental health service costs exceed
the agreed-upon funding outlined in the partnership
agreement between the county MHP or the qualified provider
and the LEA following a yearend cost reconciliation
process, and in the event that the LEA does not elect to
provide the services through other means;
e) The agreement between the county MHP, or the qualified
provider, and the LEA fulfills reporting requirements under
state and federal Individuals with Disabilities Education
Act (IDEA) and Medi-Cal EPSDT provisions, and measures the
effect of the mental health intervention and how that
intervention meets the goals in a pupil's IEP or relevant
plan for non-IEP pupils;
f) The county MHP or the qualified provider and the LEA
participate in the performance outcome system established
by the California Department of Health Care Services (DHCS)
to measure results of services provided under the
partnership agreement between the county MHP or the
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qualified provider and the LEA; and,
g) A plan to establish a partnership in at least one school
within the LEA in the first year and to expand the
partnership to three additional schools within three years.
2)Defines LEA as a school district, a county office of
education, a charter school, or a special education local plan
area.
3)States the intent of the Legislature that a health care
service plan or a health insurer be authorized to participate
in the partnerships described in this part if there is mutual
agreement between a school district and a plan or insurer.
4)Establishes the County and Local Educational Agency
Partnership Fund (Partnership Fund) in the State Treasury and
makes moneys in the fund available, upon appropriation by the
Legislature, to the California Department of Education (CDE)
for the purpose of funding the partnerships described in this
part. Requires the CDE to fund partnerships through a
competitive grant program.
5)Requires the Superintendent of Public Instruction, beginning
in the 2017-18 fiscal year (FY) and each fiscal year
thereafter, to the extent there is an appropriation in the
annual Budget Act or another measure, to allocate funds from
the Partnership Fund.
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6)Authorizes other funds identified and appropriated by the
Legislature to be deposited into the Partnership Fund and used
for the purposes purpose of funding the partnerships between
MHPs and LEAs, as provided for in this bill.
7)Requires that funds made available in the annual Budget Act
for the purpose of providing educationally related mental
health services, including out-of-home residential services
for emotionally disturbed pupils, required by an IEP, to be
used only for that purpose and prohibits the funds from being
deposited into the Partnership Fund.
8)Requires DHCS to identify children with an IEP who have a
primary mental health diagnosis as emotional disturbance, and
do both of the following:
a) Collect and utilize in the performance outcome system
academic performance data and any other data required for
the measures included within the performance outcome system
for these children and requires DHCS to enter into an
agreement with CDE, in order for CDE to provide to DHCS
relevant academic performance data, as determined by DHCS,
in consultation with CDE, for utilization in the
performance outcome system; and,
b) Requires DHCS, within 18 months of completing the first
report on comprehensive performance outcomes, to include
the data specified in a) above in its reporting.
EXISTING FEDERAL LAW:
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1)Establishes the IDEA which requires that students with
disabilities have access to a free and appropriate public
education based on their individual needs, and establishes
procedures for implementing these requirements.
2)Establishes the Medi-Cal EPSDT program for eligible people
under 21 years of age, requiring screening, vision, dental,
hearing, and other necessary services to correct or ameliorate
defects and physical and mental illnesses and conditions
discovered by the screening services, whether or not the
services are covered under the Medicaid State Plan.
EXISTING STATE LAW:
1)Establishes the Medi-Cal program, administered by DHCS, under
which qualified low-income persons receive health care
benefits.
2)Establishes, under the terms of a federal Medicaid waiver, a
managed care program providing Medi-Cal specialty mental
health services for eligible low-income persons administered
through local county MHPs under contract with DHCS.
3)Defines a LEA as the governing body of any school district or
community college district, the county office of education, a
state special school, a California State University campus, or
a University of California campus and allows LEAs to provide
and bill for Medi-Cal services provided to students receiving
special education services on Medi-Cal (generally, special
education students).
4)Defines the scope of covered services that an LEA may provide
for children with an IEP or an IFSP.
5)Requires that specified services provided by a LEA are
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Medi-Cal benefits, to the extent federal financial
participation (FFP) is available, subject to utilization
controls and standards adopted by DHCS, and are consistent
with Medi-Cal requirements for physician prescription, order,
and supervision.
6)Requires county MHPs to provide specialty mental health
services to eligible Medi-Cal beneficiaries, including both
adults and children. Includes EPSDT within the scope of
specialty mental health services for eligible Medi-Cal
beneficiaries under the age of 21 pursuant to federal Medicaid
law.
7)Establishes the Mental Health Services Oversight and
Accountability Commission (MHSOAC) to oversee the
implementation of the Mental Health Services Act, enacted by
voters in 2004 as Proposition 63, which provides funds to
counties to expand services, and develop innovative programs
and integrated service plans, for mentally ill children,
adults, and seniors through a 1% income tax on personal income
above $1 million.
8) Requires DHCS, in collaboration with the California Health
and Human Services Agency, and in consultation with the
MHSOAC, to create a plan for a performance outcome system for
EPSDT mental health services provided to eligible Medi-Cal
beneficiaries under the age of 21.
FISCAL EFFECT: According to the Senate Appropriations
Committee:
1)Unknown costs to implement the grant program as it would
depend upon the amount of funding that is transferred into the
Partnership Fund. The author's office intends for this bill
to fund about 10 LEAs at $600,000 each year for three schools
per LEA. Under this scenario, costs would be $18 million per
year. Actual costs could be higher or lower depending upon
available funding (Proposition 98).
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2)To the extent the Partnership Fund is used for mental health
services not required by an IEP, there would be a cost
pressure to increase state funds by a similar amount that is
transferred, to backfill the special education program to meet
the federal maintenance of effort requirement (Proposition
98).
3)CDE estimates the costs to prepare and report required data
and to administer the competitive grant process, to be up to
$150,000 General Fund across several positions. Unknown,
potentially significant costs to the DHCS and CDE to enter
into a data sharing agreement. Associated cost pressures and
potential significant mandate for LEAs to report the required
data to CDE (Proposition 98).
4)To the extent the use of moneys from the Partnership Fund
leads to increased access to federal Medi-Cal funds, LEAs
would presumably be able to provide additional services to
eligible students in their jurisdiction (federal funds).
COMMENTS:
1)PURPOSE OF THIS BILL. According to the author this bill
remedies a key problem uncovered by a Joint Legislative audit
request that investigated whether school districts are meeting
their legal obligations to provide the appropriate services to
students with a mental health condition identified in their
IEP following the transition of responsibility of services
from county mental health departments to school districts. The
audit was triggered by many families and advocacy
organizations who expressed difficulty accessing mental health
services for children with a mental health-related component
in their IEP.
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The audit found that LEAs and counties could benefit
financially and improve access to mental health services by
collaborating to provide services to Medi-Cal eligible
students. However, these types of partnerships were rarely
implemented. The author states as an example that the audit
researched the records of the Mt. Diablo Unified School
District and found the District receives roughly $1.3 million
in federal funds per year through their partnership with
Contra Costa County and Desert Mountain special education
local plan area's (SELPA's) agreement with San Bernardino
County has allowed it to access almost $4 million for FY
2014-15.
2)BACKGROUND.
a) ESPDT. EPSDT is a Medi-Cal benefit for individuals
under the age of 21 who have full-scope Medi-Cal
eligibility. This benefit allows for periodic screenings
to determine health care needs and based upon the
identified health care need and diagnosis, treatment
services are provided. EPSDT services include all services
otherwise covered by Medi-Cal and EPSDT beneficiaries can
receive additional medically necessary services. EPSDT
mental health services are Medi-Cal services that correct
or improve mental health problems that have been determined
by a physician, psychologist, counselor, social worker, or
other health or social services provider. EPSDT provides
eligible children with access to a range of mental health
services that include, but are not limited to:
i) Mental health assessment;
ii) Collateral contracts;
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iii) Therapy;
iv) Rehabilitation;
v) Mental health services;
vi) Medication support services;
vii) Day rehabilitation; day treatment intensive;
viii) Crisis intervention/stabilization;
ix) Targeted case management; and,
x) Therapeutic behavioral services.
LEAs are responsible for educationally necessary mental
health services that are identified in a student's IEP, but
are prohibited from directly providing or billing for EPSDT
services unless the county mental health department chooses
to contract with the LEA for those services (EPSDT is
considered specialty mental health). LEAs are required to
ensure services identified in a student's IEP are provided,
regardless of whether the county directly provides
services, denies services, or reimburses the school for any
costs if the LEA provides services (in cases where the LEA
provides services covered under general Medi-Cal that
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overlap with EPSDT services).
According to CDE, LEAs may use one or more of the following
options for sourcing mental health services to Medi-Cal
eligible students (including EPSDT and other mental health
services):
i) Provide and pay for services without seeking
Medi-Cal reimbursement;
ii) Use the LEA Medi-Cal Billing Option Program.
Through this program, the LEA employs or contracts with
qualified practitioners to provide the services pursuant
to the IEP, pays for the services, and submits a claim
for reimbursement. In order to use this option, the LEA
must meet a number of administrative conditions,
including enrollment as a Medi-Cal provider; and,
iii) For EPSDT services, collaborate with county mental
health departments to secure the specialty mental health
services through the county MHP. There are two ways an
LEA can secure these services:
(1) Enter into a contract or memorandum of
understanding with the mental health plan for a
specialty mental health service or an array of
specialty mental health services. In this case,
county mental health plans provide the service and
incur the cost, and bill Medi-Cal for federal
reimbursement; or,
(2) Request to be a certified provider of Medi-Cal
specialty mental health services from the county MHP.
If the county MHP certifies the LEA as an
organizational provider, the LEA would provide the
specialty mental health service through an LEA
qualified employee and submit a claim to the county
mental health plan for reimbursement.
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b) IEPs. Pursuant to the federal IDEA, children with
disabilities are guaranteed the right to a free,
appropriate public education, including necessary services
for a child to benefit from his or her education. Between
1976 and 1984, to meet this federal mandate, California
schools provided mental health services to special
education students who needed the services pursuant to an
IEP. An IEP is a legally binding document that determines
what special education services a child will receive and
why. IEPs include a child's classification, placement,
specialized services, academic and behavioral goals, a
behavior plan if needed, percentage of time in regular
education, and progress reports from teachers and
therapists. A child may require any related services in
order to benefit from special education, including, but not
limited to: speech-language pathology and audiology
services; early identification and assessment of
disabilities in children; medical services; physical and
occupational therapy; orientation and mobility services;
and, psychological services.
According to CDE, over 700,000 (approximately 11%)
California students received Special Education services in
the 2013-14 academic year.
c) County MHPs. In California, specialty Medi-Cal mental
health services are provided under the terms of the federal
Medicaid Medi-Cal Specialty Mental Health Services
Consolidation 1915(b) waiver program. The waiver
established a managed care program for specialty mental
health services separate from the overall Medi-Cal program.
Medi-Cal beneficiaries must receive specialty mental
health services though county-operated MHPs. County MHPs
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provide services directly or through contracts in the local
community using a combination of county funds, realignment
revenues and Mental Health Services Act funds. Counties
pay for services locally, incurring Certified Public
Expenditures (CPEs), which the state then uses as the state
match to claim federal financial participation and the
state, in turn, returns the federal funds to the county
MHPs. The Medi-Cal Specialty Mental Health Services
Consolidation waiver has been in place since the mid-1990s
and was approved for a new five-year term, from July 1,
2015, through June 30, 2020.
Prior to 2011, special education students who had a severe
emotional disturbance condition documented in their IEPs
were referred by their schools to county mental health
agencies for treatment. In 2011, the Legislature repealed
the state mandate on county mental health agencies to
provide IDEA-related mental health services and shifted
this financial responsibility to the CDE. LEAs and local
county MHPs were required to develop new agreements
defining agency responsibilities that reflected the changes
in state law. MHPs remain responsible for providing EPSDT
services for students who are Medi-Cal beneficiaries with
IDEA-related individualized education, if they meet medical
necessity criteria.
d) BSA Audit. The Bureau of State Audits (BSA) released a
report in January 2016, "Student Mental Health Services:
Some Students' Services Were Affected by a New State Law,
and the State Needs to Analyze Student Outcomes and Track
Service Costs". The report noted key points: the most
commonly offered types of mental health services and the
providers of those services generally did not change; the
number of students who received these mental health
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services remained steady or grew; the provider of the most
common mental health services generally had already been,
and continues to be, the LEA, and the majority of changes
to services were unrelated to AB 114.
However, the audit also noted that: LEAs removed mental
health services from student IEPs in the two years after AB
114 took effect, yet some IEPs did not include the
rationale for such changes; LEAs and CDE do not know
whether student outcomes have been affected by AB 114; LEAs
could not determine their total costs to provide mental
health services; and, some have not spent all the funding
they received that is dedicated for mental health services.
This audit made several recommendations; those that are
related to provisions of this bill include:
i) Require LEAs to use six performance indicators to
perform analysis annually on the subset of students
receiving mental health services;
ii) Require CDE to analyze and report on the outcomes
for students receiving mental health services, including
outcomes across six performance indicators, in order to
demonstrate whether those services are effective;
iii) Require CDE to report annually regarding outcomes
for students receiving mental health services in six key
areas;
iv) Require CDE to collect information about the
frequency of the provision of each service contained in
all students' IEPs. Require CDE to annually review the
frequency of mental health services and follow up with
special education local plan areas when it observes a
significant reduction in the frequency of services; and,
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v) Require CDE to develop, and require all LEAs to
follow, an accounting methodology to track and report
expenditures related to special education mental health
services.
e) DHCS Performance Outcome System. The Performance
Outcome System for EPSDT mental health services is intended
to improve outcomes at the individual, program, and system
levels and to inform fiscal decision-making related to the
purchase of services, and is part of the reporting effort
for the implementation of a performance outcome system for
Medi-Cal specialty mental health services for children and
youth. Since 2012, DHCS has worked with several groups to
create a structure for reporting, developing the
Performance Measurement Paradigm, and developing indicators
and measures. The Performance Outcome System will be used
to evaluate the domains of access, engagement, service
appropriateness to need, service effectiveness, linkages,
cost effectiveness, and satisfaction. Three reports will
be provided: statewide aggregate data; population-based
county groups; and, county-specific data. Initial reports
were released in 2015.
3)SUPPORT. The California Council of Community Behavioral
Health Agencies (CCCBHA) writes that this bill will: a)
ensure access to EPSDT funds for students who may need mental
health care; b) provide support to teachers to identify those
students as early as possible and before they become severe
enough to require special education; c) address the needs of
all students through incentive start-up funds that are likely
to be offset by savings in special education; and, d) develop
outcome measures to measure program effectiveness. CCCBHA
states there are now examples of excellent partnerships
between schools and counties or county funded mental health
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providers; this bill is intended to broaden those types of
partnerships throughout the state.
The Community Health Partnership writes that such partnerships
are mutually beneficial but seldom implemented and that only
six out of 122 special education local planning areas are
known to have agreements in place with a county MHP or
qualified provider that operated in the county MHP and that
California is leaving tens of millions of dollars on the
table.
4)OPPOSITION. The California Teachers Association states that
this bill suggests that resources could be diverted from
special education in order to serve other students.
Similarly, the SELPA Administrators Association of California
argues that this bill suggests that money budgeted for schools
to provide mental health services to students as a related
service to special education should be used to help pay the
state match for EPSDT reimbursement regardless of whether
these students have special education needs.
5)OPPOSE UNLESS AMENDED. The Special Opportunities for Access &
Reform (SOAR) Coalition, which includes the SELPAs of
Humboldt, Napa, Solano, Sutter, Shasta, Tehama, and Yolo
counties, recommends that this bill be amended to instead
require DHCS to develop a mediation or appeals process when an
LEA or SELPA and a county mental health agency cannot agree on
delivery of service for an eligible recipient or when EPSDT
funding is not accessible. SOAR argues that from the schools
perspective, there have been barriers to developing these
partnerships and some of the hurdles center on county mental
health not willing to contract with the LEA/SELPAs to provide
EPSDT services or the county mental health agency is charging
the LEA/SELPAs a high indirect cost for developing this
partnership.
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6)RELATED LEGISLATION.
a) SB 884 (Beall) requires LEAs and SELPAs to collect and
report specific information relative to mental health
services, requires CDE to monitor and compare specific
information relative to mental health services, and
requires LEAs to provide specified informational materials
to parents. AB 884 is pending in the Assembly Education
Committee.
b) SB 1291 (Beall) requires each county MHP to submit an
annual foster care mental health service plan to DHCS
detailing the service array, from prevention to crisis
services, available to Medi-Cal eligible children and youth
under the jurisdiction of the juvenile court and their
families, as specified. SB 1291 is pending in this
Committee.
c) SB 1466 (Mitchell) requires that screening services
provided under the EPSDT program include screening for
trauma and establishes that eligible Medi-Cal children who
are found to have experienced trauma and have been abused,
neglected, or removed from the home to be referred to
county MHPs for assessment for specialty mental health
services, as specified. SB 1466 is pending in the Assembly
Human Services Committee.
d) AB 1644 (Bonta) renames the School-based Early Mental
Health Intervention and Prevention Services for Children
Act of 1991, known as the Early Mental Health Initiative,
as the Healing from Early Adversity to Level the Impact of
Trauma in Schools Act and requires the Department of Public
Health to administer the new program, as specified. AB
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1644 is pending in the Senate Education Committee.
e) AB 1025 (Thurmond) of 2015 would have required CDE to
establish a three year pilot program to encourage inclusive
practices that integrate mental health, special education,
and school climate interventions following a multitiered
framework. AB 1025 was held in the Senate Appropriations
Committee.
7)PREVIOUS LEGISLATION.
a) AB 104 (Committee on Budget), Chapter 13, Statutes of
2015, among other things, appropriates $10 million to the
Superintendent of Public Instruction to be apportioned to a
designated county office of education to provide technical
assistance and develop statewide resources to assist LEAs
establish and align systems of learning and behavioral
supports.
b) AB 2212 (Gray) of 2014 would have required DHCS to allow
county MHPs to contract with LEAs as providers of Medi-Cal
EPSDT services to eligible students and, in counties where
the LEA does not have a contract with the county MHP, to
allow the MHP to obtain federal funds on behalf of
nonpublic agencies that contract with LEAs to provide those
services. AB 2212 died in the Assembly Appropriations
Committee.
c) AB 114 (Committee on Budget), Chapter 43, Statutes of
2011, a companion bill to the 2011-12 Budget bill, relieved
county mental health departments of the responsibility to
provide mental health services to students with
disabilities and transferred that responsibility to school
districts.
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8)DOUBLE REFERRED. This bill has been double referred and was
heard in the Assembly Education Committee on June 15, 2016 and
passed out on a 7-0 vote.
9)SUGGESTED AMENDMENTS. The Committee recommends the following
clarifying and technical amendment:
5920. (a) (2) The county mental health plan, or the
qualified provider, and the local educational agency to
utilize designated governmental funds for eligible
Medi-Cal Early and Periodic Screening, Diagnosis, and
Treatment (EPSDT) services provided to pupils enrolled
in Medi-Cal , for mental health service costs for
non-Medi-Cal enrolled pupils in special education with
individualized education programs (IEPs) pursuant to the
federal Individuals with Disabilities Education Act (20
U.S.C. Sec. 1400 et seq.), and for pupils not part of
special education if the services are provided by a
provider specified in paragraph (1).
REGISTERED SUPPORT / OPPOSITION:
Support
Mental Health America of California (Sponsor)
California Association of Marriage and Family Therapists
California Council of Community Behavioral Health Agencies
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California Youth Empowerment Network
Community Health Partnership
Steinberg Institute
Opposition
California Teachers Association (previous version)
Analysis Prepared by:Paula Villescaz / HEALTH / (916)
319-2097