BILL ANALYSIS Ó
SENATE COMMITTEE ON HEALTH
Senator Ed Hernandez, O.D., Chair
BILL NO: SB 1291
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|AUTHOR: |Beall |
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|VERSION: |March 28, 2016 |
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|HEARING DATE: |April 6, 2016 | | |
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|CONSULTANT: |Scott Bain |
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SUBJECT : Medi-Cal: specialty mental health: children and
youth
SUMMARY : Requires each county mental health plan to submit an annual
foster care mental health service plan to the Department of
Health Care Services (DHCS) detailing the services available to
Medi-Cal eligible children and youth under the jurisdiction of
the juvenile court and their families. Requires a mental health
plan review to be conducted annually by an external quality
review organization (EQRO) that includes specific data for
Medi-Cal eligible children and youth under the jurisdiction of
the juvenile court and their families. Requires DHCS to conduct
annual audits of each mental health plan for the administration
of Early and Periodic Screening, Diagnosis and Treatment
benefits for children and youth under the jurisdiction of the
juvenile court, and requires the reviews to use the standards
and criteria established pursuant to the Knox-Keene Health Care
Service Plan Act of 1975, as appropriate.
Existing law:
1)Establishes the Medi-Cal program, which is administered by the
DHCS, under which qualified low-income individuals receive
health care services. Establishes a schedule of benefits under
the Medi-Cal program, which Early and Periodic Screening,
Diagnosis and Treatment (EPSDT) for any individual under 21
years of age, consistent with federal Medicaid requirements.
2)Requires DHCS to implement managed mental health care for
Medi-Cal beneficiaries through contracts with mental health
plans. Mental health plans may include individual counties,
counties acting jointly, or an organization or nongovernmental
entity determined by DHCS to meet mental health plan
standards. A contract may be exclusive and may be awarded on a
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geographic basis.
3)Requires mental health plans 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.
4)Requires DHCS to be responsible for conducting investigations
and audits of claims and reimbursements for expenditures for
specialty mental health services provided by mental health
plans to Medi-Cal eligible individuals.
5)Requires DHCS to provide oversight to the mental health plans
to ensure quality, access, cost efficiency, and compliance
with data and reporting requirements. Requires DHCS, at a
minimum, through a method independent of any agency of the
mental health plan contractor, to monitor the level and
quality of services provided, expenditures pursuant to the
contract, and conformity with federal and state law.
Permits, upon the request of the director of DHCS, the
Director of the Department of Managed Health Care to exempt a
mental health plan from the Knox-Keene Health Care Service
Plan Act of 1975. Permits these exemptions to be subject to
conditions the director deems appropriate. Requires the DHCS
director, in consultation with the DMHC director, to analyze
the appropriateness of licensure or application of applicable
standards of the Knox-Keene Health Care Service Plan Act of
1975.
This bill:
1)Requires each mental health plan 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. Requires plans to be
submitted by July 1 of each year, beginning in 2017.
2)Requires each mental health plan 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. Requires plans to be
SB 1291 (Beall) Page 3 of ?
submitted by July 1st of each year, beginning in 2017.
3)Requires the board of supervisors of each mental health plan
to approve the plan prior to submission of the plan.
4)Requires a mental health plan review to be conducted annually
by an external quality review organization (EQRO). Requires
the review to include specific data for Medi-Cal eligible
children and youth under the jurisdiction of the juvenile
court and their families.
5)Requires the mental health plan and the mental health plan
review done by the EQRO to include, but not be limited to, all
of the following elements:
a) The number of Medi-Cal eligible children and youth
under the jurisdiction of the juvenile court served each
year;
b) The number of family members of children and youth
under the jurisdiction of the juvenile court served by
the county mental health plans;
c) Details on the types of services provided to
children and youth under the jurisdiction of the juvenile
court and their families, including prevention and
treatment services;
d) Access to and timeliness of mental health services
available to Medi-Cal eligible children and youth under
the jurisdiction of the juvenile court;
e) Quality of mental health services available to
Medi-Cal eligible children and youth under the
jurisdiction of the juvenile court;
f) Translation and interpretation services available to
Medi-Cal eligible children and youth under the
jurisdiction of the juvenile court;
g) Coordination with other systems, including regional
centers, special education local plan areas, child
welfare, and probation (this requirement is limited to
mental health service plan);
h) Family and caregiver education and support (this
requirement is limited to mental health service plan);
i) Performance data for Medi-Cal eligible children and
youth under the jurisdiction of the juvenile court in the
annual EQRO report required by this bill;
j) Utilization data for Medi-Cal eligible children and
youth under the jurisdiction of the juvenile court in the
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annual EQRO report required by this bill; and,
aa) Medication monitoring.
6)Requires DHCS to review the county mental health plan and post
each plan on its Internet Web site.
7)Requires DHCS, if it identifies deficiencies in a county
mental health plan, to notify the mental health plan, in
writing, of those deficiencies.
8)Requires the mental health plan to provide a written
corrective action plan to DHCS within 60 days, and requires
DHCS to notify the mental health plan of approval or to
request changes, if necessary, within 30 days after receiving
the corrective action plan.
9)Requires final mental health plans to be made publicly
available by, at minimum, posting on the DHCS Internet Web
site.
10)Requires DHCS to review the EQRO data for Medi-Cal eligible
children and youth under the jurisdiction of the juvenile
court and their families. Requires DHCS to notify the mental
health plans in writing of identified deficiencies if the EQRO
identifies deficiencies in a mental health plan's ability to
serve Medi-Cal eligible children and youth under the
jurisdiction of the juvenile court.
11)Requires the mental health plan to provide a written
corrective action plan to DHCS within 60 days of receiving the
notice. Requires DHCS to notify the mental health plan of
approval of the corrective action plan or request changes, if
necessary, within 30 days after receipt of the corrective
action plan. Requires final corrective action plans to be made
publicly available by, at minimum, posting on the DHCS
Internet Web site.
12)Requires DHCS to conduct annual audits of each mental health
plan for the administration of EPSDT benefits for children and
youth under the jurisdiction of the juvenile court, unless the
director determines there is good cause for additional
reviews. Requires the reviews to use the standards and
criteria established pursuant to the Knox-Keene Health Care
Service Plan Act of 1975, as appropriate. Permits DHCS to
contract with professional organizations, as appropriate, to
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perform the periodic review.
13)Requires DHCS, or its designee, to make a finding of fact
with respect to the ability of the mental health plan to
provide quality health care services, effectiveness of peer
review, and utilization control mechanisms, and the overall
performance of the mental health plan in providing mental
health care benefits to its enrollees.
14)Requires the DHCS director to publicly report the findings of
finalized annual audits conducted as soon as possible, but no
later than 90 days following completion of a corrective action
plan initiated pursuant to the audit, if any, unless the
director determines, in his or her discretion, that additional
time is reasonably necessary to fully and fairly report the
results of the audit.
15)Requires the DHCS director, if the director believes that a
mental health plan is substantially failing to comply with any
provision of the Welfare and Institutions Code or any
regulation pertaining to the administration of EPSDT benefits
for children and youth under the jurisdiction of the juvenile
court, and the director determines that formal action may be
necessary to secure compliance, to inform the county
behavioral health director and the board of supervisors of
that failure.
16)Requires the notice to the county behavioral health director
and board of supervisors to be in writing and to allow the
county and the mental health plan a period of time specified
by DHCS, but in no case less than 30 days, to correct the
failure to comply with the law or regulations.
17)Permits the DHCS director, if within the specified period the
county and the mental health plan do not comply or provide
reasonable assurances in writing that they will comply within
the additional time as the DHCS director allows, to order a
representative of the county to appear at a hearing before the
director to show cause why the director should not take
administrative action to secure compliance. Requires the
county to be given at least 30 days' notice of the hearing.
18)Requires the DHCS director to consider the case on the record
established at the hearing and, within 30 days, to render
proposed findings and a proposed decision on the issues.
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Requires the proposed findings and decisions to be submitted
to the county, and the county to have the opportunity to
appear within 10 days, at a time and place as may be
determined by the director, for the purpose of presenting oral
arguments respecting the proposed findings and decisions.
Requires the DHCS director to make a final finding and issue a
final administrative decision.
19)Permits the DHCS director to invoke either of the following
sanctions if the director determines, based on the record
established at the hearing, that the county is failing to
comply with laws or regulations pertaining to a program
administered by DHCS, or if the Department of Human Resources
certifies to the director that a county is not in conformity
with established merit system standards and that
administrative sanctions are necessary to secure compliance:
a) Withhold all or part of state and federal funds from
the county until the county demonstrates to the director
that it has complied; or,
b) Suspend all or part of an existing contract with the
mental health plan and assume, temporarily, direct
responsibility for the administration of all or part of
any programs administered by DHCS in the county until the
county provides reasonable written assurances to the
director of its intention and ability to comply.
20)Requires the DHCS director or his or her designee, during the
period of direct state administrative responsibility, to have
all of the powers and responsibilities of the county director,
except that he or she shall not be subject to the authority of
the board of supervisors.
21)Require a county, in the event that the director invokes
sanctions, to be responsible for providing any funds necessary
for the continued operation of all programs administered by
DHCS in the county. Permits the Controller to deduct an amount
certified by the director as necessary for the continued
operation of these programs by DHCS from any state or federal
funds payable to the county for any purpose if a county fails
or refuses to provide these funds, including a sufficient
amount to reimburse all costs incurred by DHCS in directly
administering a program in the county.
22)Caps, in the event of a state-imposed sanction, the amount of
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the sanction, as specified.
FISCAL
EFFECT : This bill has not been analyzed by a fiscal committee.
COMMENTS :
1) Author's statement. According to the author, as the
Legislature passed legislation last year to stop the
over-prescription of psychotropic drugs to control foster
youth with behavioral problems, there were lingering
questions about the responsiveness and efficient delivery
of mental health services. To get answers and increase
accountability, this bill proposes to consolidate data from
existing sources into one plan under the oversight of the
appropriate regulatory agency. Specifically, it requires
county mental health plans to report out this data for
children in the dependency and juvenile systems in a
standardized format. It empowers the DHCS to take
corrective action. To increase transparency, the data will
be posted on the web.
2) EQRO. Federal Medicaid regulations require states to
contract with an EQRO to perform external quality review
activities. The EQRO must have staff with demonstrated
experience and knowledge of (a) Medicaid beneficiaries,
policies, data systems, and processes; (b) managed care
delivery systems, organizations, and financing; (c) quality
assessment and improvement methods; and (d) research design
and methodology, including statistical analysis. The EQRO
and its subcontractors are independent from the state
Medicaid agency and the health plans that they review.
States must ensure that the EQR produces at least the
following information:
a) A detailed technical report that describes the
manner in which the data from all activities conducted
were aggregated and analyzed and conclusions were drawn
as to the quality, timeliness, and access to the care
furnished by the plan;
b) An assessment of each plan's strengths and
weaknesses with respect to the quality, timeliness, and
access to health care services furnished to Medicaid
beneficiaries;
c) Recommendations for improving the quality of health
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care services furnished by each plan;
d) As the State determines methodologically
appropriate, comparative information about all plans;
and,
e) An assessment of the degree to which each health
plan has addressed effectively the recommendations for
quality improvement made by the EQRO during the previous
year's EQR.
Funding for EQROs is 75% federal funds, 25% General Fund.
California contracts with two EQROs, one for its Medi-Cal
managed care plans and a second EQRO (Behavioral Health
Concepts, Inc.) for its review of specialty mental health plans.
1) Specialty mental health "carve out." The Medi-Cal
Specialty Mental Health Services Program is "carved-out" of
the broader Medi-Cal program and is administered by DHCS
under a federal waiver approved by the Centers for Medicare
and Medicaid Services (CMS). DHCS contracts with a MHP in
each county to provide or arrange for the provision of
Medi-Cal specialty mental health services. All MHPs are
county mental health departments. Specialty mental health
services are Medi-Cal entitlement services for adults and
children that meet medical necessity criteria, which
consist of having a specific covered diagnosis, functional
impairment, and meeting intervention criteria. MHPs must
certify that they incurred a cost before seeking federal
reimbursement through claims to the State. MHPs are
responsible for the non-federal share of Medi-Cal specialty
mental health services. Mental health services for Medi-Cal
beneficiaries who do not meet the criteria for specialty
mental health services are provided under the broader
Medi-Cal program either through managed care plans (by
primary care providers within their scope of practice) or
fee-for-service (for children exempt from mandatory
enrollment in Medi-Cal managed care). Children's specialty
mental health services are provided under the federal
requirements of the EPSDT benefit, which is available to
full-scope beneficiaries under age 21.
DHCS has reported data on the number of children and youth
eligible to receive Medi-Cal services in 2013-14 as slightly
over 6 million. Of these 6 million children, 262,318 received
specialty mental health services, for a penetration rate of
4.4%. The count of children and youth with 5 or more specialty
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mental health visits was 201,192, for a penetration rate of
3.3%. The average per beneficiary expenditure for approved
services in 2013-14 was $6,092.
An estimated 66,000 children and youth are in foster care under
the jurisdiction of the juvenile court due a finding of abuse or
neglect or who have been removed from their home and are under
supervised probation. Except for foster youth in the six county
organized health systems (COHS, which operate in 22 counties),
foster youth are exempt from mandatory enrollment in Medi-Cal
managed care plans.
2) Double referral. This bill has been double referred.
Should it pass out of this committee, this bill will be
re-referred to the Senate Rules Committee.
3) Related legislation. SB 1446 (Mitchell) requires
screening services provided under the Early and Periodic
Screening, Diagnosis, and Treatment Program (EPSDT) to
include screening for trauma. Requires child abuse and
neglect or removal from the parent or legal guardian by a
child welfare agency to be prima facie evidence (a fact
presumed to be true unless it is disproved) of trauma for
purposes of conducting a screening consistent with the
requirement to screen for trauma. SB 1446 is scheduled to
be heard before the Senate Health Committee on April 6,
2016.
SB 1135 (Monning) requires health plans and insurers, including
Medi-Cal managed care plans to notify enrollees and contracted
providers about information on timely access to care standards
and information about interpreter services, at least annually,
and requires the toll-free telephone number of the Department of
Managed Health Care, California Department of Insurance, or the
Medi-Cal Managed Care Office of the Ombudsman to be provided on
the enrollee or insureds proof of coverage card. SB 1135 is
scheduled to be heard before the Senate Health Committee on
April 6, 2016.
4) Support. This bill is sponsored by the National Center
for Youth Law, which argues the vast majority of
California's children and youth in foster care do not
receive safe, quality mental health services during their
time in care despite a well-documented need. An August 2011
report found California's child welfare system reported
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only 34.7% of foster children and youth received mental
health services, excluding medication and case management -
well below national prevalence rates showing need in 60% of
the foster care population. At the same time, 25% of foster
children ages 6-17 are receiving one or more psychotropic
medications and over 50% of children in group homes are
receiving these powerful drugs. Guidelines establish that
the decision to treat children with psychotropic
medications cannot be taken lightly, the benefits must
outweigh the risks, and other treatments must have been
tried prior to their use. Unfortunately, it is common for
foster children to be quickly referred for medication
without other supports that will help address their
underlying mental and behavioral health needs. This bill
requires county mental health plans to create a subsection
for foster youth and include an annual foster care mental
health plan detailing the service array-from prevention to
crisis services-available to these children and youth. SB
1291 will enable the state and county to track access,
quality and outcomes specific to foster children.
5) Policy issues.
a) Knox-Keene. Under existing law, county MHPs are
allowed to be exempt from the Knox-Keene Act. This bill
requires DHCS to conduct annual audits of each mental
health plan for the administration of EPSDT benefits for
children and youth under the jurisdiction of the juvenile
court, and requires the reviews to use the standards and
criteria established pursuant to the Knox-Keene Act as
appropriate. Amendments are needed to clarify whether the
reviews are medical versus administrative and to specify
which Knox-Keene requirements would apply to the required
audit.
b) Penalty provisions. This bill contains penalty
provisions if the DHCS director believes that a county
mental health plan is substantially failing to comply
with any provision of the Welfare and Institutions Code,
or any regulation pertaining to the administration of
EPSDT benefits for children and youth under the
jurisdiction of the juvenile court. These penalties
include allowing the director to order a county to appear
at hearing, withholding all or part of state and federal
funds from the county, and suspending all or part of an
existing contract with the county mental health plan and
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having the state assume temporary direct responsibility
for the administration of all of part of the any programs
administered by DHCS in the county, in which case the DHS
director would have all of the powers and
responsibilities of the county. The scope of the
authorized penalties could be disproportionate to the
violation. In addition, existing state law and
regulations already contains a penalty structure for
violations of the article in which these bill provisions
are placed.
c) Clarifying amendment. This bill includes a reference
to foster parents in the number of family members served
by mental health plans in the provisions relating to the
county MHPs but not the provisions dealing with the EQRO.
Amendments are needed to make the parallel change.
SUPPORT AND OPPOSITION :
Support: National Center for Youth Law (sponsor)
California Council of Community Behavioral Health
Agencies
Children's Advocacy Institute
California Youth Connection
Children Now
Consumer Watchdog
John Burton Foundation for Children Without Homes
Therapists for Peace & Justice
Woodland Community College Foster and Kinship Care
Education
Oppose: None received
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