BILL ANALYSIS                                                                                                                                                                                                    Ó



          SENATE COMMITTEE ON APPROPRIATIONS
                             Senator Ricardo Lara, Chair
                            2015 - 2016  Regular  Session

          SB 1291 (Beall) - Medi-Cal:  specialty mental health:  children  
          and youth
          
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          |Version: April 14, 2016         |Policy Vote: HEALTH 9 - 0,      |
          |                                |          HUMAN S. 5 - 0        |
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          |Urgency: No                     |Mandate: No                     |
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          |Hearing Date: May 9, 2016       |Consultant: Brendan McCarthy    |
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          This bill meets the criteria for referral to the Suspense File.

          Bill  
          Summary:  SB 1291 would require county mental health plans to  
          submit an annual foster care mental health service plan to the  
          Department of Health Care Services. The bill would require  
          county mental health plans to be reviewed by an external quality  
          review organization with specified requirements. The bill would  
          require the Department to conduct annual audits of county mental  
          health plans to assess the provision of services to foster  
          youth.


          Fiscal  
          Impact:  
           Ongoing costs of about $1.9 million per year for the  
            Department of Health Care Services to review county plans,  
            conduct audits, and take necessary enforcement actions  
            (General Fund and federal funds).

           Ongoing costs of about $450,000 per year for additional items  
            to be reviewed by the external quality review organization  







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            (General Fund and federal funds).

           Likely administrative costs in the low millions for county  
            mental health plans to develop the required foster youth  
            mental health service plans (General Fund). Much of the  
            information required for the plans is already possessed by  
            county mental health plans. However, there are likely to be  
            administrative costs to compile that information and develop  
            the required plans. Under the state constitution, the state  
            would be responsible for reimbursing counties for any  
            additional administrative costs incurred due to the bill.

           Unknown impact on the costs for counties to provide additional  
            specialty mental health services (local funds or General  
            Fund). By increasing the scrutiny on the provision of services  
            to Medi-Cal beneficiaries by county mental health plans, the  
            bill may bring to light shortcomings in the provision of those  
            services (such as delays in access to services or provider  
            shortages). To the extent that occurs, it may result in  
            counties providing additional services. To the extent that  
            there is an increase is services due to the bill and to the  
            extent that counties could demonstrate that the increase in  
            utilization was due to the effects of the bill, the state  
            could be responsible for those costs. Whether that would  
            actually occur is unknown, as there is no formal process yet  
            in place for determining when and how the state should  
            reimburse counties for additional costs relating to realigned  
            programs.


          Background:  Under current law, specialty mental health (i.e. services for  
          severe mental illness) is "carved-out" of the regular Medi-Cal  
          managed care program and is provided by county mental health  
          plans. County mental health plans are funded with county  
          realignment funds and federal funds. Mild to moderate mental  
          illness is covered by Medi-Cal managed care plans or the  
          fee-for-service Medi-Cal system. 
          Under federal law, the state must contract with an external  
          quality review organization (EQRO) to perform quality reviews of  
          Medi-Cal managed care system. The state is responsible for  
          contracting with and paying for the EQRO. The federal government  
          provides 75% matching funds for those activities. The Department  
          of Health Care Services contracts with one EQRO for review of  
          Medi-Cal managed care plans and one for review of specialty  








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          mental health services provided by county mental health plans.


          Under current law, only a juvenile court judicial officer may  
          order the administration of psychotropic medications for a minor  
          who is a dependent of the court (i.e. a foster youth). Foster  
          youth are categorically eligible for Medi-Cal benefits and hence  
          Medi-Cal provides coverage for those psychotropic medications. 


          Psychotropic medications are intended to treat a variety of  
          mental health conditions. While many patients benefit from the  
          use of psychotropic medications, there are often serious side  
          effects, particularly when taken in combination. In general, the  
          use of psychotropic medications on children and adolescents is  
          "off label" meaning that those drugs have not been specifically  
          approved for use in children or adolescents. According to the  
          Department of Social Services, about 11% of foster youth under  
          age 17 are authorized to receive psychotropic medications.  
          Concerns have been raised by advocates for foster youth that  
          many foster youth are being prescribed these medications to  
          sedate them, rather than to appropriately address their mental  
          health and behavioral health needs.


          In response to concerns about the high rate of psychotropic  
          drugs administered to foster youth, the Department of Health  
          Care Services expanded its existing policy requiring treatment  
          authorization requests for psychotropic drugs for Medi-Cal  
          beneficiaries. Previously, the Department required a prior  
          treatment authorization request before Medi-Cal would authorize  
          psychotropic drugs for Medi-Cal beneficiaries under age six. In  
          October 2014, the Department expanded this requirement for  
          children and adolescents up to age 17. The treatment  
          authorization request process allows for emergency prescriptions  
          while the request is under review. In addition, in April 2015  
          the Department of Health Care Services and the Department of  
          Social Services released guidelines for the use of psychotropic  
          medications in foster youth.




          Proposed Law:  








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            SB 1291 would require county mental health plans to submit an  
          annual foster care mental health service plan to the Department  
          of Health Care Services. The bill would require county mental  
          health plans to be reviewed by an external quality review  
          organization with specified requirements. The bill would require  
          the Department to conduct annual audits of county mental health  
          plans to assess the provision of services to foster youth.
          Specific provisions of the bill would:
                 Require each county mental health plan to submit an  
               annual foster care mental health service plan to the  
               Department of Health Care Services and require the county  
               Board of Supervisors to approve the plan;
                 Specify the information that must be included in the  
               plan;
                 Require the Department to review each plan and notify a  
               county if any deficiencies are found;
                 Require county mental health plans to be reviewed  
               annually by an EQRO, with specified information for all  
               Medi-Cal eligible children and foster youth;
                 Require the Department to review the EQRO data and  
               notify a county mental health plan of any deficiencies;
                 Require the Department to conduct annual audits of each  
               county mental health plan for the administration of Early  
               and Periodic Screening Diagnosis and Treatment benefits for  
               children and foster youth, using the criteria established  
               in the Knox-Keene Act for health plans;
                 Authorize the Department to impose sanctions as provided  
               in law for failure to comply by a county mental health  
               plan.


          Related  
          Legislation:  SB 1174 (McGuire) would require the Department of  
          Health Care Services to provide data to the Medical Board of  
          California relating to the prescribing of psychotropic  
          medications to foster youth and require the Medical Board to  
          review the data to determine if overprescribing is occurring.  
          That bill is on this committee's Suspense File.
          Under current law, both Medi-Cal specialty mental health has  
          been realigned to the counties. Generally, this require counties  
          to provide the non-federal share of program costs using  
          realignment funds. However, Proposition 30 of 2012 provides that  
          any legislation enacted after September 30, 2012 that has an  
          overall effect of increasing the costs already borne by a local  








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          agency for realigned services applies to local agencies only to  
          the extent that the State provides annual funding for the cost  
          increase. Therefore, any additional costs experienced by the  
          counties due to the reporting requirements in the bill would be  
          a state responsibility. Whether the state would be responsible  
          for costs associated with the provision of additional specialty  
          mental health services is unknown, as there is no formal process  
          in place for determining state responsibility for local costs  
          under realignment.




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