BILL ANALYSIS Ó SB 1291 Page 1 Date of Hearing: June 21, 2016 ASSEMBLY COMMITTEE ON HEALTH Jim Wood, Chair SB 1291 (Beall) - As Amended June 13, 2016 SENATE VOTE: 39-0 SUBJECT: Medi-Cal: specialty mental health: children and youth. SUMMARY: Requires each mental health plan (MHP) to submit a foster care mental health service plan (foster care plan) to the Department of Health Care Services (DHCS) detailing the service array available to Medi-Cal eligible children and youth under the jurisdiction of the juvenile court and their families; requires annual reviews to be conducted by an external quality review organization (EQRO); and, requires corrective action plans to be prepared by the MHP, as specified. Specifically, this bill: 1)Requires foster care plans to be consistent with the Special Terms and Conditions outlined in the federal Centers for Medicare and Medicaid Services (CMS) approved 1915(b) Medi-Cal Specialty Mental Health Services Waiver (Waiver). 2)Requires foster care plans to be submitted by July 1 of each year, beginning in 2017. Requires the board of supervisors of each MHP, prior to submittal to DHCS, to approve the foster care plans. Foster care plans requirements include, but are not SB 1291 Page 2 limited to, 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, including foster parents, of children and youth under the jurisdiction of the juvenile court served by the county MHPs; c) Details on the types of mental health services provided to children and youth under the jurisdiction of the juvenile court and their families, including prevention and treatment services. Allows the types of services to include, but not limited to, screenings, assessments, home-based mental health services, outpatient services, day treatment services, or inpatient services, psychiatric hospitalizations, crisis interventions, case management, and psychotropic medication support 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; g) Coordination with other systems, including regional centers, special education local plan areas, child welfare, and probation; h) Family and caregiver education and support; i) Performance data for Medi-Cal eligible children and youth under the jurisdiction of the juvenile court; j) Utilization data for Medi-Cal eligible children and youth under the jurisdiction of the juvenile court; and, SB 1291 Page 3 aa) Medication monitoring consistent with the Healthcare Effectiveness Data and Information Set (HEDIS), including, but not limited to, the child welfare psychotropic medication measures developed by the State Department of Social Services and HEDIS measures related to psychotropic medications, as specified. 3)Requires DHCS to post each foster care plan on its Internet Website. 4)Requires a MHP review to be conducted annually by an EQRO. Specifies review requirements including specific data for Medi-Cal eligible children and youth under the jurisdiction of the juvenile court and their families. 5)Requires DHCS to review the EQRO data for Medi-Cal eligible children and youth under the jurisdiction of the juvenile court and their families. 6)Requires DHCS to notify the MHP in writing of any identified deficiencies found by the EQRO that would impact a MHP's ability to serve Medi-Cal eligible children and youth under the jurisdiction of the juvenile court. 7)Requires the MHP to provide a written corrective action plan to DHCS within 60 days of receiving the notice required pursuant to 6) above. Requires DHCS to notify the MHP of approval of the SB 1291 Page 4 corrective action plan or to request changes, if necessary, within 30 days after receipt of the corrective action plan. Requires a final corrective action plan to be made publicly available by, at minimum, posting on the DHCS's Internet Web site. 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 for Medi-Cal eligible children through the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) program 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 MHPs. Allows MHPs to include individual counties, counties acting jointly, or an organization or nongovernmental entity determined by DHCS to meet mental health plan standards. Allows a contract to be exclusive and to be awarded on a geographic basis. 3)Requires 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. 4)Requires DHCS to be responsible for conducting investigations and audits of claims and reimbursements for expenditures for specialty mental health services provided by MHPs to Medi-Cal eligible individuals. 5)Requires DHCS to provide oversight to the MHPs to ensure quality, access, cost efficiency, and compliance with data and reporting requirements. Requires DHCS, at a minimum, through a SB 1291 Page 5 method independent of any agency of the MHP contractor, to monitor the level and quality of services provided, expenditures pursuant to the contract, and conformity with federal and state law. 6)Permits, upon the request of the Director of DHCS, the Director of the Department of Managed Health Care (DMHC) to exempt a MHP from the Knox-Keene Health Care Service Plan Act of 1975 (Knox-Keene). Permits these exemptions to be subject to conditions the Director of DMHC 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 Act. FISCAL EFFECT: According to the Senate Appropriations Committee: 1)Ongoing costs likely in the hundreds of thousands per year for DHCS to review county plans, EQRO reports, and take necessary enforcement actions (General Fund (GF)/federal funds (FF)). 2)Ongoing costs of about $450,000 per year for additional items to be reviewed by the EQRO (GF/FF). 3)Likely administrative costs in the low millions for county MHPs to develop the required foster youth mental health service plans (GF/FF). Much of the information required for the plans is already possessed by county MHPs. 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 this bill. SB 1291 Page 6 4)Unknown impact on the costs for counties to provide additional specialty mental health services (local funds or GF/FF). By increasing the scrutiny on the provision of services to Medi-Cal beneficiaries by county MHPs, this bill may bring to light shortcomings in the provision of those services (such as delays in access to services or provider shortages). COMMENTS: 1)PURPOSE OF THIS BILL. According to the author, after legislation passed 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 MHPs to report out this data for children in the dependency and juvenile systems in a standardized format. Additionally, it increases accountability and transparency by requiring an external review of the data and for the results to be made public. 2)BACKGROUND. a) The Waiver and County MHPs. Specialty Medi-Cal mental health services are provided under the terms of a federal 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 through county-operated MHPs. County MHPs provide services directly or through contracts in the local community using a SB 1291 Page 7 combination of county funds, realignment revenues, and Mental Health Services Act funds. Counties pay for services locally, incurring Certified Public Expenditures, 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 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. 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 or 4.4%, received specialty mental health services. The number of children and youth with five or more specialty mental health visits was 201,192 or 3.3%. The average per beneficiary expenditure for approved services in 2013-14 was $6,092. b) 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 access to a range of mental health services that include, but are not limited to: i) Mental health assessment; ii) Collateral contracts; iii) Therapy; iv) Rehabilitation; SB 1291 Page 8 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. c) 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 EQRO produces at least the following information: i) A detailed technical report that describes the manner in which the data from all activities conducted were SB 1291 Page 9 aggregated and analyzed and conclusions were drawn as to the quality, timeliness, and access to the care furnished by the plan; ii) 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; iii) Recommendations for improving the quality of health care services furnished by each plan; iv) As the state determines methodologically appropriate, comparative information about all plans; and, v) 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 EQRO. Funding for EQROs is 75% FF/25% GF. California contracts with two EQROs, one for its Medi-Cal managed care plans and a second for its review of specialty MHPs. The State conducted a procurement process to assure an ongoing external quality review process is in place. The EQRO contract with Behavioral Health Concepts for review of specialty MHPs was secured by the state for fiscal year (FY) 2014-15 through FY 2016-17 with an option to extend the contract for two additional one year extension periods. The MHP contract specifies the standards for the MHP's quality management and quality improvement programs which includes conducting at least two Performance Improvement Projects (PIPs), one clinical and one non-clinical that meet the validation standards applied by the EQRO contractor. The validation standards are: i) Monitoring the service delivery capacity of the MHP; ii) Monitoring the accessibility of services; iii) Monitoring beneficiary satisfaction; SB 1291 Page 10 iv) Monitoring the MHP's service delivery system and meaningful clinical issues affecting beneficiaries, including safety and effectiveness of medication practices; and, v) Monitoring continuity and coordination of care with physical health care providers and other human services agencies. Data gathered from the PIPs will be available to assist MHPs to continue to make program enhancements to improve the coordination, quality, effectiveness, and/or efficiency of service delivery to children who are receiving EPSDT services. Currently, there are ongoing discussions between DHCS and the EQRO regarding the possible development of a statewide PIP related to timeliness of and access to services, although timeliness and access may instead be validated through Performance Measures. d) 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 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, develop the Performance Measurement Paradigm, and develop 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. SB 1291 Page 11 3)SUPPORT. The National Center for Youth Law, sponsor of the bill, states that a 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. 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 needs. This bill requires county MHPs to create a subsection for foster youth and an annual foster care MHP detailing the service array - from prevention to crisis services - available to these children and youth. 4)CONCERNS. The County Behavioral Health Directors Association (CBHDA) states that this bill would duplicate existing county reporting requirements. CBHDA argues California's EQRO conducts reviews of county Medi-Cal Specialty Mental Health Services annually. These reviews are conducted in accordance with Medi-Cal regulations and address, in detail, quality, outcomes, timeliness of services, and access to services provided by Mental Health Plans. CBHDA states the reporting requirements established in this bill will create substantial county workload, and this duplicative demand on county staffing would result in a net loss of available resources to serve youth. 5)RELATED LEGISLATION. a) SB 884 (Beall) requires LEAs and special education local plan areas 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 local education agencies (LEAs) to provide specified informational materials to parents. AB 884 is pending in the Assembly Education Committee. SB 1291 Page 12 b) SB 1113 (Beall) permits LEAs and county MHPs to enter into partnerships for the provision of EPSDT mental health services, as specified. SB 1113 is pending in the Assembly Health 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. This bill 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 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. 5)PREVIOUS LEGISLATION. 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. 6)DOUBLE REFERRAL. Upon passage in this Committee, this bill will SB 1291 Page 13 be referred to the Assembly Committee on Human Services. 7)POLICY COMMENT. CBHDA notes with concern that the EQRO process is duplicative. As discussed above, an EQRO process exists specifically for the Waiver. This bill requires that the EQRO specifically examine the foster care plan established under this bill, however it is unclear why this would not already be included in the EQRO review of MHPs in their entirety. The Committee may wish to consider if the EQRO requirement in this bill is necessary. 8)SUGGESTED AMENDMENTS. The Committee may wish to consider a technical amendment clarifying that the MHPs discussed in the bill are county MHPs. REGISTERED SUPPORT / OPPOSITION: Support National Center for Youth Law (sponsor) American Association for Marriage and Family Therapy Bay Area Youth Center California Association of Marriage and Family Therapists California Court Appointed Special Advocates SB 1291 Page 14 California Council of Community Behavioral Health Agencies California Youth Connection California Youth Empowerment Network Center for the Study of Social Policy Children's Advocacy Institute Children's Defense Fund Children Now Children's Partnership Consumer Watchdog County of Contra Costa Family Voices of California First Focus Campaign for Children Hillsides SB 1291 Page 15 John Burton Foundation for Children without Homes Mental Health America of California National Association of Social Workers Pacific Juvenile Defender Center Peers Envisioning and Engaging in Recovery Services Planned Parenthood Mar Monte San Luis Obispo County Department of Social Services Therapists for Peace & Justice The Jamestown Community Center Woodland Community College Foster and Kinship Care Education Opposition None on file. SB 1291 Page 16 Analysis Prepared by:Paula Villescaz / HEALTH / (916) 319-2097