BILL ANALYSIS Ó
SB 1291
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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
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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,
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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
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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
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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.
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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
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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;
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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
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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;
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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.
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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.
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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
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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
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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
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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.
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Analysis Prepared by:Paula Villescaz / HEALTH / (916)
319-2097