BILL ANALYSIS Ó SB 1291 Page 1 Date of Hearing: August 3, 2016 ASSEMBLY COMMITTEE ON APPROPRIATIONS Lorena Gonzalez, Chair SB 1291 (Beall) - As Amended June 27, 2016 ----------------------------------------------------------------- |Policy |Health |Vote:|17 - 0 | |Committee: | | | | | | | | | | | | | | ----------------------------------------------------------------- Urgency: No State Mandated Local Program: NoReimbursable: No SUMMARY: This bill institutes more stringent oversight of county Medi-Cal mental health plans' provision of services to foster youth requiring treatment for severe mental illness. Specifically, this bill: 1)Requires each county mental health plan to submit an annual foster care mental health service plan to the Department of Health Care Services (DHCS, the department that administers Medi-Cal). The plan must be approved by the applicable board of supervisors, and must include specified elements related to provision of mental health services to foster children. SB 1291 Page 2 2)Requires an external quality review organization (EQRO) review of each mental health plan annually, and requires the review to include a number of specified elements related to foster youth. 3)Requires DHCS to review the EQRO's review, and to post the EQRO results publicly. 4)Specifies a process whereby deficiencies are identified by the department and corrected by the county mental health plans through written corrective action plans. 5)Requires DHCS to annually share performance outcome system data with counties in order to inform the foster care mental health service plans, and to ensure the performance outcome system data metrics include disaggregated data for Medi-Cal eligible foster children. FISCAL EFFECT: 1)Ongoing costs of about $1 million per year for DHCS to review county plans, review EQRO findings and corrective action plans, and provide data on foster youth to counties (50% GF/50% federal). 2)Ongoing costs of about $450,000 per year for additional items to be reviewed by the external quality review organization (50% GF/50% federal). SB 1291 Page 3 3)Administrative costs, potentially in the millions statewide, for county mental health plans to develop the required foster youth mental health service plans (50% GF/50% federal). Much of the required information is already collected. However, there are likely to be administrative costs to compile that information and develop the plans. Under the State Constitution, local governments are not required to implement state laws that increase local costs to administer programs realigned in 2011, including specialty mental health, unless the state provides additional funding annually to pay for the increased costs. This estimate assumes funding is provided by the state to implement this bill. For example, if each mental health plan dedicated one full-time staff on average to the foster youth-specific efforts, costs would be $9.8 million annually (GF/federal). 4)Unknown potential cost pressure on counties to provide additional or enhanced specialty mental health services (likely local/federal funds, but potentially GF/federal). By increasing scrutiny, the bill may bring to light shortcomings in the provision of mental health services (such as delays in access to services or provider shortages). To the extent that occurs, it may result in counties providing additional services, for which the nonfederal share of cost would be local funds, pursuant to 2011 realignment. However, to the extent it can be it can be demonstrated that there are additional costs due to the effects of this bill, there could be state fiscal liability. This does not appear likely, but it could be possible. For example, in the bill's description of the process of identifying and correcting deficiencies, it does not limit a deficiency to a failure to meet requirements under current law or contract. Any requirements beyond those currently in place would become a state fiscal responsibility. As of yet, there is no formal process in place for determining the state responsibility to reimburse counties for additional costs relating to realigned programs. SB 1291 Page 4 COMMENTS: 1)Purpose. 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 efficiency of local mental health service delivery. To 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 data for children on foster youth in a standardized format. Additionally, it increases accountability by requiring an external review of the data and for the results to be made public. 2)Background. Specialty Medi-Cal mental health services, those services provided for severe mental illness, are provided exclusively by county-operated mental health plans (MHPs) under the terms of a federal waiver. Efforts related to the 2011 public safety realignment included the transfer of fiscal responsibility for specialty mental health services for Medi-Cal-eligible youth to counties. Counties provide mental health services directly or through contracts in the local community using a combination of realignment revenues, county funds, and Mental Health Services Act funds. For Medi-Cal beneficiaries, the state matches local funds with federal funds on behalf of the counties, and also monitors the county MHPs to ensure delivery and payment of services consistent with state and federal rules. State oversight for the provision of mental health services to Medi-Cal eligible children and youth includes monitoring access to care, utilization, quality, and other performance measures. It also includes an EQRO review of county MHPs. Requirements governing MHPs are found in federal and state code, SB 1291 Page 5 regulations, federal special terms and conditions (STCs) of waiver approval, and contracts between the state and the MHPs. 3)Support. This bill is sponsored by National Center for Youth Law and supported by youth and foster advocacy groups, as well as mental health providers. 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 MHPs. 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)Staff Comments. Although it is desirable for certain purposes to have data related to foster youth collected and reported through one mechanism as the bill envisions, it is unclear whether the cost to reimburse counties for additional administrative work to create a brand-new annual plan is an efficient use of state funds. To the extent this reporting could be streamlined to reduce administrative costs by aligning more closely with existing activities, this could reduce state fiscal exposure. Also, it is worth considering whether it is necessary to report data, externally review, and conduct a state review of the data and the external review every year, or whether it could be done on a less frequent basis. In addition, being more explicit that the bill's requirement SB 1291 Page 6 for counties to correct deficiencies only refers to deficiencies in compliance with existing-law requirements, and does not require a level of service beyond what is required under applicable laws, STCs, and contracts, would eliminate any potential for GF risk related to provision of enhanced service levels. The required "foster care mental health service plan" seems more like a data report than a plan. The author may wish to clarify whether it is a plan that governs the provision of care to foster youth, or a report that simply consolidates and makes public data relevant to foster youth- and adjust the language accordingly. Finally, the intent of this bill appears to be to align with the department's existing oversight and data collection activities, but to ensure the needs of foster youth are specifically considered. However, the bill as written is fairly prescriptive, and codifies a number of existing practices in addition to putting in place new requirements specific to foster youth. The bill could benefit from additional clarification about what is actually a new or enhanced activity versus an existing practice or requirement, and the language could better express the stated intent to align with existing activities. Analysis Prepared by:Lisa Murawski / APPR. / (916) 319-2081 SB 1291 Page 7