BILL ANALYSIS                                                                                                                                                                                                    Ó



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          Date of Hearing:  August 3, 2016


                        ASSEMBLY COMMITTEE ON APPROPRIATIONS


                               Lorena Gonzalez, Chair


          SB 1291  
          (Beall) - As Amended June 27, 2016


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          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. 








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          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). 










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          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. 








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          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,  








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            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  








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            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
















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