BILL ANALYSIS                                                                                                                                                                                                    Ó




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          |SENATE RULES COMMITTEE            |                       SB 1291|
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                                UNFINISHED BUSINESS 


          Bill No:  SB 1291
          Author:   Beall (D) 
          Amended:  8/15/16  
          Vote:     21 

           SENATE HEALTH COMMITTEE:  9-0, 4/6/16
           AYES:  Hernandez, Nguyen, Hall, Mitchell, Monning, Nielsen,  
            Pan, Roth, Wolk

           SENATE HUMAN SERVICES COMMITTEE:  5-0, 4/12/16
           AYES:  McGuire, Berryhill, Hancock, Liu, Nguyen

           SENATE APPROPRIATIONS COMMITTEE:  7-0, 5/27/16
           AYES:  Lara, Bates, Beall, Hill, McGuire, Mendoza, Nielsen

           SENATE FLOOR:  39-0, 6/2/16
           AYES:  Allen, Anderson, Bates, Beall, Berryhill, Block,  
            Cannella, De León, Fuller, Gaines, Galgiani, Glazer, Hall,  
            Hancock, Hernandez, Hertzberg, Hill, Hueso, Huff, Jackson,  
            Lara, Leno, Leyva, Liu, McGuire, Mendoza, Mitchell, Monning,  
            Moorlach, Morrell, Nguyen, Nielsen, Pan, Pavley, Roth, Stone,  
            Vidak, Wieckowski, Wolk
           NO VOTE RECORDED:  Runner

           ASSEMBLY FLOOR:  78-0, 8/18/16 - See last page for vote
           
           SUBJECT:   Medi-Cal:  specialty mental health:  minor and  
                     nonminor dependents


           SOURCE:    Mental Health America of California
                     National Center for Youth Law


          DIGEST:  This bill requires a mental health plan review to be  








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          conducted annually by an external quality review organization  
          (EQRO) that includes specific data for specific data for  
          Medi-Cal eligible minor and nonminor dependents in foster care.

          Assembly Amendments delete provisions requiring a county  
          specialty mental health plan to submit an annual foster care  
          mental health service plan to DHCS, require the EQRO mental  
          health plan review to be on minor and non-minor dependents in  
          foster care, instead of children and youth under the  
          jurisdiction of the juvenile court and their families, delete  
          specific drug-related monitoring performance measures, and  
          require DHCS to share data with county boards of supervisors to  
          assist in the development of foster youth mental health plans.
          
          ANALYSIS: 

          Existing law:

           1) Establishes the Medi-Cal program, which is administered by  
             the DHCS, under which qualified low-income individuals  
             receive health care services. 

           2) Requires DHCS to implement managed mental health care for  
             Medi-Cal beneficiaries through contracts with mental health  
             plans. Mental health plans may include individual counties,  
             counties acting jointly, or an organization or  
             nongovernmental entity determined by DHCS to meet mental  
             health plan standards. A contract may be exclusive and may be  
             awarded on a geographic basis.

           3) Requires mental health plans to provide specialty mental  
             health services to eligible Medi-Cal beneficiaries, including  
             both adults and children.

           4) Requires DHCS to be responsible for conducting  
             investigations and audits of claims and reimbursements for  
             expenditures for specialty mental health services provided by  
             mental health plans to Medi-Cal eligible individuals.

           5) Requires DHCS to provide oversight to the mental health  
             plans to ensure quality, access, cost efficiency, and  
             compliance with data and reporting requirements. Requires  








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             DHCS, at a minimum, through a method independent of any  
             agency of the mental health plan contractor, to monitor the  
             level and quality of services provided, expenditures pursuant  
             to the contract, and conformity with federal and state law.

          This bill:

           1) Requires a county specialty mental health plan review to be  
             conducted annually by an external quality review organization  
             (EQRO) pursuant to federal regulations. 

           2) Requires, commencing July 1, 2018, the review to include  
             specific data for Medi-Cal eligible minor and nonminor  
             dependents in foster care, including all of the following:

              a)    The number of Medi-Cal eligible minor and nonminor  
                dependents in foster care served each year; 
              b)    Details on the types of mental health services  
                provided to children, including prevention and treatment  
                services. These types of services may include, but are 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.
              c)    Access to, and timeliness of, mental health services  
                available to Medi-Cal eligible minor and nonminor  
                dependents in foster care;
              d)    Quality of mental health services available to  
                Medi-Cal eligible minor and nonminor dependents in foster  
                care;
              e)    Translation and interpretation services available to  
                Medi-Cal eligible minor and nonminor dependents in foster  
                care;
              f)    Performance data for Medi-Cal eligible minor and  
                nonminor dependents in foster care;
              g)    Utilization data for Medi-Cal eligible minor and  
                nonminor dependents in foster care.
              h)    Medication monitoring consistent with the child  
                welfare psychotropic medication measures developed by the  
                Department of Social Services and any Healthcare  
                Effectiveness Data and Information Set (HEDIS) measures  








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                related to psychotropic medications, including but not  
                limited to, specified measures.

          3)Requires DHCS to post the EQRO data disaggregated by Medi-Cal  
            eligible minor and nonminor dependents in foster care on the  
            department's Internet Web site in a manner that is publicly  
            accessible.

           4) Requires DHCS to review the EQRO data for Medi-Cal eligible  
             minor and nonminor dependents in foster care.

           5) Requires DHCS, if the EQRO identifies deficiencies in a  
             mental health plan's ability to serve Medi-Cal eligible minor  
             and nonminor dependents in foster care, to notify the mental  
             health plan in writing of identified deficiencies.

           6) Requires the mental health plan to provide a written  
             corrective action plan to DHCS within 60 days of receiving  
             the notice. Requires DHCS to notify the mental health plan of  
             approval of the corrective action plan or to request changes,  
             if necessary, within 30 days after receipt of the corrective  
             action plan. Requires final corrective action plans to be  
             made publicly available by, at minimum, posting on DHCS  
             Internet Web site.

           7) Requires DHCS, to the extent possible, to share with county  
             boards of supervisors data that will assist in the  
             development of mental health service plans.

           8) Requires DHCS to annually share performance outcome system  
             data with county boards of supervisors for the purpose of  
             informing mental health service plans.

           9)  Requires performance outcome system data shared with county  
             boards of supervisors to include, but not be limited to, the  
             following disaggregated data for Medi-Cal eligible minor and  
             nonminor dependents in foster care:

              a)    The number of youth receiving specialty mental health  
                services.
              b)    The racial distribution of youth receiving specialty  
                mental health services.








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              c)    The gender distribution of youth receiving specialty  
                mental health services.
              d)    The number of youth, by race, with one or more  
                specialty mental health service visits.
              e)    The number of youth, by race, with five or more  
                specialty mental health service visits.
              f)    Utilization data for intensive home services,  
                intensive care coordination, case management, therapeutic  
                behavioral services, medication support services, crisis  
                intervention, crisis stabilization, full-day intensive  
                treatment, full-day treatment, full-day rehabilitation,  
                and hospital inpatient days.
              g)    A unique count of youth receiving specialty mental  
                health services who are arriving, exiting, and continuing  
                with services.

           10)Requires DHCS to ensure that the performance outcome system  
             data metrics include disaggregated data for Medi-Cal eligible  
             minor and nonminor dependents in foster care, and requires  
             this data to be in a format that can be analyzed.

          Comments
          
          1)Author's statement. According to the author, as the  
            Legislature passed legislation 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 mental  
            health plans to report out this data for children in the  
            dependency and juvenile systems in a standardized format. It  
            empowers the DHCS to take corrective action. To increase  
            transparency, the data will be posted on the web.

          2)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,  








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            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 EQR produces at least the following information: 

             a)   A detailed technical report that describes the manner in  
               which the data from all activities conducted were  
               aggregated and analyzed and conclusions were drawn as to  
               the quality, timeliness, and access to the care furnished  
               by the plan; 
             b)   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; 
             c)   Recommendations for improving the quality of health care  
               services furnished by each plan;
             d)   As the State determines methodologically appropriate,  
               comparative information about all plans; and,
             e)   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  
               EQR. 

          3)Specialty mental health "carve out." The Medi-Cal Specialty  
            Mental Health Services Program is "carved-out" of the broader  
            Medi-Cal program and is administered by DHCS under a federal  
            waiver approved by the Centers for Medicare and Medicaid  
            Services (CMS). DHCS contracts with a MHP in each county to  
            provide or arrange for the provision of Medi-Cal specialty  
            mental health services. All MHPs are county mental health  
            departments. Specialty mental health services are Medi-Cal  
            entitlement services for adults and children that meet medical  
            necessity criteria, which consist of having a specific covered  
            diagnosis, functional impairment, and meeting intervention  
            criteria. MHPs must certify that they incurred a cost before  
            seeking federal reimbursement through claims to the State.  
            MHPs are responsible for the non-federal share of Medi-Cal  
            specialty mental health services. Mental health services for  
            Medi-Cal beneficiaries who do not meet the criteria for  
            specialty mental health services are provided under the  
            broader Medi-Cal program either through managed care plans (by  








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            primary care providers within their scope of practice) or  
            fee-for-service (for children exempt from mandatory enrollment  
            in Medi-Cal managed care). Children's specialty mental health  
            services are provided under the federal requirements of the  
            EPSDT benefit, which is available to full-scope beneficiaries  
            under age 21.
          
          FISCAL EFFECT:   Appropriation:    No          Fiscal  
          Com.:YesLocal:   No

          According to the Assembly Appropriations Committee: 

           Ongoing costs in the range of $200,000 per year for DHCS to  
            oversee EQRO findings and corrective action plans (50% General  
            Fund (GF)/50% federal funds (FF)).


           Ongoing costs of about $450,000 per year for additional items  
            to be reviewed by the EQRO (50% GF/50% FF). 


           Unknown potential cost pressure on counties to provide  
            additional or enhanced specialty mental health services  
            (local/FF). 


          SUPPORT:  (Verified  8/18/16)

           Mental Health America of California (co-source)
           National Center for Youth Law (co-source)
           Accessing Health Services for California's Children in Foster  
            Care Task Force
           Advokids
           American Association for Marriage and Family Therapy,  
            California Division
           Bay Area Youth Center
           California Alliance of Child and Family Services
           California Association of Marriage and Family Therapists
           California CASA Association
           California Council of Community Behavioral Health Agencies
           California Youth Connection
           California Youth Empowerment Network








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           Center for the Study of Social Policy
           Children Now
           Children's Advocacy Institute
           Consumer Watchdog
           Contra Costa County Board of Supervisors
           County Welfare Directors Association of California
           David Walker, PhD., Member, NCYL, Medical and Scientific  
            Advisory Board
           Family Voices of California
           First Focus Campaign for Children
           Hillsides
           John Burton Foundation for Children Without Homes
           Kids in Common
           National Association of Social Workers, California Chapter
           Pacific Juvenile Defender Center
           Peers Envisioning and Engaging in Recovery Services (PEERS)
           San Luis Obispo County Department of Social Services
           Sunny Hills Services
           The Children's Partnership
           The Jamestown Community Center
           Therapists for Peace and Justice
           Woodland Community College Foster & Kinship Care Education

          OPPOSITION:(Verified 8/18/16)

          Department of Finance


          This bill is sponsored by the National Center for Youth Law,  
          which argues the 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. An August 2011 report found California's child welfare  
          system reported only 34.7% of foster children and youth received  
          mental health services, excluding medication and case  
          management, well below national prevalence rates showing need in  
          60% of the foster care population. At the same time, 25% of  
          foster children ages 6-17 are receiving one or more psychotropic  
          medications and over 50% of children in group homes are  
          receiving these powerful drugs. Guidelines establish that the  
          decision to treat children with psychotropic medications cannot  
          be taken lightly, the benefits must outweigh the risks, and  








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          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 health needs.  
          This bill requires county mental health plans to create a  
          subsection for foster youth and include an annual foster care  
          mental health plan detailing the service array-from prevention  
          to crisis services-available to these children and youth to  
          enable the state and county to track access, quality and  
          outcomes specific to foster children.
          
          ARGUMENTS IN OPPOSITION: The Department of Finance (DOF) writes  
          in opposition to the previous version of this bill, arguing this  
          bill would result in unknown, but likely significant General  
          Fund costs. In addition, DOF states that DHCS indicates that the  
          bill may increase administrative costs for local Child Health  
          and Disability Prevention (CHDP) programs and county Mental  
          Health Plans. DHCS and DSS may incur additional workload  
          associated with developing the new tools and protocols for  
          trauma screenings; however, it is unknown what level of  
          additional resources may be needed. The state would be  
          responsible for the non-federal share of all new costs under  
          this bill based on the requirements of Article XIII, Section 36  
          of the California Constitution (Proposition 30) which prohibits  
          local agencies from being obligated to provide levels of service  
          above the level for which funding has been provided under 2011  
          Realignment.

           ASSEMBLY FLOOR:  78-0, 8/18/16
           AYES: Achadjian, Alejo, Travis Allen, Arambula, Atkins, Baker,  
            Bigelow, Bloom, Bonilla, Bonta, Brough, Brown, Burke,  
            Calderon, Campos, Chang, Chau, Chávez, Chiu, Chu, Cooley,  
            Cooper, Dababneh, Dahle, Daly, Dodd, Eggman, Frazier, Beth  
            Gaines, Gallagher, Cristina Garcia, Eduardo Garcia, Gatto,  
            Gipson, Gomez, Gonzalez, Gordon, Gray, Grove, Hadley, Harper,  
            Holden, Irwin, Jones, Jones-Sawyer, Lackey, Levine, Linder,  
            Lopez, Low, Maienschein, Mathis, Mayes, McCarty, Medina,  
            Melendez, Mullin, Nazarian, Obernolte, O'Donnell, Olsen,  
            Patterson, Quirk, Ridley-Thomas, Rodriguez, Salas, Santiago,  
            Steinorth, Mark Stone, Thurmond, Ting, Wagner, Waldron, Weber,  
            Wilk, Williams, Wood, Rendon
           NO VOTE RECORDED: Roger Hernández, Kim








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          Prepared by:Scott Bain / HEALTH / (916) 651-4111
          8/25/16 17:45:11


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