SB 1466, as introduced, Mitchell. Mental health benefits: children: medical necessity.
Existing law provides for the Medi-Cal program, which is administered by the State Department of Health Care Services, under which qualified low-income individuals receive health care services. The Medi-Cal program is, in part, governed and funded by federal Medicaid Program provisions. Existing law provides that a service is “medically necessary” or a “medical necessity,” for purposes of these provisions, when it is reasonable and necessary to protect life, to prevent significant illness or significant disability, or to alleviate severe pain.
This bill would require the department, in partnership with the State Department of Social Services, to convene a stakeholder workgroup to revise and update the existing definition of “medically necessary” and “medical necessity” to be applied specifically with respect to children, youth, and their families for purposes of access to mental health services provided under the Early and Periodic Screening, Diagnosis, and Treatment Program (EPSDT). The bill would require the workgroup to convene by February 1, 2017, and to include representatives of specified organizations, foster youth, and legislative staff. The bill would set forth the information for the department to consider when developing the definition, and would require the department to adopt emergency regulations implementing the revised definitions by October 1, 2017. This bill would require the department to submit to the federal Centers for Medicare and Medicaid Services any state plan amendments or waiver applications necessary to implement those provisions.
Vote: majority. Appropriation: no. Fiscal committee: yes. State-mandated local program: no.
The people of the State of California do enact as follows:
Section 14059.6 is added to the Welfare and
2Institutions Code, to read:
(a) The department, in partnership with the State
4Department of Social Services, shall convene a stakeholder
5workgroup to revise and update the definition of “medically
6necessary” and “medical necessity,” which would be applied
7specifically with respect to children, youth, and their families for
8purposes of access to mental health services provided under the
9Early and Periodic Screening, Diagnosis, and Treatment Program
10(EPSDT). The workgroup shall be convened no later than February
12(b) Stakeholders shall include, but need not be limited to,
13representatives of all of the following:
14(1) The California State Association of Counties.
15(2) The County Behavioral Health Directors Association of
17(3) The County Welfare Directors Association of California.
18(4) The Chief Probation Officers of California.
19(5) Current or former foster youth.
20(6) Legislative staff.
21(7) Any other representatives determined appropriate by the
22department and the State Department of Social Services.
23(c) In developing the definition, the workgroup shall consider
24all of the following:
25(1) Acknowledgment that the current diagnosis system for
26children and youth affected by trauma, including from abuse and
27neglect, does not accurately identify those who need services to
28maintain appropriate functioning in the community, nor prevent
29the onset of mental health needs and is inconsistent with emerging
30research and national practices in meeting the behavioral health
31needs of children and youth.
32(2) Services should promote health, well-being, and independent
33functioning of children and youth so that they may safely remain
P3 1with families, in their own communities, and avoid institutional
2care whenever possible.
3(3) Services should be individualized to meet the child’s or
4youth’s needs, inclusive of the family or adult caregivers,
5regardless of whether the services are described in the state plan.
6(4) The objective of these services should be to improve or
7maintain the health of the child or youth in the best condition
8possible, prevent conditions from worsening or interfering with
9the child’s or youth’s capacity for normal activity, and improve
10or maintain the overall health and well-being of the child or youth.
11(5) Both currently accepted standard clinical practices, as well
12as emerging and promising practices, should be recognized to
13achieve the desired outcomes, and support the delivery of those
14services in community-based settings, without delay, upon the
15initial identification of need. The service delivery system should
16allow for a combination of licensed and paraprofessional staff,
17working in collaborative partnerships.
18(d) The department shall adopt emergency regulations
19implementing the definition developed pursuant to this section no
20later than October 1, 2017. The department may readopt any
21emergency regulation authorized by this section that is the same
22as, or substantially equivalent to, any emergency regulation
23previously adopted pursuant to this section. The initial adoption
24of regulations pursuant to this section and one readoption of
25emergency regulations shall be deemed to be an emergency and
26necessary for the immediate preservation of the public peace,
27health, safety, or general welfare. Initial emergency regulations
28and the one readoption of emergency regulations authorized by
29this section shall be exempt from review by the Office of
30Administrative Law. The initial emergency regulations and the
31one readoption of emergency regulations authorized by this section
32shall be submitted to the Office of Administrative Law for filing
33with the Secretary of State and each shall remain in effect for no
34more than 180 days, by which time final regulations shall be
36(e) The department shall submit to the federal Centers for
37Medicare and Medicaid Services any state plan amendments or
38waiver applications necessary to implement this section.