BILL ANALYSIS Ó
SENATE COMMITTEE ON HEALTH
Senator Ed Hernandez, O.D., Chair
BILL NO: SB 1466
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|AUTHOR: |Mitchell |
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|VERSION: |March 28, 2016 |
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|HEARING DATE: |April 6, 2016 | | |
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|CONSULTANT: |Scott Bain |
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SUBJECT : Mental health benefits: children: medical necessity
SUMMARY : Requires screening services provided under the Early and
Periodic Screening, Diagnosis, and Treatment Program (EPSDT) to
include screening for trauma. Requires child abuse and neglect
or removal from the parent or legal guardian by a child welfare
agency to be prima facie evidence (a fact presumed to be true
unless it is disproved) of trauma for purposes of conducting a
screening consistent with the requirement to screen for trauma
under EPSDT.
Existing law:
1)Establishes the Medi-Cal program, administered by the
Department of Health Care Services (DHCS), under which
qualified low-income individuals receive health care services.
2)Establishes a schedule of benefits under the Medi-Cal program,
which includes EPSDT for any individual under 21 years of age,
consistent with federal Medicaid requirements. Defines,
through regulation, "screening services" for purposes of EPSDT
to mean:
a) An initial, periodic, or additional health assessment
of a Medi-Cal eligible individual under 21 years of age
provided in accordance with the requirements of the Child
Health and Disability Prevention (CHDP) program;
b) A health assessment, examination, or evaluation of a
Medi-Cal eligible individual under 21 years of age by a
licensed health care professional acting within his or her
scope of practice, at intervals other than the CHDP
intervals, to determine the existence of physical or
mental illnesses or conditions; or
c) Any other encounter with a licensed health care
SB 1466 (Mitchell) Page 2 of ?
professional that results in the determination of the
existence of a suspected illness or condition or a change
or complication in a condition for a Medi-Cal eligible
person under 21 years of age.
3)Requires mental health plans 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, in collaboration with the California Health and
Human Services Agency, and in consultation with the Mental
Health Services Oversight and Accountability Commission, to
create a plan for a performance outcome system for EPSDT
mental health services provided to eligible Medi-Cal
beneficiaries under the age of 21
This bill:
1)Requires screening services provided under the EPSDT Program
to include screening for trauma.
2)Requires child abuse and neglect or removal from the parent or
legal guardian by a child welfare agency to be prima facie
evidence (a fact presumed to be true unless it is disproved)
of trauma for purposes of conducting a screening consistent
with the requirement to screen for trauma under EPSDT
established under 1) above.
FISCAL
EFFECT : This bill has not been analyzed by a fiscal committee.
COMMENTS :
1)Author's statement. According to the author, adverse
childhood experiences (ACEs) are potentially traumatic events
that can have negative, lasting effects on health and
well-being. These experiences range from physical, emotional,
or sexual abuse to parental divorce or the incarceration of a
parent or guardian. A growing body of research has sought to
quantify the prevalence of adverse childhood experiences and
illuminate their connection with negative behavioral and
health outcomes, such as obesity, alcoholism, and depression,
later in life.
Children in foster care have suffered from abuse, neglect or
SB 1466 (Mitchell) Page 3 of ?
exploitation, and have suffered secondary trauma as a result
of being removed from their parents. Research clearly shows
that nearly all children associated with Child Welfare systems
have an underlying condition of complex trauma as a result of
an adverse childhood experience. At a minimum this underlying
condition contributes to the poor outcomes - social,
educational and health - for foster children. This bill would
require that existing screenings under EPSDT to include a
trauma screen. Additionally, the legislation includes child
abuse and neglect and removal from the home by a child welfare
agency as evidence of trauma.
2)EPSDT. The EPSDT benefit provides comprehensive screening,
diagnostic, treatment, and preventive health care services for
children under age 21 who are enrolled in Medi-Cal, and is key
to ensuring that children who are eligible for EPSDT services
receive appropriate preventive, dental, mental health,
developmental, and specialty services. Federal Medicaid law
defines the EPSDT benefit to include a comprehensive array of
preventive, diagnostic, and treatment services for low-income
children under age 21. States are required to provide coverage
of any services listed in a section of the federal Medicaid
Act to children who are eligible for EPSDT services when the
services are determined to be medically necessary to correct
or ameliorate any physical or behavioral conditions. The EPSDT
benefit is more robust than the Medi-Cal benefit package
provided to adults and is designed to ensure that eligible
children receive early detection and preventive care in
addition to medically necessary treatment services, so that
health problems are averted or diagnosed and treated as early
as possible.
Medi-Cal managed care plans are required to cover and ensure
the provision of screening, preventive, and medically
necessary diagnostic and treatment services for individuals
under the age of 21 (including EPSDT), except certain services
are "carved out" of the plan. For individuals enrolled in
Medi-Cal managed care, the Medi-Cal managed care is
responsible for "mild to moderate" mental health coverage,
while more severe mental health conditions are "carved out"
and are the responsibility of the county specialty mental
health plan (MHP).
3)Specialty mental health "carve out." The Medi-Cal Specialty
Mental Health Services Program is "carved-out" of the broader
SB 1466 (Mitchell) Page 4 of ?
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 an 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 a 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
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 EPSDT
benefit, which is available to full-scope beneficiaries under
age 21.
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 received
specialty mental health services, for a penetration rate of
4.4%. The count of children and youth with 5 or more specialty
mental health visits was 201,192, for a penetration rate of
3.3%. The average per beneficiary expenditure for approved
services in 2013-14 was $6,092.
4)Double referral. This bill has been double referred. Should it
pass out of this committee, this bill will be re-referred to
the Senate Human Services Committee.
5)Related legislation. SB 1291 (Beall) requires each county
mental health plan to submit an annual foster care mental
health service plan to DHCS detailing the service array, from
prevention to crisis services, available to Medi-Cal eligible
children and youth under the jurisdiction of the juvenile
court and their families. In addition, SB 1291 requires a
mental health plan review to be conducted annually by an
external quality review organization (EQRO) that includes
specific data for Medi-Cal eligible children and youth under
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the jurisdiction of the juvenile court and their families. SB
1291 is scheduled to be heard in the Senate Health Committee
on April 6, 2016.
6)Prior legislation. SB 1009 (Committee on Budget and Fiscal
Review, Chapter 34, Statutes of 2012), requires DHCS, in
collaboration with the California Health and Human Services
Agency, and in consultation with the Mental Health Services
Oversight and Accountability Commission and a stakeholder
advisory committee to develop a plan for a performance
outcomes system for EPSDT specialty mental health services
provided to eligible Medi-Cal beneficiaries under the age of
21. The purpose of the system is to improve beneficiary
outcomes and inform decisions regarding the purchase of
services.
7)Support. Californians for Safety and Justice (CSJ) writes in
support that this bill ensures that medical professionals
conducting already mandated health screenings look for signs
of trauma to ensure that children who have suffered trauma
receive the care they need - care they are legally entitled to
receive. In light of the overwhelming evidence confirming the
traumatic nature of child abuse and neglect and the secondary
trauma of removal from one's home - this measure unambiguously
establishes that foster children have suffered trauma and
should be assessed for appropriate EPSDT services. CSJ states
the State has the legal and moral obligation to act as the
parent of all children in the child welfare system, and this
bill is consistent with long-standing policies that ensure
children in the child welfare system receive the best possible
care that will help them thrive as adults.
The San Luis Obispo County Department of Social Services
(SLOCDSS) writes in support that it serves, in conjunction
with its partners in the County Probation Department, over 300
foster children who have experienced abuse or neglect that
spans the spectrum of severity. SLOCDSS states it has
encountered difficulties in ensuring that these children
receive the therapeutic services they need, as mental health
providers debate with one another over the relative severity
of the trauma these children have endured. Too often, these
children-especially those who suffered secondary trauma as a
result of being removed from their caregivers-are shuffled
back and forth between unresponsive systems of care, are
denied the therapy they need to heal from the impacts of
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trauma and ultimately suffer the cumulative effects of
untreated trauma as they transition to adulthood.
8)Policy issues.
a) Definition of "trauma." This bill requires screening
services provided under the EPSDT Program to include
screening for trauma but does not define the term. The
sponsor has proposed the following definition of trauma:
Trauma, as used in this subsection is defined as any
physiological response an event, series of events, or set
of circumstances that is experienced by an individual as
physically or emotionally harmful or life threatening and
that has lasting adverse effects on the individual's
functioning and mental, physical, social, emotional, or
spiritual well-being.
b) Payment responsibility for mental health services. In
background material on this bill, the author indicates
situations have arisen where foster children have
experienced significant delays in receiving mental health
treatment while the county MHP and the Medi-Cal managed
care plan decide which system should be responsible for
treatment. The author argues state law and regulations do
not provide a clear definition of services and therefore it
is not always clear which agency needs to provide what
services, and this results in foster children suffering
from some of the most severe forms of trauma and not
receiving the care they need.
Under state law, Medi-Cal managed care plans are required
to provide mental health benefits covered in the state plan
excluding those benefits provided by county mental health
plans under the Specialty Mental Health Services Waiver.
The state's Medi-Cal Specialty Mental Health waiver states
county mental health plans are not responsible for the
screening function of EPSDT. Under the waiver, county
mental health plans may perform the diagnosis function
through assessments of beneficiaries requesting services.
Mental health plans are responsible only for arranging for
or providing "corrective treatment" identified by a
screening and referral, or by the mental health plan's own
assessment process.
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While adding "trauma" to the existing EPSDT screening
requirement could make it more likely that children are
screened for trauma, this bill would not resolve the issue
identified by the author over the current division of
payment responsibility between the Medi-Cal managed care
plan and the county specialty MHP.
SUPPORT AND OPPOSITION :
Support: Californians for Safety and Justice (co-sponsor)
Youth Law Center (co-sponsor)
Advokids
Alliance for Children's Rights
California Alliance of Child and Family Services
California Pan-Ethnic Health Network
Children Now
County Welfare Directors Association of California
Fight Crime Invest in Kids California
Futures Without Violence
National Health Law Program
San Luis Obispo County Department of Social Services
Western Center on Law and Poverty
Youth Law Center
Oppose: None received
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