BILL ANALYSIS                                                                                                                                                                                                    



          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  







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                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  








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            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  








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            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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