BILL ANALYSIS Ó SENATE COMMITTEE ON HEALTH Senator Ed Hernandez, O.D., Chair BILL NO: SB 1466 --------------------------------------------------------------- |AUTHOR: |Mitchell | |---------------+-----------------------------------------------| |VERSION: |March 28, 2016 | --------------------------------------------------------------- --------------------------------------------------------------- |HEARING DATE: |April 6, 2016 | | | --------------------------------------------------------------- --------------------------------------------------------------- |CONSULTANT: |Scott Bain | --------------------------------------------------------------- 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 SB 1466 (Mitchell) Page 5 of ? 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 SB 1466 (Mitchell) Page 6 of ? 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. SB 1466 (Mitchell) Page 7 of ? 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 -- END --