BILL ANALYSIS                                                                                                                                                                                                    






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          |SENATE RULES COMMITTEE            |                       SB 1466|
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                                   THIRD READING 


          Bill No:  SB 1466
          Author:   Mitchell (D) 
          Amended:  5/31/16  
          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
           
           SUBJECT:   Early and Periodic Screening, Diagnosis, and  
                     Treatment Program:  trauma screening


          SOURCE:    Californians for Safety and Justice
                     Youth Law Center
          
          DIGEST:  This bill requires screening services provided under  
          the Early and Periodic Screening, Diagnosis, and Treatment  
          Program (EPSDT) to include screening for trauma, as defined, at  
          all screenings. Requires a child who is removed from the custody  
          or care of his or her parent or legal guardian to be assessed by  
          the county mental health plan for specialty mental health  
          services.

          ANALYSIS:  

          Existing law:








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          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  
               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, consistent with federal law, screening services  







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            provided under the EPSDT benefit to include screening for  
            trauma at all screenings.

          2)Defines "trauma," as any physiological response to 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 functional and mental, physical, social,  
            emotional, or spiritual well-being.

          3)Requires a child who is removed from the custody or care of  
            his or her parent or legal guardian pursuant to specified  
            provisions of existing law to be assessed by the county mental  
            health plan for specialty mental health services.


          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  
            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  
            requires that existing screenings under EPSDT to include a  
            trauma screen. Additionally, this bill 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  







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            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  
            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  







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            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.


          FISCAL EFFECT:   Appropriation:    No          Fiscal  
          Com.:YesLocal:   No


          According to the Senate Appropriations Committee:






            
          1)Increased costs in the low millions per year for additional  
            screening provided to Medi-Cal eligible children (General Fund  
            [GF] and federal funds). Under current federal and state law,  
            children enrolled in Medi-Cal are eligible for the Early and  
            Periodic Screening, Diagnosis, and Treatment (EPSDT) benefit.  
            This benefit covers screening for both physical and mental  
            health issues. By specifically requiring screening for trauma,  
            the bill is likely to increase the costs to provide screening  
            services due to additional time spent by providers with  
            eligible children. It is not clear to what extent children are  
            already being screened for trauma. It is likely that the  
            specific requirement in the bill will lead to increased focus  
            on trauma during screening. For example, if the cost to  







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            provide trauma screening increased the overall cost of  
            screening under EPSDT by 5%, the cost would be about $2  
            million per year.

          2)Increased costs of $5 million to $10 million per year to  
            provide assessments for specialty mental health services by  
            county mental health plans (GF and federal funds). The bill  
            would require all children who have been removed from the home  
            to be assessed by a county mental health plan for specialty  
            mental health services. There are about 15,000 new foster care  
            placements per year in the stat. The cost to provide an  
            assessment for specialty mental health services is around  
            $500. 

          3)Likely increase in specialty mental health services in the  
            hundreds of millions per year (GF and federal funds). Under  
            the bill, about 6.5 million children are likely to get  
            additional screening for trauma. Currently, there is a very  
            low rate of utilization of specialty mental health services by  
            Medi-Cal eligible children. It is likely that the requirement  
            for additional screening in the bill will result in a  
            significant number of children receiving being referred for  
            specialty mental health services who are not currently  
            receiving those services. Currently, 4.4% of children receive  
            specialty mental health services, at an average annual costs  
            of $6,000. If 5% of the children who are likely to be found to  
            have experienced trauma under the bill are subsequently found  
            to be eligible for specialty mental health services, the cost  
            would be about $500 million per year.

          4)Unknown potential future costs savings for Medi-Cal services  
            (GF, federal funds, local funds). Under the bill, it is likely  
            that a significant number of Medi-Cal children will be  
            determined to have experienced trauma and are in need of  
            mental health services - over and above those who are  
            currently being identified. By identifying those children, it  
            is possible that early mental health interventions could  
            improve those children's long-term prognoses and reduce future  
            costs, such as psychiatric hospitalizations and other health  
            care costs associated with trauma (for example health care  
            services related to alcohol or substance abuse). The extent to  
            which those would occur is unknown.









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          SUPPORT:   (Verified5/31/16)


          Californians for Safety and Justice (co-source)
          Youth Law Center (co-source)
          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


          OPPOSITION:   (Verified5/31/16)


          None received

          ARGUMENTS IN 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  







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          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 trauma and  
          ultimately suffer the cumulative effects of untreated trauma as  
          they transition to adulthood. 

          Prepared by:Scott Bain / HEALTH / (916) 651-4111
          5/31/16 20:45:30


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