BILL ANALYSIS                                                                                                                                                                                                    



                                                                    SB 1466


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          Date of Hearing:  June 14, 2016


                            ASSEMBLY COMMITTEE ON HEALTH


                                   Jim Wood, Chair


          SB  
          1466 (Mitchell) - As Amended May 31, 2016


          SENATE VOTE:  39-0


          SUBJECT:  Early and Periodic Screening, Diagnosis, and Treatment  
          Program:  trauma screening.


          SUMMARY:  Requires that screening services provided under the  
          Early and Periodic Screening, Diagnosis, and Treatment (EPSDT)  
          Program include screening for trauma and establishes that  
          eligible Medi-Cal children who are found to have experienced  
          trauma and have been abused, neglected, or removed from the home  
          to be referred to county mental health plans (MHPs) for  
          assessment for specialty mental health services.  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.





          EXISTING FEDERAL LAW:  Places responsibility for caring for a  
          child who has been removed from home and placed in foster care  








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          with the state and any public agency which is administering the  
          foster care plan with the state.


          EXISTING STATE 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 less than 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 MHPs 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.









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          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.

          5)Establishes the MHSA, enacted by voters in 2004 by Proposition  
            63, to provide funds to counties to expand services, develop  
            innovative programs, and integrated service plans for mentally  
            ill children, adults, and seniors through a 1% income tax on  
            personal income above $1 million.

          FISCAL EFFECT:  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).  By specifically requiring screening  
            for trauma, this bill is likely to increase the costs to  
            provide screening services due to additional time spent by  
            providers with eligible children. 


          2)Increased costs of $5 million to $10 million per year to  
            provide assessments for specialty mental health services by  
            county MHPs (GF and federal funds).  This 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 state.  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  
            this bill, about 6.5 million children are likely to get  








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            additional screening for trauma.  It is likely that the  
            requirement for additional screening in this bill will result  
            in a significant number of children being referred for  
            specialty mental health services who are not currently  
            receiving those services.


          4)Unknown potential future costs savings for Medi-Cal services  
            (GF, federal funds, local funds).  Under this 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). 


          COMMENTS:


          1)PURPOSE OF THIS BILL.  According to the author, 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.  This bill is needed to  
            ensure that distressed children are appropriately screened for  
            trauma without delay.  Under California law, the treatment of  
            children's mental health needs is determined by the severity  
            of the diagnosis.  Because we do not currently screen under  
            EPSTD for trauma, we run the risk of delaying treatment to  
            this vulnerable population because of this complicated  
            delivery model.  By requiring trauma screening by a designated  
            agency on the front-end, we minimize possible delays in  
            critically-needed treatment.


          2)BACKGROUND.  








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             a)   ESPDT.  EPSDT is a Medi-Cal benefit for individuals  
               under the age of 21 who have full-scope Medi-Cal  
               eligibility.  This benefit allows for periodic screenings  
               to determine health care needs and based upon the  
               identified health care need and diagnosis, treatment  
               services are provided.  EPSDT services include all services  
               otherwise covered by Medi-Cal and EPSDT beneficiaries can  
               receive additional medically necessary services. EPSDT  
               mental health services are Medi-Cal services that correct  
               or improve mental health problems that have been determined  
               by a physician, psychologist, counselor, social worker, or  
               other health or social services provider.  EPSDT provides  
               eligible children access to a range of mental health  
               services that include, but are not limited to:



                 i)       Mental health assessment;
                 ii)      Collateral contracts;


                 iii)     Therapy; 


                 iv)      Rehabilitation;


                 v)       Mental health services; 


                 vi)      Medication support services; 


                 vii)     Day rehabilitation; day treatment intensive; 








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                 viii)    Crisis intervention/stabilization;


                 ix)      Targeted case management; and,


                 x)       Therapeutic behavioral services. 





             a)   Section 1915(b) Medi-Cal Specialty Mental Health  
               Services Waiver.  Specialty Medi-Cal mental health services  
               are provided under the terms of the federal  
               Medicaid/Medi-Cal Specialty Mental Health Services  
               Consolidation 1915(b) waiver program.  The waiver  
               established a managed care program for specialty mental  
               health services separate from the overall Medi-Cal program.  
                Medi-Cal beneficiaries must receive specialty mental  
               health services through county-operated MHPs.  County MHPs  
               provide services directly or through contracts in the local  
               community using a combination of county funds, realignment  
               revenues, and Mental Health Services Act funds.  Counties  
               pay for services locally, incurring Certified Public  
               Expenditures, which the state then uses as the state match  
               to claim federal Medicaid reimbursement and the state, in  
               turn, returns the federal funds to the county MHPs.  The  
               Medi-Cal Specialty Mental Health Services Consolidation  
               waiver has been in place since the mid-1990s and was  
               approved for a new five-year term, from July 1, 2015,  
               through June 30, 2020.  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 or 4.4%, received specialty  
               mental health services.  The count of children and youth  
               with five or more specialty mental health visits was  








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               201,192 or  3.3%.  The average per beneficiary expenditure  
               for approved services in 2013-14 was $6,092.
               
             b)   Federal Guidance.  A 2013 letter from the U.S.  
               Department of Health and Human Services encouraged state  
               social services and Medicaid directors to use  
               trauma-focused screening, assessments, and evidence-based  
               practices.  "Complex trauma is a common yet serious concern  
               for children, especially those referred to child welfare  
               services.  Rates of trauma exposure are approximately 90%  
               among children in foster care," said the letter, which was  
               signed by the directors of three key federal agencies.  The  
               letter drew a link between high rates of untreated, complex  
               trauma and high prescribing rates of psychotropic  
               medications for foster youth.

               "These high rates of trauma have far-reaching consequences.  
                The term "complex trauma" describes children's exposure to  
               multiple or prolonged traumatic events, which are often  
               invasive and interpersonal in nature.  Complex trauma  
               exposure involves the simultaneous or sequential occurrence  
               of child maltreatment, including psychological  
               maltreatment, neglect, exposure to violence and physical  
               and sexual abuse.
               
             c)   Class Action Lawsuit.  In 2002, plaintiffs filed a class  
               action lawsuit, Katie A. vs Bonta 2.02-cv-5662 (C.D. Cal.),  
               alleging violations of federal Medicaid laws, and the  
               American with Disabilities Act.  The suit sought to improve  
               the provision of mental health and supportive services for  
               children and youth in, or at imminent risk of placement in,  
               foster care in California.  Katie A. entered foster care at  
               age four, received a mental health assessment at age five,  
               and, by age 14, had been assigned 37 foster care  
               placements, 19 psychiatric institution placements, and  
               seven stays in children's shelters. 

               The Katie A. lawsuit alleged a failure to properly assess  
               her mental health needs, a failure to provide adequate  








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               mental health treatment and an overuse of congregate and  
               shelter care.  A subsequent settlement requires children in  
               foster care, who are being considered for high-level group  
               care, inpatient psychiatric care or other intensive  
               treatments, as specified, to be eligible for EPSDT  
               services.  The state subsequently developed a series of  
               intensive mental health services for such children, a  
               manual for care coordination between state and local mental  
               health and child welfare providers, and a program of  
               therapeutic foster care. 
               
          3)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 argues  
            that 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) states that it serves, in conjunction with its  
            partners in the County Probation Department, over 300 foster  
            children who have experienced abuse or neglect that span 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  








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            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.
          4)RELATED LEGISLATION.  SB 1291 (Beall) requires each county MHP  
            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 MHP review to be  
            conducted annually by an external quality review organization  
            that includes specific data for Medi-Cal eligible children and  
            youth under the jurisdiction of the juvenile court and their  
            families.  SB 1291 is pending in this Committee.


          5)PREVIOUS 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.


          6)DOUBLE REFERRAL. This bill is double-referred and upon passage  
            will be referred to the Committee on Human Services. 

          REGISTERED SUPPORT / OPPOSITION:




          Support










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          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










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          Youth Law Center




          Opposition


          None on file.




          Analysis Prepared by:Paula Villescaz / HEALTH / (916)  
          319-2097