BILL ANALYSIS Ó
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