BILL ANALYSIS
AB 1808
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Date of Hearing: April 13, 2010
ASSEMBLY COMMITTEE ON HUMAN SERVICES
Jim Beall Jr., Chair
AB 1808 (Galgiani) - As Amended: April 5, 2010
SUBJECT : Medi-Cal: mental health services
SUMMARY : Shifts responsibility for the provision of mental
health services for foster youth in out-of-county placements
from the jurisdictional county to the host county, and allows
for corresponding adjustments in the payment and administration
of those services. Specifically, this bill :
1) Requires that when a foster child is in an out-of-county
placement:
a) Responsibility for ensuring that the child receives
mental health services shall transfer from the county of
original jurisdiction to the county of residence (host
county);
b) Applicable funding for mental health services is
received by the host county; and,
c) Adjustments in Medi-Cal program administration will be
made to facilitate payment to the host county.
2) Requires the California Child Welfare Council (CWC) and
other stakeholders to document the problems faced by foster
children when seeking mental health services in an
out-of-county placement and to include solutions in a
report to the Legislature by January 1, 2012.
EXISTING LAW
1) Provides children in foster care with categorical
Medi-Cal eligibility.
2) Requires the Department of Mental Health (DMH) to
provide mental health services to Medi-Cal beneficiaries
through contracts with local managed care plans, generally
administered by individual counties. Welfare and
Institutions Code (WIC) Section 5775.
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3) Provides that foster children receive Medi-Cal mental
health services in the county of original placement in the
foster care system. WIC 14684(e), 319.1, 5777(a)(3).
4) Requires DMH, in consultation with the California
Institute of Mental Health, the Child and Family Policy
Institute, the California Mental Health Directors
Association and the California Alliance of Child and Family
Services, to develop and implement a set of standardized
contracts, forms and procedures to facilitate the receipt
of medically necessary mental health services for a foster
child in an out-of-county placement. WIC 5777.7.
5) Under federal law, establishes the Early and Periodic
Screening, Diagnosis, and Treatment (EPSDT) program to
provide medically necessary physical and mental health
services to Medicaid beneficiaries under age 21. 42 U.S.C.
Section 1396(a)(43) & 1396d(r)(5).
6) Requires each local mental health plan to establish a
procedure ensuring access to foster children in
out-of-county placements, as required by the EPSDT program
standards. WIC 5777.6.
7) Defines a "Medi-Cal managed care plan" as any prepaid
health plan or Medi-Cal managed care plan contracting with
the State Department of Health Care Services to provide
services to enrolled Medi-Cal beneficiaries. WIC 5777.5.
8) Requires that, when a foster child is adopted or placed
in a relative guardianship and the court's jurisdiction is
terminated:
a) The child shall be provided medically necessary
specialty mental health services by the local mental health
plan in the child's county of residence;
b) The host county mental health plan shall assume
responsibility for submitting the treatment authorization
request (TAR) to the mental health plan in the county of
origin; and,
c) The county of origin shall retain responsibility for
authorization of services. WIC 11376, WIC 16125.
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9) Requires DMH to collect and keep statistics to allow for
a comparison of access to outpatient specialty mental
health services for foster children placed in their home
county and foster children in out-of-county placements.
WIC 5777.6.
10)Establishes the CWC as an advisory body within the
California Health and Human Services Agency (HHSA) to
improve collaboration and processes among the various
agencies and courts serving children in the child welfare
and foster care systems. WIC 16540.
FISCAL EFFECT : Unknown
COMMENTS :
Rationale: According to the author:
The State Department of Mental Health is the state
agency responsible for administering California's
county-based mental health system. Almost all of
California's 58 counties have a Mental Health Plan
(MHP), in contract with the state. Each MHP, in turn,
contracts with local private service providers (or
uses county mental health staff) to deliver services.
When a foster child is placed out-of-county, his or
her care remains the responsibility of the county of
origin, financially and otherwise. This leads to a
number of problems:
The county of origin rather than the host county
receives state funds for this child. The host county
then has to work with the county of origin to recover
its costs associated with this child. Sometimes, this
can be a slow process and, as a result, the child will
either not receive needed services, or experience a
long delay.
Given the absence of an efficient reimbursement
mechanism between the two counties, this could be a
slow process.
In an effort to assist host counties to be able to
provide mental health services to foster youth placed
from out of the county, AB 1808 will have all funds
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for mental health services for foster youth be
redirected to the host county to provide services,
instead of the county of origin. It also will require
the CA Child Welfare Council, along with other
stakeholders, to compile a report documenting the
problem and report their findings to the Legislature.
By virtue of their history of trauma, abuse and neglect,
children in foster care are more likely to require
effective mental health services. This bill will attempt
to overcome a long history of bureaucratic barriers that
have led to delays and difficulties in the provision of
mental health services to foster children in out-of-county
placements.
Out-of-county placements : Although child welfare agencies
responsible for a child's placement must first seek placement
options in the parent's county of residence, there are a variety
of circumstances under which children are placed in another
county. For example, California's policy priority to place
foster children removed from their homes with relative
caregivers who sometimes reside in another county; cases where
two counties are close in proximity; and children placed in
group homes providing intensive care and supervision. Over 20%
of California's foster children are in out-of-county placements.
Once the child is placed out-of-county, the placing county
maintains jurisdiction, and as such, is still responsible for
managing the child's case plan, and ensuring their health,
educational, and other needs are met. It is the responsibility
of placing counties to detail, when necessary, a mental health
treatment plan for children placed in another county, and to
ensure services are delivered accordingly.
Medi-Cal managed care for mental health : In 1998, California
established a managed care system administered by individual
counties, to contract for the delivery of mental health services
to Medi-Cal beneficiaries. In the more than twenty years since
this policy was enacted, there have been ongoing difficulties
associated with ensuring timely access to needed mental health
services for foster children in out-of-county placements. The
barriers documented over that time have often, but not always,
been administrative, relating to payment and administration of
mental health services across county lines.
Prior reform efforts : The most recent, among various attempts
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to resolve this issue, culminated in the passage of SB 785
(Steinberg), Chapter 469, Statutes of 2007. SB 785 directed DMH
to create standardized contracts, forms, and procedures to
facilitate the receipt of medically necessary specialty mental
health services to foster youth in out-of-county placements and
to require use of the standardized documents and procedures upon
their completion. DMH provided counties with the standard
agreement and forms for the provision of out-of-county services
on May 4, 2009. As such, counties are still in the process of
implementing protocols established by SB 785.
Another provision of SB 785, required adopted children and
children placed with relative guardians, no longer under the
court's jurisdiction, receive mental health services in their
county of residence, and required the host county to submit TARs
to the county of origin.
Administrative problems with the delivery of services and
payment for services to foster children in out-of-county
placements persist, despite the initial reforms put in place by
SB 785.
Child Welfare Council : The CWC was established by the
Legislature under the Child Welfare Leadership and Performance
Accountability Act of 2006 as an advisory body within the
California Health and Human Services Agency (HHSA) to improve
collaboration among the various agencies and courts serving
children in the child welfare and foster care systems. By
statute, the CWC is to be co-chaired by the Chief Justice of the
California Supreme Court or his or her designee, and the
Secretary of the HHSA. Included in its mandate, the CWC is
required to issue reports to the Governor, Legislature, Judicial
Council, and the public, at least annually, covering a variety
of topics, including how to create efficiencies and improve
coordination among agencies serving children receiving child
welfare services. The CWC has already engaged in the issue of
out-of-county mental health services for foster youth, and the
Child Development and Successful Youth Transitions Committee
(CDSYT Committee) even included this issue in its draft
recommendations:
In addition to addressing successful youth
transitions, the Committee is recommending improving
access to mental health services, especially for youth
placed out-of-county. Available research studies show
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that foster children and youth represent an extremely
high-risk population for socio-emotional, behavioral
and psychiatric problems requiring mental health
treatment. While California has made recent strides
to address mental health access with the passage of
the Mental Health Services Act and SB 785, for
example, many foster children and youth do not receive
equal access to the mental health treatment to which
they are entitled and need to succeed in school, at
work or in the community.
The recommendations put forth by the CDSYT Committee
include suggestions that the state extend provisions of SB
785 to ensure all foster youth are provided access to
medically necessary mental health services in the county of
residence.
Suggested amendments:
1)Staff recommends the following clarifying technical amendment,
consistent with existing state and federal law on page 3 line
2:
5777.8. (a) When a child is placed in foster care
outside of the county of original jurisdiction, the
county in which the child is placed shall be
responsible for ensuring that the child receives
medically necessary specialty mental health services,
and any adjustments in the administration of the
Medi-Cal program shall be made, to ensure that the
funding applicable to the mental health services for
that child is received by the new county of residence.
2)As the transfer of responsibility for the provision of mental
health services would occur upon enactment of this bill in
January 1, 2011, a report on the problems associated with the
former delivery and payment system would no longer be
required. The author may wish to receive the report and
recommendations prior to the transferred responsibility by
delaying implementation of those provisions, or change the
nature of the report. For example, the author may wish to
request a report on the outcomes of the new mental health
delivery and payment system to track the effectiveness of this
change.
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3)In addition, the author may wish to describe which
stakeholders should be included in compiling the report and
recommendations.
Other outstanding concerns and questions : There are a number of
other questions with some of the details of this bill that may
need to be further addressed or clarified. Chief among those
concerns the lack of specificity regarding how the transfer of
responsibilities would occur and the possibility for unintended
consequences. For example, if the responsibility for providing
mental health services, and ensuring payment (including county
share-of-cost and costs of administration) is shifted entirely
to the host county, without adequate safeguards, this bill could
create a financial incentive for county placing agencies to
place foster children with greater (higher cost) mental health
needs in another county, thereby increasing the numbers of
children placed out-of-county.
Staff recommends that the author continue to engage and work
with DMH and other stakeholders, including, but not limited to,
county mental health directors, the CWC, the National Center for
Youth Law, the California Institute of Mental Health, the Child
and Family Policy Institute, and the California Alliance of
Child and Family Services to address outstanding fiscal,
procedural and other issues with improving access to medically
necessary mental health services.
Prior and related legislation:
SB 785 (Steinberg) Chapter 469, Statutes of 2007 required DMH to
standardize agreements, forms and procedures, and to require
their use in an effort to facilitate access to specialty mental
health services for foster youth in out-of-county placements.
AB 1689 (Lieber) of 2006 would have required placing counties to
reimburse certified mental health providers for all
preauthorized medically necessary mental health services in
accordance with EPSDT reimbursement procedures, irrespective of
whether a contract was in place between the provider and the
placing county. The bill was held by the Assembly
Appropriations Committee.
SB 745 (Escutia) Chapter 811, Statutes of 2000, requires each
local mental health plan to establish a procedure to ensure
access to outpatient mental health services for any foster
child in an out-of-county placement. The bill also required DMH
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to collect and keep statistics to enable it to compare access to
mental health services by foster children placed in the home
county with that of children in out-of-county placements.
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REGISTERED SUPPORT / OPPOSITION :
Support
None on file.
Opposition
None on file.
Analysis Prepared by : Michelle Doty Cabrera / HUM. S. / (916)
319-2089