BILL ANALYSIS �
AB 2212
Page 1
Date of Hearing: April 8, 2014
ASSEMBLY COMMITTEE ON HEALTH
Richard Pan, Chair
AB 2212 (Gray) - As Introduced: February 20, 2014
SUBJECT : Medi-Cal: Early and Periodic Screening, Diagnosis, and
Treatment (EPSDT).
SUMMARY : Requires the California Department of Health Care
Services (DHCS) to allow county mental health plans (MHPs) to
contract with local education agencies (LEAs) as providers of
Medi-Cal EPSDT services to eligible students and, in counties
where the LEA does not have a contract with the county MHP, to
allow the MHP to obtain federal funds on behalf of nonpublic
agencies that contract with LEAs to provide those services, as
specified. Specifically, this bill :
1)Requires DHCS to allow county MHPs to contract with LEAs to
provide EPSDT services to eligible students. EPSDT services
are federally mandated services and benefits offered by
Medi-Cal for children.
2)If the LEA does not have a contract with the county MHP,
requires DHCS to allow the MHP to obtain federal financial
participation for nonpublic agencies under contract with the
LEA to provide EPSDT services.
3)Requires LEAs and nonpublic agencies to be reimbursed for all
eligible EPSDT services they provide, unless precluded by
federal law.
4)Specifies that county MHPs may contract for, and nonpublic
agencies may receive, federal funds for the following
services:
a) Mental health assessments;
b) Targeted case management services;
c) Behavioral services;
d) Mental health, social work, and counseling services;
e) Individual and group services;
f) Crisis intervention;
g) Day treatment;
h) Residential treatment; and,
i) Medication support services.
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5)Requires DHCS to examine methodologies for increasing LEA
participation in the Medi-Cal program so that schools can meet
the educationally related health care needs of their students,
including simplifying the claiming processes for Medi-Cal
billing to the extent possible.
6)Requires DHCS to seek any necessary Medi-Cal state plan or
waiver amendments to implement this bill and to undertake any
and all necessary activities to obtain federal funding for
services provided by LEAs and nonpublic agencies.
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EXISTING LAW :
1)Provides for the Medi-Cal program, administered by DHCS, under
which eligible low-income individuals receive health care
services subject to state and federal laws and funding.
2)Establishes the Medi-Cal EPSDT program for eligible
individuals under 21 years pursuant to state and federal law.
3)Defines LEAs as a school district, a county office of
education, a nonprofit charter school participating as a
member of a special education local plan area, or a special
education local plan area and allows LEAs to provide and bill
for Medi-Cal services provided to students receiving special
education services on Medi-Cal (generally, special education
students).
4)Establishes, under the terms of a federal Medicaid waiver, a
managed care program providing Medi-Cal specialty mental
health services for eligible low-income persons administered
through local county MHPs under contract with the state.
FISCAL EFFECT : This bill has not been analyzed by a fiscal
committee.
COMMENTS :
1)PURPOSE OF THIS BILL . According to the author, this bill is
needed to assure that the families who are entitled to EPSDT
services have the option to contract with a school
district/LEA to provide these critical services. The author
argues that there is currently no state policy or direction on
how an LEA can seek direct access to EPSDT mental health
funding but instead each LEA or Special Education Local Plan
Area (SELPA) must negotiate separately with each county MHP in
order to be able to provide and be reimbursed for EPSDT mental
health services for eligible students. Each MHP determines
locally whether they want the LEA or SELPA to be vendorized or
certified to provide and bill Medi-Cal for these services.
The author contends that in 2011 the state shifted 100% of the
service responsibility for the mental health special education
needs of children, but left responsibility for EPSDT services
with counties, and did not provide schools access to the EPSDT
funding. The author states this bill is necessary to allow
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LEAs to seek reimbursement directly from the EPSDT program
which previously were a source of services and funding for
eligible students with the mental health service needs.
2)BACKGROUND .
a) County Mental Health Plans. In California, 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 though 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 (CPEs), 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 just approved by the Centers for Medicare and
Medicaid Services for a new two-year term, from July 1,
2013, through June 30, 2015.
b) AB 3632 Mental Health Services. Under federal law,
disabled children are guaranteed the right to a free,
appropriate public education, including necessary services
for a child to benefit from his or her education. Between
1976 and 1984, to meet this federal mandate, California
schools provided mental health services to special
education students who needed the services pursuant to an
Individualized Education Plan (IEP). In 1984, AB 3632 (W.
Brown), Chapter 1747, Statutes of 1984, assigned the
responsibility for providing these services to county
mental health departments. Under AB 3632, county
departments of mental health were responsible for providing
services such as case management, counseling, medication
management, residential placement, and sometimes
out-of-state residential placement. Counties administered
the AB 3632 services program until 2011.
During the years counties administered AB 3632 services, the
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state provided general funds to support the program but
significant unreimbursed county mandate claims accrued,
according to the Legislative Analyst's Office (LAO),
reaching more than $250 million in 2010. Multiple state
budgets suspended payments of the mandate claims and the
program was the subject of lawsuits. The 2011-12 Budget
repealed the AB 3632 mandate on counties, required schools
to provide mental health services in a student's IEP and
provided additional special education funding to the
schools for this purpose. One rationale for doing so,
according to the LAO at the time, was to reorient the
program to providing the services students need to be
successful in school and to more closely link the schools
to the services provided.
c) EPSDT. 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;
viii) Crisis intervention/stabilization; and
ix) Targeted case management; therapeutic behavioral
services.
3)SUPPORT . According to the author, this bill is sponsored by
the Special Opportunities for Access and Reform Coalition
which includes the SSELPAs of Merced, Napa, Solano, Sutter and
Yolo counties. The sponsors point out that research shows
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that early identification, intervention, and treatment can
minimize the long-term disability of mental disordersand are
essential to recovery and resiliency for children and
adolescents who are suffering with mental illness. Access to
the EPSDT program in school settings provides this opportunity
for some of the state's most at-risk students. SELPA
administrators write in support of this bill stating that it
will allow LEAs to access EPSDT funds directly. They argue
that prior to the shift of responsibility for mental health
services to special education students from the counties to
the schools only a few LEAs applied and became vendors with
county MHPs. They add that since the transfer this has gotten
more difficult and is entirely at the discretion of the county
MHPs. According to the Merced County Superintendent of
Schools in support of this bill, it would give LEAs access to
critical federal funds to serve the mental health needs of
school age children and adolescents.
Disability Rights California (DRC) would support this bill if
it were amended to require that contracts between LEAs and
county MHPs include a detailed plan for the services. DRC
states that this bill is a step in the right direction but
would like to see clarification of the services that must be
provided by LEAs, including a required plan that specifically
provides for intensive home and community-based services if
students need them.
4)OPPOSITION . California Mental Health Directors Association
(CMHDA) opposes this bill and states there is currently no
prohibition on county MHPs entering into the type of
relationship that this bill seeks to mandate. According to
CMHDA, the reason for such agreements not being in place is a
function of local constraints and opportunities that will not
disappear because of a new mandate. CMHDA further argues this
bill restricts local control and could result in funds being
spent in ways that are not as effective as when EPSDT services
are administered locally.
5)PREVIOUS LEGISLATION . AB 114 (Committee on Budget), Chapter
43, Statutes of 2011, a companion measure to the 2011-12
Budget bill, relieved county mental health departments of the
responsibility to provide mental health services to students
with disabilities (AB 3632 program) and transferred that
responsibility to school districts.
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6)POLICY COMMENTS .
a) Permissive or mandate. According to the author and
sponsors of this bill, it would allow LEAs direct access to
EPSDT mental health services funding and reimbursement.
However, the provisions of this bill may not fully
accomplish the author's stated intent. For example, this
bill requires DHCS to allow counties to contract with LEAs
which is an option already available. County MHPs can
directly provide or contract with community-based and local
providers, including LEAs, to provide the services for
which the MHPs are responsible. Some counties do contract
with LEAs and some do not. It also requires DHCS to allow
LEAs without a county MHP contract to obtain federal
Medi-Cal funds for entities under contract with the state.
If the intent of this bill is to require county MHPs to
contract with LEAs, or to require DHCS to allow LEAs
without a county MHP contract to bill directly for EPSDT
mental health services, this bill as drafted does not
accomplish that.
b) Specialty mental health waiver. This bill requires DHCS
to seek any and all federal waivers and amendments and
pursue activities to ensure federal funds are available for
LEAs and nonpublic agencies under contract with LEAs.
Typically, federal Medicaid waivers are based on complex
funding formulas and federal requirements. This bill would
require DHCS to re-negotiate the terms of the existing
specialty mental health waiver. It is not clear whether
the state could secure a revised waiver allowing LEAs to
directly bill for EPSDT mental health services outside of
the county MHP structure.
c) Medicaid match. Counties currently provide the funds
for the state's 50% Medicaid match for mental health
services based on CPEs, using a variety of county funding
sources including realignment, Mental Health Services Act
funds and other county funds. This bill does not specify
whether counties would continue to be responsible for the
federal match, whether LEAs would provide the match or
whether the match would come from state general funds or
other sources. This should be clarified.
d) Managed Care Precedent. California's county MHPs
operate a managed care delivery system for specialty mental
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health services and serve under the terms of the federal
waiver as public prepaid health plans. Managed care
delivery systems are now the predominant model in the
state's Medi-Cal program generally. As the author and
sponsors describe the intent of this bill it would allow
LEAs who are unable or unwilling to contract with county
MHPs to still directly access reimbursement for EPSDT
mental health services. Permitting LEAs to do so could set
a precedent for allowing providers to bypass county mental
health and other Medi-Cal managed care delivery systems.
e) Utilization management. This bill requires LEAs and
contracting non-public agencies to be reimbursed for all
eligible EPSDT services provided unless precluded by
federal law. Typically, in managed care systems, services
are subject to utilization review and management to ensure
that the services are medically necessary and appropriate.
This bill does not specify whether EPSDT services provided
by LEAs would be subject to review or what entity would
have the responsibility to conduct the review, particularly
if the services are provided without county MHP management
under the terms of contracts with LEAs.
REGISTERED SUPPORT / OPPOSITION :
Support
California Medical Association
Merced County Superintendent of Schools
SELPA Administrators of California
Opposition
California Mental Health Directors Association of California
Analysis Prepared by : Deborah Kelch / HEALTH / (916) 319-2097