BILL ANALYSIS �
SENATE COMMITTEE ON HEALTH
Senator Ed Hernandez, O.D., Chair
BILL NO: SB 1045
AUTHOR: Beall
AMENDED: March 28, 2014
HEARING DATE: May 7, 2014
CONSULTANT: Diaz
SUBJECT : Medi-Cal Drug Treatment Program: group outpatient drug
free services.
SUMMARY : For the purposes of Drug Medi-Cal reimbursement,
changes the number from a minimum of 4 and a maximum of 10
individuals to a minimum of 2 and a maximum of 14 allowed in a
group for outpatient drug free services. Requires at least one
individual in the group to be a Medi-Cal-eligible beneficiary.
Existing 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.Allows DHCS to enter into Drug Medi-Cal (DMC) Treatment
Program contracts with each county for the provision of
alcohol and drug use services within the county service area.
3.Requires DHCS to contract for DMC services in a county that
does not enter into or terminates its DMC contract with DHCS
to ensure beneficiary access to alcohol and drug use services.
Requires contracts be made in accordance with federal Medicaid
and state Medi-Cal laws and in accordance with the federal
court order and any future action in the case of Sobky v.
Smoley (E.D.Cal 1994) 855 F.Supp. 1123.
4.Requires a group for outpatient drug free services and
narcotic treatment programs to consist of a minimum of 4 and a
maximum of 10 individuals, of which at least one must be a
Medi-Cal-eligible beneficiary.
5.Defines "group counseling" for DMC substance use disorder
(SUD) services as face-to-face contacts in which one or more
therapists or counselors treat two or more clients at the same
time and focus on the needs of the individuals served.
This bill: For the purposes of DMC reimbursement, changes the
Continued---
SB 1045 | Page 2
number from a minimum of 4 and a maximum of 10 individuals to a
minimum of 2 and a maximum of 14 allowed in a group for
outpatient drug free services. Requires at least one individual
in the group to be a Medi-Cal-eligible beneficiary.
FISCAL EFFECT : This bill is keyed non-fiscal.
COMMENTS :
1.Author's statement. According to the author, even though DMC
treatment services have been expanded, many counties find it
difficult to offer these benefits due to state-only
restrictions, such as the limitation on group size for
outpatient treatment (counseling services). Current state law
specifies that outpatient counseling groups must have between
four and 10 participants in order for the program to bill for
and receive Medi-Cal reimbursement.
This restriction poses a problem for both small and large
population counties. Small-population rural counties, in which
program participants may have to travel long distances to
attend group counseling sessions, often have trouble getting
four or more people together for a group, but if they have
less than four participants, they cannot receive Medi-Cal
reimbursement for that counseling session. Large-population
counties have the opposite problem. When more than 10 people
show up for a group session, a common occurrence, some
participants may have to be excluded, otherwise the county
cannot bill Medi-Cal for any of the services provided to the
Medi-Cal-eligible participants. Thus, the group size
restriction presents a significant barrier to effective
treatment.
2.Background. According to the National Institute on Drug
Abuse's (NIDA) Principles of Drug Addiction Treatment, Third
Edition (revised December 2012), because addiction is a
disease, most people cannot simply stop using drugs for a few
days and be cured. Patients typically require long-term or
repeated episodes of care to achieve the ultimate goal of
sustained abstinence and recovery of their lives. NIDA also
states that potential patients can be lost if treatment is not
immediately available or readily accessible, and as with other
chronic diseases, the earlier treatment is offered in the
disease process, the greater the likelihood of positive
outcomes. NIDA states that in 2011, 21.6 million people aged
12 or older needed treatment for an illicit drug or alcohol
use problem, but only 2.3 million received treatment at a
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specialty substance abuse facility. NIDA states that substance
abuse costs the nation over $600 billion annually, and
treatment is much less expensive than its alternatives, such
as incarcerating addicted people.
3.DMC. According to DHCS, the DMC program provides SUD treatment
services to Medi-Cal beneficiaries. Funding for the program
was realigned to the counties as part of the 2011 Public
Safety Realignment, but the delivery system remained
unchanged. DHCS certifies and monitors DMC treatment providers
to ensure adherence to Title 9 and Title 22, California Code
of Regulations (CCR), which govern DMC treatment. DMC SUD
services include narcotic treatment programs, outpatient drug
free treatment, day care habilitative, perinatal residential
SUD, and naltrexone treatment. Title 22, CCR, defines group
counseling as face-to-face contacts in which one or more
therapists or counselors treat two or more clients at the same
time, focusing on the needs of the individuals served.
However, for outpatient drug free treatment services and
narcotic treatment programs, group counseling is required to
be conducted with no less than 4 and no more than 10
individuals at the same time, of which only one individual
needs to be a Medi-Cal-eligible beneficiary
4.Group modality and size. According to a 2002 publication,
Motivational Groups for Community Substance Abuse Programs, by
the Mid-Atlantic Addiction Technology Transfer Center (MAATTC)
with funding from the federal Substance Abuse and Mental
Health Services Administration (SAMHSA), a group approach to
therapy can be a powerful vehicle for providing clients
support, modeling, and relief from a sense of isolation. The
group environment can enhance most clients' willingness to
thoroughly examine their life situations and substance use,
and reduce their hesitation for considering new ways of being.
The MAATTC states that in some localities group treatment may
be the primary service an agency can afford to provide for
most clients. MAATTC also states the ideal size for a group
may be between six and twelve individuals; however, if a group
size exceeds that range, the leaders of the group might
consider increasing the length of the group session. SAMHSA's
Center for Substance Abuse Treatment's Treatment Improvement
Protocols No. 47 from 2006 states that the optimal size of a
group in most intensive outpatient treatment programs is
between 8 and 15 individuals. According to SUD providers in
the state, groups consisting of more than 15 individuals may
SB 1045 | Page 4
be difficult to manage, but some have had effective group
sessions with as many as 18 individuals.
5.Support. The County Alcohol and Drug Program Administrators
Association of California (CADPAAC), the sponsor, argues that
both small and large population counties often have
difficulties meeting the minimum and maximum requirements for
a group, respectively, so programs often cannot receive
Medi-Cal reimbursement and program participants may have to be
excluded when the maximum is reached. CADPAAC states that this
bill modifies group size requirements to be consistent with
provisions of state law for other types of Medi-Cal services
that specify groups sizes are two or more individuals. Pacific
Clinics writes that this bill removes antiquated billing
restrictions on DMC group outpatient services. Pacific Clinics
argues that due to clients' no-show rates, meeting or
exceeding the current number requirement is detrimental to
clients and service providers.
6.Policy comment. The author indicates that counties currently
encounter problems with DMC reimbursement when fewer than four
or more than 10 people show up for group counseling. The
sponsor of this bill indicates there is no industry norm on
group size and that some providers have had groups of up to 18
individuals. The definition of "group counseling" in current
law for DMC SUD services specifies two or more clients, but
has no upper limit on group size, with the exception of
outpatient drug free and narcotic treatment programs. This
bill proposes a group size of two to 14 individuals for
outpatient drug free services. However, the rationale for this
range is unclear. Is there a clinical or evidence-based group
size for SUD outpatient drug free group counseling?
7.Technical amendment. Committee staff suggests the follow
technical amendment.
1) Section 14021.6 of the Welfare and Institutions
Code:
(b)(2) For the fiscal years 2005-06 and 2006-07, if the
State Department of Health Care Services and the State
Department of Alcohol and Drug Programs determine that
reasonably reliable and complete cost report data are
available, the methodology specified in this subdivision
shall be applied to either or both of those years. If
reasonably reliable and complete cost report data are not
SB 1045 | Page
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available, the State Department of Health Care Services
and the State Department of Alcohol and Drug Programs
shall establish rates for either or both of those years
based upon the usual, customary, and reasonable charge
for the services to be provided, as these two departments
may determine in their discretion. This subdivision is
not intended to modify subdivision (h) of Section
14124.24 of the Welfare and Institutions Code , that which
requires certain providers to submit performance reports.
SUPPORT AND OPPOSITION :
Support: County Alcohol and Drug Program Administrators
Association of California (sponsor)
Pacific Clinics
Oppose: None received.
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