Existing law provides for the Medi-Cal program, which is administered by the State Department of Health Care Services, under which qualified low-income individuals receive health care services. The Medi-Cal program is, in part, governed and funded by federal Medicaid Program provisions. Existing law provides that specialty mental health services and Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) for any individual under 21 years of age are covered under Medi-Cal, consistent with the requirements of federal law. Federal law defines EPSDT to include screening services, vision services, dental services, hearing services, and other necessary services to correct or ameliorate defects and physical and mental illnesses and conditions discovered by the screening services, whether or not the services are covered under the state plan. Existing law provides that specialty mental health services include EPSDT services provided to eligible Medi-Cal beneficiaries under 21 years of age.

Existing law requires each local mental health plan to establish a procedure to ensure access to outpatient specialty mental health services, as required by the EPSDT program standards, for children in foster care who have been placed outside their county of adjudication. Existing law includes standardized contracts, procedures, documents, and forms, to facilitate the receipt of medically necessary specialty mental health services by a foster child who is placed outside his or her county of original jurisdiction.

This bill would declare the intent of the Legislature to ensure that foster children who are placed outside of their county of original jurisdiction, are able to access mental health services in a timely manner consistent with their individualized strengths and needs and the requirements of EPSDT program standards and requirements. The bill would require the department to issue policy guidance that establishes the conditions for and exceptions to presumptive transfer of responsibility for providing or arranging for mental health services to a foster child from the county of original jurisdiction to the county in which the foster child resides, as prescribed. The bill would define presumptive transfer for these purposes. The bill would authorize any interested party who owes a legal duty to the child involving the childs health or welfare to seek a waiver of presumptive transfer and would provide that the county probation agency or child welfare services agency with responsibility for the care and placement of the child is responsible for determining whether presumptive transfer is appropriate under specified conditions, including when a determination is made that the transfer of mental health services would disrupt continuity of care or timely access to services, as specified. The bill would require the mental health plan in the host county to assume responsibility for the authorization and provision of mental health services, and payments for services, upon the presumptive transfer. By increasing the responsibilities of county probation agencies or child welfare services agencies with respect to determining whether presumptive transfer is appropriate, the bill would impose a state-mandated local program.

This bill would require the department to seek approval from the United States Department of Health and Human Services, federal Centers for Medicare and Medicaid Services (CMS) prior to implementing these provisions if the department determines that approval is necessary. The bill would authorize the department and the State Department of Social Services to adopt regulations to implement these provisions by July 1, 2019, as specified.

The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.

This bill would provide that, if the Commission on State Mandates determines that the bill contains costs mandated by the state, reimbursement for those costs shall be made pursuant to these statutory provisions.

Existing law provides for the Medi-Cal program, which is administered by the State Department of Health Care Services, under which qualified low-income individuals receive health care services. The Medi-Cal program is, in part, governed and funded by federal Medicaid Program provisions. Existing law provides that specialty mental health services and Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) for any individual under 21 years of age are covered under Medi-Cal, consistent with the requirements of federal law. Federal law defines EPSDT to include screening services, vision services, dental services, hearing services, and other necessary services to correct or ameliorate defects and physical and mental illnesses and conditions discovered by the screening services, whether or not the services are covered under the state plan. Existing law provides that specialty mental health services include EPSDT services provided to eligible Medi-Cal beneficiaries under 21 years of age.

Existing law requires each local mental health plan to establish a procedure to ensure access to outpatient specialty mental health services, as required by the EPSDT program standards, for children in foster care who have been placed outside their county of adjudication. Existing law includes standardized contracts, procedures, documents, and forms, to facilitate the receipt of medically necessary specialty mental health services by a foster child who is placed outside his or her county of original jurisdiction.

This bill would declare the intent of the Legislature to ensure that foster children who are placed outside of their county of original jurisdiction, are able to access mental health services in a timely manner consistent with their individualized strengths and needs and the requirements of EPSDT program standards and requirements. The bill would require the department to issue policy guidance that establishes the conditions for and exceptions to presumptive transfer of responsibility for providing or arranging for mental health services to a foster child from the county of original jurisdiction to the county in which the foster child resides, as prescribed. The bill would define presumptive transfer for these purposes. The bill would authorize any interested party who owes a legal duty to the child involving the childs health or welfare to seek a waiver of presumptive transfer and would provide that the county probation agency or child welfare services agency with responsibility for the care and placement of the child is responsible for determining whether presumptive transfer is appropriate under specified conditions, including when a determination is made that the transfer of mental health services would disrupt continuity of care or timely access to services, as specified. The bill would require the mental health plan in the host county to assume responsibility for the authorization and provision of mental health services, and payments for services, upon the presumptive transfer. By increasing the responsibilities of county probation agencies or child welfare services agencies with respect to determining whether presumptive transfer is appropriate, the bill would impose a state-mandated local program.

This bill would require the department to seek approval from the United States Department of Health and Human Services, federal Centers for Medicare and Medicaid Services (CMS) prior to implementing these provisions if the department determines that approval is necessary. The bill would authorize the department and the State Department of Social Services to adopt regulations to implement these provisions by July 1, 2019, as specified.

The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.

This bill would provide that, if the Commission on State Mandates determines that the bill contains costs mandated by the state, reimbursement for those costs shall be made pursuant to these statutory provisions.

Existing law provides for the Medi-Cal program, which is administered by the State Department of Health Care Services, under which qualified low-income individuals receive health care services. The Medi-Cal program is, in part, governed and funded by federal Medicaid program provisions. Existing law provides that specialty mental health services and Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) for any individual under 21 years of age are covered under Medi-Cal, consistent with the requirements of federal law. Federal law defines EPSDT mental health services to include screening services, vision services, dental services, hearing services, and other necessary services to correct or ameliorate defects and physical and mental illnesses and conditions discovered by the screening services, whether or not the services are covered under the state plan. Existing law provides that specialty mental health services include EPSDT services provided to eligible Medi-Cal beneficiaries under 21 years of age.

Existing law requires each local mental health plan to establish a procedure to ensure access to outpatient specialty mental health services, as required by the EPSDT program standards, for children in foster care who have been placed outside their county of adjudication. Existing law includes standardized contracts, procedures, documents, and forms, to facilitate the receipt of medically necessary specialty mental health services by a foster child who is placed outside his or her county of original jurisdiction.

This bill would declare the intent of the Legislature to ensure that foster children who are placed outside of their county of original jurisdiction, are able to access mental health services in a timely manner consistent with their individualized strengths and needs and the requirements of EPSDT program standards and requirements. The bill would require the department to issue policy guidance that establishes the conditions for and exceptions to presumptive transfer of responsibility for providing or arranging for mental health services to a foster child from the county of original jurisdiction to the county in which the foster child resides, as prescribed. The bill would define presumptive transfer for these purposes. The bill would authorize any interested party who owes a legal duty to the child involving the childs health or welfare to seek a waiver of presumptive transfer and would provide that the county probation agency or child welfare services agency with responsibility for the care and placement of the child is responsible for determining whether presumptive transfer is appropriate under specified conditions, including when a determination is made that the transfer of mental health services would disrupt continuity of care or timely access to services, as specified. The bill would require the mental health plan in the host county to assume responsibility for the authorization and provision of mental health services, and payments for services, upon the presumptive transfer. By increasing the responsibilities of county probation agencies or child welfare services agencies with respect to determining whether presumptive transfer is appropriate, the bill would impose as state-mandated local program.

This bill would require the department to seek approval from the United States Department of Health and Human Services, federal Centers for Medicare and Medicaid Services (CMS) prior to implementing these provisions if the department determines that approval is necessary. The bill would authorize the department and the State Department of Social Services to adopt regulations to implement these provisions by July 1, 2019, as specified.

The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.

This bill would provide that, if the Commission on State Mandates determines that the bill contains costs mandated by the state, reimbursement for those costs shall be made pursuant to these statutory provisions.

Existing law provides for the Medi-Cal program, which is administered by the State Department of Health Care Services, under which qualified low-income individuals receive health care services. The Medi-Cal program is, in part, governed and funded by federal Medicaid program provisions. Existing law provides that specialty mental health services and Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) for any individual under 21 years of age is are covered under Medi-Cal, consistent with the requirements of federal law. Federal law defines EPSDT mental health services to include screening services, vision services, dental services, hearing services, and other necessary services to correct or ameliorate defects and physical and mental illnesses and conditions discovered by the screening services, whether or not the services are covered under the state plan. EPSDT is classified under the Medi-Cal program as a specialty mental health service. plan. Existing law provides that specialty mental health services include EPSDT services provided to eligible Medi-Cal beneficiaries under 21 years of age.

Existing law requires each local mental health plan to establish a procedure to ensure access to outpatient specialty mental health services, as required by the EPSDT program standards, for children in foster care who have been placed outside their county of adjudication. Existing law includes standardized contracts, procedures, documents, and forms, to facilitate the receipt of medically necessary specialty mental health services by a foster child who is placed outside his or her county of original jurisdiction.

This bill would declare the intent of the Legislature to ensure that foster children who are placed outside of their county of original jurisdiction, are able to access mental health services in a timely manner consistent with their individualized strengths and needs and the requirements of EPSDT program standards and requirements. The bill would require the department to issue policy guidance that establishes the conditions for and exceptions to presumptive transfer of responsibility for providing or arranging for mental health services to foster youth a foster child from the county of original jurisdiction to the county in which the foster child resides, as prescribed. The bill would define presumptive transfer for these purposes. The bill would authorize the person or agency that is responsible for making health care decisions on behalf of the foster child to waive the presumptive transfer if specified conditions occur, including any interested party who owes a legal duty to the child involving the childs health or welfare to seek a waiver of presumptive transfer and would provide that the county probation agency or child welfare services agency with responsibility for the care and placement of the child is responsible for determining whether presumptive transfer is appropriate under specified conditions, including when a determination is made that the transfer of mental health services would disrupt continuity of care or timely access to services, as specified. The bill would require the mental health plan in the host county to assume responsibility for the authorization and provision of mental health services, and payments for services, upon the presumptive transfer. The bill would require the department, no later than July 1, 2016, to amend its contract with each mental health plan to ensure that the mental health plan in the host county is reimbursed for mental health services provided within the fiscal year in which services are provided. By increasing the responsibilities of county probation agencies or child welfare services agencies with respect to determining whether presumptive transfer is appropriate, the bill would impose as state-mandated local program.

This bill would require the department to determine whether it is necessary to seek approval under the states Section 1915(b) Medicaid waiver from the federal Centers for Medicare and Medicaid Services (CMS) prior to implementing the bill, and if so, to do everything within its power necessary to secure an expeditious approval. seek approval from the United States Department of Health and Human Services, federal Centers for Medicare and Medicaid Services (CMS) prior to implementing these provisions if the department determines that approval is necessary. The bill would authorize the department and the State Department of Social Services to adopt regulations to implement these provisions by July 1, 2019, as specified.

Existing law provides for the Medi-Cal program, which is administered by the State Department of Health Care Services, under which qualified low-income individuals receive health care services. The Medi-Cal program is, in part, governed and funded by federal Medicaid program provisions. Existing law provides that Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) for any individual under 21 years of age is covered under Medi-Cal, consistent with the requirements of federal law. Federal law defines EPSDT mental health services to include screening services, vision services, dental services, hearing services, and other necessary services to correct or ameliorate defects and physical and mental illnesses and conditions discovered by the screening services, whether or not the services are covered under the state plan. EPSDT is classified under the Medi-Cal program as a specialty mental health service.

Existing law requires each local mental health plan to establish a procedure to ensure access to outpatient specialty mental health services, as required by the EPSDT program standards, for children in foster care who have been placed outside their county of adjudication. Existing law includes standardized contracts, procedures, documents, and forms, to facilitate the receipt of medically necessary specialty mental health services by a foster child who is placed outside his or her county of original jurisdiction.

This bill would declare the intent of the Legislature to ensure that foster children who are placed outside of their county of original jurisdiction, are able to access mental health services in a timely manner consistent with their individualized strengths and needs and the requirements of EPSDT program standards and requirements. The bill would require the department to issue policy guidance that establishes the conditions for and exceptions to presumptive transfer of responsibility for providing or arranging for mental health services to foster youth from the county of original jurisdiction to the county in which the foster childs county of residence, child resides, as prescribed. The bill would define presumptive transfer for these purposes. The bill would authorize the person or agency that is responsible for making health care decisions on behalf of the foster child to waive the presumptive transfer if specified conditions occur, including when a determination is made that the transfer of mental health services would disrupt continuity of care or timely access to services, as specified. The bill would require the mental health plan in the host county to assume responsibility for the authorization and provision of mental health services, and payments for services, upon the presumptive transfer. The bill would require the department, no later than July 1, 2016, to amend its contract with each mental health plan to ensure that the mental health plan in the host county is reimbursed for mental health services provided within the fiscal year in which services are provided.

This bill would require the Department of Finance, by May 1,2016, to set or adjust its allocation schedule of the Behavioral Health Subaccount pursuant to realignment provisions enacted pursuant to a specified measure, in order that counties that have paid, or will pay, for the specialty mental health services provided pursuant to the bill, are fully reimbursed during the fiscal year in which the services were provided. This bill would require the department to determine whether it is necessary to seek approval under the states Section 1915(b) Medicaid waiver from the federal Centers for Medicare and Medicaid Services (CMS) prior to implementing the bill, and if so, to do everything within its power necessary to secure an expeditious approval.

Existing law provides for the Medi-Cal program, which is administered by the State Department of Health Care Services, under which qualified low-income individuals receive health care services. The Medi-Cal program is, in part, governed and funded by federal Medicaid program provisions. Existing law provides that Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) for any individual under 21 years of age is covered under Medi-Cal, consistent with the requirements of federal law. Federal law defines EPSDT mental health services to include screening services, vision services, dental services, hearing services, and other necessary services to correct or ameliorate defects and physical and mental illnesses and conditions discovered by the screening services, whether or not the services are covered under the state plan. EPSDT is classified under the Medi-Cal program as a specialty mental health service.

Existing law requires each local mental health plan to establish a procedure to ensure access to outpatient specialty mental health services, as required by the EPSDT program standards, for children in foster care who have been placed outside their county of adjudication. Existing law includes standardized contracts, procedures, documents, and forms, to facilitate the receipt of medically necessary specialty mental health services by a foster child who is placed outside his or her county of original jurisdiction.

This bill would declare the intent of the Legislature to ensure that foster children who are placed outside of their county of original jurisdiction, are able to access mental health services in a timely manner consistent with their individualized strengths and needs and the requirements of EPSDT program standards and requirements. The bill would require the department to issue policy guidance that establishes the presumptive transfer of responsibility for providing or arranging for mental health services to foster youth from the county of original jurisdiction to the foster childs county of residence, as prescribed. The bill would define presumptive transfer for these purposes.

This bill would require the Department of Finance, by May 1,2016, to set or adjust its allocation schedule of the Behavioral Health Subaccount pursuant to realignment provisions enacted pursuant to a specified measure, in order that counties that have paid, or will pay, for the specialty mental health services provided pursuant to the bill, are fully reimbursed during the fiscal year in which the services were provided. This bill would require the department to determine whether it is necessary to seek approval under the states Section 1915(b) Medicaid waiver from the federal Centers for Medicare and Medicaid Services (CMS) prior to implementing the bill, and if so, to do everything within its power necessary to secure an expeditious approval.

Existing law provides for the Medi-Cal program, which is administered by the State Department of Health Care Services, under which qualified low-income individuals receive health care services. The Medi-Cal program is, in part, governed and funded by federal Medicaid program provisions. Existing law provides that Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) for any individual under 21 years of age is covered under Medi-Cal, consistent with the requirements of federal law. Federal law defines EPSDT mental health services to include screening services, vision services, dental services, hearing services, and other necessary services to correct or ameliorate defects and physical and mental illnesses and conditions discovered by the screening services, whether or not the services are covered under the state plan. EPSDT is classified under the Medi-Cal program as a specialty mental health service.

Existing law requires each local mental health plan to establish a procedure to ensure access to outpatient specialty mental health services, as required by the EPSDT program standards, for children in foster care who have been placed outside their county of adjudication. Existing law includes standardized contracts, procedures, documents, and forms, to facilitate the receipt of medically necessary specialty mental health services by a foster child who is placed outside his or her county of original jurisdiction.

This bill would declare the intent of the Legislature to ensure that foster children who are placed outside of their county of original jurisdiction, are able to access mental health services in a timely manner consistent with their individualized strengths and needs and the requirements of EPSDT program standards and requirements. The bill would require the department to issue policy guidance that establishes the presumptive transfer of responsibility for providing or arranging for mental health services to foster youth from the county of original jurisdiction to the foster childs county of residence, as prescribed. The bill would define presumptive transfer for these purposes.

This bill would require the Department of Finance, by May 1,2016, to set or adjust its allocation schedule of the Behavioral Health Subaccount pursuant to realignment provisions enacted pursuant to a specified measure, in order that counties that have paid, or will pay, for the specialty mental health services provided pursuant to the bill, are fully reimbursed during the fiscal year in which the services were provided. This bill would require the department to determine whether it is necessary to seek approval under the states Section 1915(b) Medicaid waiver from the federal Centers for Medicare and Medicaid Services (CMS) prior to implementing the bill, and if so, to do everything within its power necessary to secure an expeditious approval.

CONCURRENCE IN SENATE AMENDMENTS

CSA1 Bill Id:AB 1299

Author:(Ridley-Thomas)

As Amended Ver:August 18, 2016

Majority vote

Original Committee Reference: HUM. S.

SUMMARY: Provides for the presumptive transfer of responsibility from the county of original jurisdiction to the foster child's county of residence for providing or arranging mental health services for foster youth, as specified.

The Senate amendments:

1. Move provisions of the bill to a different section of the Welfare and Institutions Code.
2. Delete provisions requiring, as specified, presumptive transfer to occur immediately when a foster child is placed in a county other than the county of original jurisdiction and when the request for transfer of responsibility is made by specified entities or individuals, and instead require transfer to take place promptly when either of the following conditions exist:
   1. A foster child is placed in a county other than the county of original jurisdiction on or after July 1, 2017; or
   2. A foster youth who resides in a county other than the county of original jurisdiction after June 30, 2017, and is not receiving specialty mental health services, as specified, requests transfer of responsibility.
3. Require a foster youth who resided in a county other than the county of original jurisdiction after June 30, 2017, and who continues to reside outside the county of original jurisdiction after December 31, 2017, to have jurisdiction transferred no later than the child's first regularly scheduled status review hearing, as specified.
4. Delete provisions requiring the California Health and Human Services Agency (HHS) to coordinate with the Department of Health Care Services (DHCS) and the Department of Social Services (DSS) to take specified actions regarding establishing presumptive transfer by July 1, 2016, and instead, require HHS to coordinate with DHCS and DSS to, by July 1, 2017, have DHCS issue policy guidance concerning the conditions for and exceptions to presumptive transfer, as specified, in consultation with specified parties, and that ensures that certain conditions are met, including, but not limited to, presumptive transfer not interrupting the continuity of care.
5. Provide for conditions under which presumptive transfer made be waived, and establish related requirements and processes, as specified.
6. Require a county in which a foster child resides to accept an assessment of needed services for that child completed in the county of original jurisdiction and further, authorize the county in which a child resides to conduct additional assessments, as specified.
7. Require a county in which a child resides to assume responsibility for the authorization and provision of specialty mental health services and payments for services upon presumptive transfer.
8. Require a foster child transferred to the mental health plan in the county in which the child resides to be considered part of the county of residence caseload for claiming purposes from the Behavioral Health Subaccount and the Behavioral Health Services Growth Special Account, as specified.
9. Require DSS and DHCS to adopt regulations to implement the provisions of this bill by July 1, 2019, and further, authorize DSS and DHCS to implement and administer the changes made by this bill through all-county letters, information notices, or similar written instruction, as specified, until regulations are adopted.
10. Modify requirements related to DHCS seeking federal approval for implementation of the provisions of this bill by:
    1. Maintaining that, if DHCS determines it necessary, it shall seek approval from the federal Centers for Medicare and Medicaid Services (CMS), but removing the requirement that approval be sought specifically under the state's Section 1915(b) Medicaid waiver;
    2. Moving the deadline by which approval must be sought from CMS from not later than July 1, 2016, to no later than January 1, 2017;
    3. Removing the requirement that DHCS do everything within its power necessary to secure an expeditious approval from CMS; and
    4. Removing the statement that DHCS shall not be required to implement any provision of the bill that CMS determines is not permitted under the state's waiver and, instead, requiring the provisions of this bill to be implemented only if and to the extent that federal financial participation, as specified, is available and all necessary federal approvals have been obtained.
11. Make technical amendments.

EXISTING LAW:

1. Establishes a state and local system of child welfare services, including foster care, for children who have been adjudged by the court to have been abused or neglected, or at risk of abuse or neglect, as specified. (Welfare and Institutions Code (WIC) Section 202)
2. States that the purpose of foster care law is to provide maximum safety and protection for children who are currently being physically, sexually, or emotionally abused, neglected, or exploited, and to ensure the safety, protection, and physical and emotional well-being of children who are at risk of harm. (WIC Section 300.2)
3. Establishes rights of foster children, including the right to receive medical, dental, vision, and mental health services. (WIC Section 16001.9)
4. Establishes the federal Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program to provide comprehensive and preventive health services, including preventive, dental, mental health, and developmental, and specialty services, to Medicaid beneficiaries under the age of 21. Requires states to administer EPSDT as a condition of receiving federal Medicaid funds. (42 United States Code Section 1396(d))
5. Requires county mental health departments that receive full system of care funding, as specified, to provide children served by county social services and probation departments mental health screening, assessment, participation in multidisciplinary placement teams and specialty mental health treatment services for children placed out of home in group care, for those children who meet the definition of medical necessity, to the extent resources are necessary. (WIC Section 5867.5)
6. Requires each local mental health plan to establish a procedure to ensure access to outpatient specialty mental health services, as required by EPSDT program standards, for any child in foster care who has been placed outside his or her county of adjudication. (WIC Section 14716).
7. Establishes the Behavioral Health Subaccount within the Support Services Account. (Government Code Section 30025)

FISCAL EFFECT: Unknown.

COMMENTS:

Mental health needs of foster youth: Foster youth have a higher likelihood of experiencing emotional, behavioral, and developmental problems when compared to their non-foster peers. Abuse and neglect and unstable placements can contribute to, and exacerbate, mental health issues. These problems, in turn, can lead to other problems, like difficulty forming stable relationships and succeeding in school.

Research underscores the need for improved access to health and mental health services for foster children and youth, and points to the high incidence of behavioral or mental health problems necessitating intervention among foster youth. The disproportionately high rates of emotional and behavioral health issues for youth placed in foster care, youth transitioning from foster care, and former foster youth can be correlated with other barriers foster youth face (such as higher rates of incarceration and homelessness and diminished rates of high school completion and college attendance).

EPSDT: One in three children under the age of six in the United States is eligible for Medicaid. EPSDT is Medicaid's child health component. Federal law requires a comprehensive set of benefits and services to be provided to children and youth under the age of 21 through Medicaid. On top of the standard benefits that Medi-Cal beneficiaries receive, children and youth are eligible for additional medically necessary services. Mental health services are recognized as an important component of children's health care. Comprehensive well-child examinations including screening services through EPSDT, and screening for potential developmental, mental, behavioral, and/or substance use disorders are required by federal law.

Need for this bill: According to the author, foster children are three to six times more likely to experience emotional, behavioral, and developmental problems compared to non-foster children. When these mental health needs go unmet, placement instability, disruptions in permanency plans, barriers to educational attainment, and other consequences can result.

Youth dubbed "out-of-county" have been placed in a county other than the one in which they originally enter foster care (i.e., the "county of original jurisdiction"). The author reports that, as of July 2014, close to 20% of foster children (13,000) were considered "out-of-county." "Out-of-county" foster youth may be placed at greater risk because of lengthy delays or denials in accessing mental health services that can result from the way the system of care provision currently operates. This is because, when a youth in foster care is placed out of county, the county of original jurisdiction remains responsible for providing or arranging for necessary medical and mental health treatment for that youth. Mental health services – "Specialty Mental Health Medi-Cal" – are separate from other medical services and each county's mental health plan must authorize and provide payment for the mental health services received by the child.

There are indications that out-of-county foster youth may have higher needs and less access when it comes to mental health care. A 2011 report issued by the California Child Welfare Council found that out-of-county foster youth were more likely to have been diagnosed with a serious mental health disorder, yet were 10% to 15% less likely to have received any mental health services compared to their in-county peers. And among those that did receive services, in-county foster youth fared better, receiving more care and more intensive treatment.

Analysis Prepared by: Daphne Hunt / HUM. S. / (916) 319-2089 FN: 0004753

 THIRD READING  

Bill No: AB 1299

Author: Ridley-Thomas (D), et al.

Amended: 8/18/16 in Senate

Vote: 21

SENATE HEALTH COMMITTEE: 9-0, 6/17/15

AYES: Hernandez, Nguyen, Hall, Mitchell, Monning, Nielsen, Pan, Roth, Wolk

SENATE HUMAN SERVICES COMMITTEE: 5-0, 7/14/15

AYES: McGuire, Berryhill, Hancock, Liu, Nguyen

ASSEMBLY FLOOR: 80-0, 6/1/15 - See last page for vote

SUBJECT: Medi-Cal: specialty mental health services: foster children

SOURCE: California Alliance of Child and Family Services

Steinberg Institute

The Women’s Foundation of California/Women’s Policy Institute

DIGEST: This bill requires the California Health and Human Services Agency (CHHSA) to coordinate with the Department of Health Care Services (DHCS) and the Department of Social Services (DSS) to facilitate the receipt of medically necessary specialty mental health services for foster youth, as specified. Requires DHCS to seek federal approval, as specified, to implement the provisions in this bill.

Senate Floor Amendments of 8/18/16 add coauthors, and change all references to the added Welfare and Institutions Code Section 14717.5 in this bill and instead number it as 14717.1.

ANALYSIS:

Existing law:

1. Establishes California’s Medicaid program, Medi-Cal, through which eligible low-income individuals receive health care services.
2. Establishes the federal Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program to provide comprehensive and preventive health services, including preventive, dental, mental health (MH), developmental, and specialty services to Medi-Cal beneficiaries under the age of 21 who have full-scope Medi-Cal eligibility. Requires states to administer EPSDT as a condition of receiving federal Medicaid funds.
3. Requires county MH departments that receive full system of care funding, as specified, to provide children who are served by county social services and probation departments with MH screening, assessment, participation in multidisciplinary placement teams, and specialty MH treatment services for children placed out of home in group care and who meet the definition of medical necessity, to the extent resources are necessary.
4. Requires each local MH plan to establish a procedure to ensure access to outpatient specialty MH services, as required by EPSDT program standards, for any child in foster care who has been placed outside his or her county of adjudication. Requires the local MH plan of the county of original jurisdiction for a foster youth to remain responsible for providing or arranging for specialty MH services, including the costs of services, unless there is a written contract in which the county of residence accepts responsibility for payment.
5. Establishes rights of foster youth, including the right to receive medical, dental, vision, and MH services.

This bill:

1. Requires the CHHSA to coordinate with DHCS and DSS to facilitate the receipt of medically necessary specialty MH services by foster youth placed outside his or her county of original jurisdiction, and to take specified actions on or before July 1, 2017.
2. Requires DHCS to issue policy guidance concerning the conditions for and exceptions to “presumptive transfer,” as defined, in consultation with DSS and with input of stakeholders, as specified, to ensure that the transfer or responsibility improves access to MH services and does not impede the continuity of existing care, as well as other specified criteria.
3. Defines “presumptive transfer” as, absent any exceptions established by this bill, responsibility for providing or arranging for specialty MH services is promptly transferred from the county of original jurisdiction to the county in which the foster child resides, as specified.
4. Allows, on a case-by-case basis and when consistent with the medical rights of a foster child, presumptive transfer to be waived and the responsibility for the provision of specialty MH services to remain with the county of original jurisdiction if any of the following exceptions exist:
   1. The transfer would disrupt continuity of care or delay access to services.
   2. The transfer would interfere with family reunification efforts documented in the individual case plan.
   3. The foster child’s placement in the county other than the county of original jurisdiction is expected to last less than six months.
   4. The foster child’s residence is within 30 minutes of travel time to his or her established specialty MH care provider in the county of original jurisdiction.
5. Requires a waiver, as described in 4) above, to be contingent upon specified criteria, including an MH plan in the county of original jurisdiction demonstrating an existing contract with a specialty MH services provider, and the ability to deliver timely specialty MH services directly to a foster child.
6. Requires DSS and DHCS to adopt regulations by July 1, 2019, to implement the provisions in this bill.
7. Requires DHCS, if it determines it is necessary, to seek approval from the Centers for Medicare and Medicaid Services (CMS) prior to implementing the provisions in this bill, and to make an official request for approval from CMS no later than January 1, 2017. Requires this provision in this bill to be implemented only if and to the extent that federal financial participation, as specified, is available and all necessary federal approvals have been obtained.

Background

The purpose of the state’s Child Welfare Services (CWS) system is to protect children from abuse and neglect and provide for their health and safety. When children are identified as being at risk of abuse, neglect, or abandonment, county juvenile courts hold legal jurisdiction, and children are served by the CWS system through the appointment of a social worker. Through this system, there are multiple opportunities for the custody of the child, or his or her placement outside of the home, to be evaluated, reviewed, and determined by the judicial system, in consultation with the child's social worker, to help provide the best possible services to the child. The CWS system seeks to help children who have been removed from their homes reunify with their parents or guardians, whenever appropriate, or unite them with other individuals they consider to be family. There are currently close to 63,000 children in the state’s CWS.

California has a decentralized public MH system with most direct services provided through the county MH system. Counties (county MH plans) have the primary funding and programmatic responsibility for the majority of local MH programs. The state is required to meet certain federal requirements, including those set forth by Medicaid’s child health component, known as the EPSDT program. Federal law—including statutes, regulations, and guidelines—requires Medi-Cal to cover a very comprehensive set of benefits and services for children, different from adult benefits. EPSDT provides eligible children access to a range of MH services that include, but are not limited to, MH assessment and services, therapy, rehabilitation, medication support services, day rehabilitation, day treatment intensive, crisis intervention/stabilization, targeted case management, and therapeutic behavioral services.

MH needs of foster youth. Foster youth have a higher likelihood of experiencing emotional, behavioral, and developmental problems when compared to their non-foster peers. Abuse and neglect and unstable placements can contribute to and exacerbate MH issues. These problems can lead to other problems, like difficulty forming stable relationships and succeeding in school. Research underscores the need for improved access to health and MH services for foster youth, and points to the high incidence of behavioral or MH problems necessitating intervention among foster youth. The disproportionately high rates of emotional and behavioral health issues for youth placed in foster care, youth transitioning from foster care, and former foster youth can be correlated with other barriers foster youth face, such as higher rates of incarceration and homelessness, diminished rates of high school completion and college attendance, and disproportionate prescribing of antipsychotic and psychotropic medications, as highlighted in an 2014 exposé by the San Jose Mercury News.

There are indications that out-of-county foster youth may have higher needs and less access when it comes to MH treatment. A 2011 report issued by the California Child Welfare Council found that out-of-county foster youth were more likely to have been diagnosed with a serious MH disorder, yet were 10-15 percent less likely to have received any MH services compared to their in-county peers. And among those that did receive services, in-county foster youth fared better, receiving more care and more intensive treatment.

Comments

1. Author’s statement. According to the author, foster youth are three to six times more likely than non-foster youth to experience emotional, behavioral, and developmental problems. When a foster youth’s MH needs are not met, the result is often placement instability; disruptions in permanency plans; school failure; costly care in group homes, residential treatment facilities, and psychiatric hospitals; delinquency; and even death. Especially at risk are foster youth placed across county lines, who often experience lengthy delays or denials in accessing MH services. According to the most recent data from the California Child Welfare Indicators Project at UC Berkeley, almost one-in-five foster youth statewide (an estimated 13,000) live in placements across county lines, or “out-of-county.” This disparity in access to MH services between in-county and out-of-county youth exists despite both having the same entitlement to MH services under federal and state law.

Related/Prior Legislation

AB 1808 (Galgiani, 2009) was substantially similar to this bill. AB 1808 was held on the suspense file of the Assembly Appropriations Committee.

SB 785 (Steinberg, Chapter 469, Statutes of 2007) facilitates the access to MH services for foster youth who are placed outside of the original county of jurisdiction, including those being adopted or entering into a guardianship with a relative.

FISCAL EFFECT: Appropriation: No Fiscal Com.: Yes Local: Yes

According to the Senate Appropriations Committee:

1. Minor anticipated costs for CHHSA to coordinate with other departments (General Fund).
2. One-time costs of about $900,000 over two years and ongoing administrative costs of about $130,000 per year for DHCS to develop policies, adopt regulations, monitor disputes between counties, and monitor the provision of services under the bill (General Fund and federal funds).
3. Likely increase in county spending for specialty MH services in the low millions per year (local realignment funds and federal funds). There are indications that foster youth who are placed out-of-county are more likely to need MH services but are less likely to access such services. In part, this reduced access to services is due to administrative barriers that prevent county MH plans from determining which county is responsible for providing services. By improving the system for assigning responsibility for providing and paying for MH services, the bill is likely to increase utilization amongst foster youth who are underserved under the current system. Assuming that about 10% of foster youth in out-of-county placements would access specialty MH services for an additional six months, the annual costs would be about $3 million per year. Under the provisions of the bill, county costs for services would be paid for with realignment growth funding and would not be a state responsibility.
4. Projected ongoing shift of realignment funding between counties of about $48 million per year (local realignment funds). According to projections by DHCS, foster youth impacted by the presumptive transfer process in the bill would receive annual services costing about $48 million. Under the bill, counties would be compensated for any increased cost through the allocation of realignment growth funding.

SUPPORT: (Verified 8/17/16)

California Alliance of Child and Family Services (co-source)

Steinberg Institute (co-source)

The Women’s Foundation of California – Women’s Policy Institute (co-source)

A Better Way, Inc.

Accessing Health Services for California’s

Alameda Foster Youth Alliance

Alternative Family Services

Aspiranet

Association of Community Human Service Agencies

Aviva Family and Children’s Services

Bayfront Youth and Family Services

Bill Wilson Center

Boys Republic

California Hospital Association

California Mental Health Advocacy for Children and Youth

California State Association of Counties

California State PTA

California Youth Connection

Casa Pacifica Centers for Children and Families

ChildNet Youth and Family Services

Children in Foster Care Task Force

Children Now

Children’s Law Center of California

Children’s Receiving Home of Sacramento

County Welfare Directors Association

Crittenton Services for Children and Families

David and Margaret Youth and Family Services

Edgewood

Ettie Lee Youth and Family Services

Families Now

Family Care Network, Inc.

First Place for Youth

Fred Finch Youth Center

Hathaway-Sycamores Child and Family Services

Humboldt County Transition Age Youth Collaboration

John Burton Foundation

Junior Blind of America

Lilliput Children’s Services

Maryvale

Mendocino County Health and Human Services Agency

National Association of Social Workers

National Center for Youth Law

North Star Family Center

Optimist Youth Homes and Family Services

Orange County Alliance for Children and Families

Sacramento Children’s Home

San Diego Center for Children

Seneca Family of Agencies

Sierra Forever Families

Sierra Sacramento Valley Medical Society

Stars Behavioral Health Group

Sunny Hills Services

Tahoe Turning Point

The Village Family Services

TLC Child and Family Services

Trinity Youth Services

United Advocates for Children and Youth

Unity Care

Uplift Family Services

Valley Teen Ranch

Victor Treatment Center

Westcoast Children’s Clinic

Young Minds Advocacy Project

Youth Homes, Inc.

OPPOSITION: (Verified 8/17/16)

None received

ARGUMENTS IN SUPPORT: Supporters of this bill, largely behavioral health and family advocates, argue that the question of which MH plan is responsible for providing much-needed services to foster youth who have been placed outside of their counties of jurisdiction has vexed California for more than 20 years. They state that foster youth go through transitions where their mental stability takes a toll and that this bill will ensure that the MH needs of these foster youth will not be delayed or denied as the youth transition to a new county of residence. Supporters further argue that foster youth already have a rough start in life, and not being able to access MH services, which they are entitled to, in a timely and efficient manner puts them at an even greater risk of serious harm and potentially permanent negative outcomes.

ASSEMBLY FLOOR: 80-0, 6/1/15

AYES: Achadjian, Alejo, Travis Allen, Baker, Bigelow, Bloom, Bonilla, Bonta, Brough, Brown, Burke, Calderon, Campos, Chang, Chau, Chávez, Chiu, Chu, Cooley, Cooper, Dababneh, Dahle, Daly, Dodd, Eggman, Frazier, Beth Gaines, Gallagher, Cristina Garcia, Eduardo Garcia, Gatto, Gipson, Gomez, Gonzalez, Gordon, Gray, Grove, Hadley, Harper, Roger Hernández, Holden, Irwin, Jones, Jones-Sawyer, Kim, Lackey, Levine, Linder, Lopez, Low, Maienschein, Mathis, Mayes, McCarty, Medina, Melendez, Mullin, Nazarian, Obernolte, O'Donnell, Olsen, Patterson, Perea, Quirk, Rendon, Ridley-Thomas, Rodriguez, Salas, Santiago, Steinorth, Mark Stone, Thurmond, Ting, Wagner, Waldron, Weber, Wilk, Williams, Wood, Atkins

Prepared by: Reyes Diaz / HEALTH / (916) 651-4111

8/23/16 10:58:35

**** END ****

SENATE COMMITTEE ON APPROPRIATIONS

Senator Ricardo Lara, Chair

2015 - 2016 Regular Session

AB 1299 (Ridley-Thomas) - Medi-Cal: specialty mental health services: foster children

This bill meets the criteria for referral to the Suspense File.

Bill Summary:

AB 1299 would require the Department of Health Care Services to develop policies and procedures establishing the presumptive transfer of responsibility for providing and paying for specialty mental health services for foster youth, from the county of original jurisdiction to the county of residence.

Fiscal Impact:

• Minor anticipated costs for the Health and Human Services Agency to coordinate with other Departments (General Fund).

• Ongoing administrative costs of about $300,000 per year for the Department of Health Care Services to develop policies, adopt regulations, monitor disputes between counties, and monitor the provision of services under the bill (General Fund and federal funds).

• Likely one-time administrative costs in the low hundreds of thousands for the Department of Social Services to develop policies in conjunction with the Department of Health Care Services (General Fund).

• Likely increase in county spending for specialty mental health services in the low millions per year (local funds, General Fund, federal funds). There are indications that foster youth who are placed out-of-county are more likely to need mental health services but are less likely to access such services. In part, this reduced access to services is due to administrative barriers that prevent county mental health plans from determining which county is responsible for providing services. By improving the system for assigning responsibility for providing and paying for mental health services, the bill is likely to increase utilization amongst foster youth who are underserved under the current system. Assuming that about 10% of foster youth in out-of-county placements would access specialty mental health services for an additional six months, the annual costs would be about $3 million per year. See below for more discussion about who would pay for those services.

• Unknown increase in state spending for services provided by counties of residence (General Fund). Under current law, the provision of specialty mental health services for foster youth has been realigned to the counties. It is not clear whether the responsibility to pay for additional services by a county of residence under this bill would require additional state funding to offset those county costs. See below.

Background:

Under state and federal law, the Department of Health Care Services operates the Medi-Cal program, which provides health care coverage to low income individuals, families, and children. Medi-Cal provides coverage to childless adults and parents with household incomes up to 138% of the federal poverty level and to children with household incomes up to 266% of the federal poverty level. The federal government provides matching funds that vary from 50% to 90% of expenditures depending on the category of beneficiary. Federal law requires the state to provide a comprehensive set of benefits to Medi-Cal beneficiaries under age 21 known as Early and Periodic Screening, Diagnosis, and Treatment (EPSDT). Under current law, the provision of specialty mental health services covered under EPSDT is the responsibility of county mental health plans. Funding for those services generally comes from county realignment funds and federal funds.

Under current law, county mental health plans are required to establish procedures to ensure access to specialty mental health services for children in foster care who have been placed out-of-county. Unless there is a written agreement between the county of original jurisdiction and the county of residence transferring responsibility for paying for services, the county of original jurisdiction retains the responsibility to arrange for and pay for specialty mental health services provided by the county of residence.

Proposed Law:

AB 1299 would require the Department of Health Care Services to develop policies and procedures establishing the presumptive transfer of responsibility for providing and paying for specialty mental health services for foster youth, from the county of original jurisdiction to the county of residence.

Specific provisions of the bill would:

• Require the California Health and Human Services agency to coordinate with the Department of Health Care Services and the Department of Social Services to take specified actions:

• Require the Department of Health Care services to issue policy guidance that establishes conditions for the presumptive transfer of responsibility for providing mental health services to foster youth, from the county of original jurisdiction to the county of residence;

• Require the procedures for implementing presumptive transfer to be consistent with the requirements of EPSDT and include a procedure for expedited transfer;

• Provide authority for specified individuals to waive presumptive transfer of responsibility;

• Require that, upon presumptive transfer, the mental health plan in the county of residence shall assume responsibility for the provision of mental health services and for paying for those services;

• Require the Department to amend its contracts with county mental health plans to ensure that county mental health plans in counties of residence are reimbursed for services provided under the bill;

• Make implementation of the bill contingent on federal approval.

Related Legislation:

AB 1808 (Galgiani, 2009) was substantially similar to this bill. That bill was held on the Assembly Appropriations Committee’s Suspense File.

Staff Comments:

Pursuant to Government Code Section 30026.5, legislation enacted after September 30, 2012, that has an overall effect of increasing the costs already borne by a local agency for programs or levels of service under the 2011 Realignment shall apply to local agencies only to the extent that the state provides annual funding for the cost increase. Local agencies are not be obligated to provide programs or levels of service required by legislation above the level for which funding has been provided. Both foster care and specialty mental health services for foster youth are programs that have been realigned to the counties.

The bill would not increase overall statewide responsibilities for counties to provide mental health services. However, the impact on individual counties will vary depending on how many foster youth formerly residing in the county have been placed in another county verses how many foster youth are now resident in the county, having been moved from another county. There are likely to be winners and losers amongst the counties – some counties will experience a net reduction in foster youth placements and the costs associated with those placements, while other counties will experience a net gain.

Government Code Section 30026.5 requires additional state funding to be provided whenever a state law or regulation results in an increase in costs borne by a local agency. Under this requirement, counties that experience an overall increase in their costs are likely to request additional state funding before complying with the requirements of the bill. It is not likely that counties experiencing an overall reduction in their costs would be willing to compensate counties experiencing increased costs and the bill does not mandate that they do so. Thus, the overall impact of the bill will be to increase state costs relating to counties that experience cost increases while the state is unlikely to recover any funds from counties that experience cost savings.

In addition the bill is likely to increase overall utilization of services by foster youth, due to the improved system of assigning responsibility to the appropriate county. To the extent that this does result in additional provision of services, counties could seek additional state funding to offset those increased costs.

-- END --

SENATE COMMITTEE ON HUMAN SERVICES

Senator McGuire, Chair

2015 - 2016 Regular

Bill No: AB 1299

Subject: Medi-Cal: specialty mental health services: foster children

SUMMARY

This bill establishes Legislative intent to ensure that foster children placed outside of their county of original jurisdiction are able to access mental health services in a timely manner and to overcome barriers to care that exist when the responsibility for providing services remains with the county of original jurisdiction. It requires the California Health and Human Services Agency to coordinate with the Department of Health Care Services (DHCS) and the California Department of Social Services (CDSS) to issue policy guidance establishing presumptive transfer, as defined, of responsibility for providing mental health services from the county of original jurisdiction to the foster child’s county of residence. Finally, it requires the Department of Finance to set or adjust the Behavioral Health subaccount allocations to ensure that counties who pay for mental health services pursuant to the bill are fully reimbursed

ABSTRACT

Existing law:

1. Establishes the criteria by which a child who has suffered, or is at risk of suffering, significant abuse or harm shall be within the jurisdiction of the juvenile court which may adjudge that person to be a dependent child of the court. (WIC 300)

2. Requires that a child who has been removed from the physical custody of the parent or guardian, unless placed with relatives, to be placed in the county of residence of the parent or guardian in order to facilitate reunification of the family. Further provides that, in the event that there are no appropriate placements available, a placement may be made in another county, preferably a county adjacent to the parent’s or guardian’s residence. (WIC 362.2 (g))

3. Provides that the sending county shall be responsible for providing direct supervision and services or arranging for the provision of supervision and services by the receiving county based on a developed plan or formal agreement, if applicable, specifying the activities to be provided. (WIC 362.2 (g)(5) and (6); MPP 31-505)

4. Establishes California’s Medicaid program, Medi-Cal, though which eligible low-income individuals receive health care services, including foster youth, certain recipients of the Adoption Assistance Program, and Kin-Gap. (WIC 14000 et seq.; 42 USC 1396, et seq.)

5. Pursuant to federal law, provides that children with Title IV-E Adoption Assistance, Foster Care or Guardianship care are defined as “mandatory categorically needy” when determining Medicaid eligibility. (42 CFR 435.145)

6. Establishes the federal Early and Periodic Screening, Diagnosis and Treatment (EPSDT) program to provide comprehensive and preventive health services including specialty mental health services to Medi-Cal beneficiaries under the age of 21 who have full-scope Medi-Cal eligibility. (42 USC Section 1396d)

7. Requires county mental health departments to provide children served by county social services and probation departments mental health screening, assessment, participation in multidisciplinary placement teams and specialty mental health treatment services for children placed out of home in group care, for those children who meet the definition of medical necessity, to the extent resources are available. Requires first priority be given to children currently receiving psychoactive medication. (WIC 5867.5)

8. Requires each local mental health plan to establish a procedure to ensure access to outpatient specialty mental health services, as required by EPSDT program standards, for any child in foster care who has been placed outside his or her county of adjudication. (WIC 14716)

9. Establishes the behavioral health subaccount within the support services account of the Local Revenue Fund 2011. Requires the state Controller to distribute funds on a monthly or quarterly basis pursuant to a schedule provided by the Department of Finance created in consultation with appropriate state agencies and the California State Association of Counties. Provides that funds distributed to counties from the behavioral health subaccount can only be used to provide Medi-Cal Specialty Mental Health Services, including the EPSDT benefit, and specified substance use disorder programs. (GOV 30025 and 30029.6 pursuant to SB 1020 (Chapter 40, Statutes of 2012))

This bill:

1. Establishes codified Legislative intent to ensure that foster children who are placed in their county of original jurisdiction are able to access mental health services, as specified. Further states the intent of the Legislature to overcome the barriers to mental health care existing in the current system for foster children who are placed outside their county of original jurisdiction.

2. Requires the California Health and Human Services Agency to coordinate with DHCS and CDSS to facilitate the receipt of medically necessary specialty mental health services by foster youth placed outside the county of original jurisdiction.

3. Requires DHCS to do the following on or before July 1, 2016:

1. Issue policy guidance that establishes the presumptive transfer of responsibility for providing or arranging mental health services to foster youth, consistent with EPSDT standards and requirements, from the county of original jurisdiction to the foster youth’s county of residence;

2. Establish conditions and exceptions to presumptive transfer in consultation with CDSS and with input from stakeholders, as specified.

3. Establish procedures for implementing a presumptive transfer that are consistent with the purpose and intent of the provisions of this bill and EPSDT standards and requirements. Requires DHCS to include a procedure for expedited transfer within 48 hours.

4. Defines “presumptive transfer” as responsibility for providing or arranging for mental health services being immediately transferred from the county of original jurisdiction to the county of residence, when the following occur, absent any specified conditions or exceptions:

   1. A foster child is placed in a county other than the county of original jurisdiction; and;

   2. The transfer of responsibility is requested by the county child welfare services agency, county probation department, foster caregiver, or any other person authorized to make medical decisions on behalf of the foster child.

5. Requires Department of Finance by May 1, 2016, to set or adjust its allocation schedule of the behavioral health subaccount so that counties that have paid, or will pay, for specialty mental health services for foster youth placed out-of-county are fully reimbursed during the fiscal year in which the services were provided.

6. Requires DHCS, if it determines it is necessary, to seek approval under the state’s Section 1915 (b) Medicaid waiver from the Centers for Medicare and Medicaid Services (CMS) prior to implementing the provisions in this bill. Prohibits DHCS from implementing any provision that CMS determines is not permitted under the state’s 1915 (b) waiver. (The state’s specialty mental health services are operated under a section of the 1915 (b) waiver.)

FISCAL IMPACT

According to an Assembly Appropriations Committee analysis, this bill is expected to incur annual increased costs in the medical EPSDT program in the low millions (approx 50% GF), possibly more to the extent this bill increases access to mental health services for youth who face treatment and service barriers when placed out-of-county.

BACKGROUND AND DISCUSSION

Purpose of the bill:

According to the author, the disparity in access to mental health services between in-county and out-of-county children exists despite both having the same entitlement to mental health services under federal and state law. The author states that county-based mental health plans face substantial administrative barriers when services must be provided to children placed out-of-county. Additionally, the author states that foster children are three to six times more likely to experience emotional, behavioral, and developmental problems than non-foster children. When these mental health needs go unmet, placement instability, disruptions in permanency plans, barriers to educational attainment, and other consequences can result. According to the author, “out-of-county” foster youth may be at greater risk because of lengthy delays or denials in accessing mental health services that can result from the way the system of care provision currently operates.

Background:

California is home to nearly 67,000 child welfare and probation foster children who have been removed from their homes as a result of traumatic life events usually involving severe abuse and neglect. California’s child welfare system, in assuming responsibility as the acting “parent” for dependent children, seeks to provide a continuum of placement settings, services and supports for children and their biological and foster families. An important component of these services and supports are mental health services provided under the direction of county-operated mental health plans which provide specialty Medi-Cal mental health services to children and adults.

Long-standing divisions and competing priorities between local child welfare, mental health, and education systems have led to insurmountable barriers to effectively serving many of these children within individual counties. Such barriers are further complicated when dependent children move out of their county of jurisdiction, the county with legal and financial responsibility to provide child welfare and mental health services, to a new county that often lacks mechanisms enabling the child to access needed services in the new county.

California Child Welfare System

California has a complex child welfare system incorporating federal, state and local funds expended for the broad purpose of child welfare, including child abuse prevention and response. The federal Administration of Children and Families administers numerous federal grants intended to assist states with child abuse prevention and response and to support the foster care system which provides board and care payments for eligible dependent children as well as a variety of “child welfare services” intended to support the child and family in accordance with the child’s case plan. Within the statutorily established parameters for each grant, states have substantial flexibility in how to apportion funds but are accountable to significant federal oversight of program administration.

CDSS supervises the 58 county-administered Child Welfare Services systems that investigate approximately 32,000 reports of abuse and neglect of children annually. According to CDSS, as of April of 2015, nearly one in three foster children live in Los Angeles County. Following a court order to remove a child from parental custody, existing law requires the court to order the care, custody, control and conduct of the child to be under the supervision of the social worker.¹ The social worker from the county of jurisdiction is responsible to visit the child at least monthly, to assess the child for needed services and supports and to establish a case plan that documents the services the child needs and receives.

Out-of-county placements

When children move across county lines, the county of jurisdiction retains legal responsibility for these child welfare-related activities. However, a sending county may arrange for the receiving county to assume the child welfare and/or mental health responsibilities through a formal agreement. As of January 2015, approximately 20 percent of foster youth were placed out-of-county (13,440 children) with Los Angeles County having the largest number (3,580 children) in out-of-county placement, while hosting 860 children from other counties.² Children may be placed out-of-county for a variety of reasons – to be placed with a relative, because the only appropriate and available foster home is across county lines, or because a child requires placement in a residential group home. Among children placed in group homes, 33 percent are placed out of county while 21 percent of children placed in Foster Family Agencies (FFAs) and 22 percent of children placed with relatives.³ There is wide variation across counties in the frequency and patterns of children being placed out of county and in the number of children a county “hosts.”

Existing law requires mental health plans to establish a procedure to ensure access to outpatient specialty mental health services for any child in foster care who has been placed outside the county of jurisdiction. However, children’s mental health advocates state that such care is often difficult to access. As a result, the county of jurisdiction frequently lacks relationships with a receiving county or the direct contracts with providers to enable access to needed care.

Mental Health Services for Foster Youth

A principal point of access for mental health services for foster youth is though specialty Medi-Cal mental health services, through the EPSDT program, by county-operated mental health plans amounting to at least $1.4 billion (FY2012-13).⁴ Mental health plans may provide services directly, or by contracting with local providers including group homes, FFAs, clinics and community providers.

Foster youth, like all children enrolled in Medi-Cal, are eligible for the EPSDT benefit based on their assessed medical need. This uncapped entitlement includes periodic screenings to determine a child’s medical needs and treatment services based on identified mental health needs. EPSDT mental health services ideally provide Medi-Cal enrolled children access to a continuum of mental health services including:

• Mental health assessment;

• Crisis Intervention/Stabilization;

• Day Rehabilitation/Day Treatment Intensive;

• Intensive Care Coordination;

• Medication support services;

• Targeted case management;

• Therapeutic behavioral services.

The intent of the EPSDT program is to provide children with a benefit at an exceptionally high standard of care. According to the U.S. Department of Health and Human Services:

“While there is no federal definition of preventive medical necessity, federal amount, duration and scope rules require that coverage limits must be sufficient to ensure that the purpose of a benefit can be reasonably achieved. Since the purpose of EPSDT is to prevent the onset of worsening of disability and illness and children, the standard of coverage is necessarily broad. the standard of medical necessity used by a state must be one that ensures a sufficient level of coverage to not merely treat an already-existing illness or injury but also, to prevent the development or worsening of conditions, illnesses, and disabilities.”⁵

In many counties, foster youth may also access mental health benefits through a managed care plan, which may screen for mental health needs and refer a foster youth to a provider directly, or to a county mental health plan where the child receives “specialty mental health services.”

Although EPSDT specialty mental health services are officially uncapped, they are apportioned largely according to an allocation schedule based on a mixture of 1991 and 2011 realignment formulas structured as a “rolling base” that grows each year that growth funds are available. If counties overspend their allocation, the county may seek reimbursement, however the process for this is lengthy and depends on the availability of growth monies. As a result of these complex historical financial arrangements, there is wide variation in the average payment per client, with some counties spending as little as $1,500 while others spend more than $8,000. Although some spending disparity may be the result of cost-of-living differences and population characteristics, mental health advocates argue that this spending disparity reflects disparities in access to services and standards of care.

Stakeholders describe the limited availability and scope of county mental health services for children across counties despite repeated assurances from the DHCS and county mental health departments that services are available to all children who meet very broad medical necessity criteria under EPSDT.⁶ Foster youth, caregivers, community service providers and advocates report that when a foster youth has been assessed as being in need of mental health services, it often is not until the youth is exhibiting more acute symptoms that the child accesses services -- despite the intended “early” nature of EPSDT.

Performance Outcome System

DHCS is engaged in the development of a Performance Outcome System (POS)⁷ intended to establish outcome and performance measures for EPSDT services. According to DHCS, the POS will be “used to evaluate the domains of access, engagement, service appropriateness to need, service effectiveness, linkages, cost effectiveness and satisfaction.” Additionally, the department states that three reports will be provided regarding statewide aggregate data, county groups, and county-specific data and that these reports will be updated every six months. The current report provides data for all medically eligible youth, although it is anticipated that foster-care-specific reports are forthcoming.

Related legislation:

SB 785 (Steinberg, Chapter 469, Statutes of 2007) established a form of presumptive transfer by requiring a host county provide specialty mental health services for foster youth placed out of county who move into permanency, largely through kinship guardianship and adoption.

COMMENTS

According to children’s mental health advocates, the model of presumptive transfer established under SB 785, which applied to adoptive and guardianship youth, has successfully enabled those youth to better access services. This bill proposes to expand presumptive transfer to all foster youth living outside their original county of jurisdiction, while providing exceptions to accommodate instances in which a foster youth may be better served by the original county.

The author has solicited and received substantial feedback from numerous stakeholders representing counties, mental health providers and children’s advocacy organizations, and is proposing the committee amendments in attached mock-up. Staff notes that the author and sponsors intend to continue working with stakeholders, including county representatives, to resolve several remaining concerns.

PRIOR VOTES

POSITIONS

Support:

California Alliance/Steinberg Institute/Women’s Foundation of California/Women’s Policy Institute (Co-Sponsor)

California Alliance of Child and Family Services (Co-Sponsor)

Accessing Health Services for California’s Children in Foster Care Taskforce

Alliance for Children’s Rights

Alternative Family Services

Aspiranet

Assessing Health Services for California’s Children in Foster Care Task Force

Aviva Family and Children’s Services

Bayfront Youth & Family Services

California Council of Community Mental Health Agencies

California State PTA

California Youth Connection

California Mental Health Advocates for Children and Youth

Casa Pacifica Centers for Children and Families

Child and Family Policy Institute of California

Children Now

Crittenton Services for Children and Families

Community Clinic Association of Los Angeles County

David & Margaret Youth and Family Services

Ettie Lee Youth & Family Services

Faith Advisory Council, Alameda County

Families Now

Family & Youth Roundtable

Family Care Network, Inc.

Fred Finch Youth Center

Hathaway Sycamores

Health Access California

Hillsides

Humboldt County Transition Age Youth Collaboration

Integral Community Solutions Institute

John Burton Foundation for Children Without Homes

Junior Blind of America

Lilliput Children's Services

Maryvale

Mendocino County Health and Human Services Agency

National Association of Social Workers, CA Chapter

North Star Family Center

OPTIMIST Youth Homes and Family Services

San Diego Center for Children

Seneca Family of Agencies

Sierra Forever Families

Special Education Local Plan Area

Stanford Youth Solutions

The Village Family Services

TLC Child and Family Services

Trinity Youth Services

United Advocates for Children and Families

Unity Care Group, Inc.

United Parents

Victor Treatment Centers

West Coast Children's Clinic

Young Minds Advocacy Project

Youth Homes Inc.

Oppose:

None received.

Amendments Mock-up for 2015-2016 AB-1299 (Ridley-Thomas (A))

*********Amendments are in BOLD*********

Mock-up based on Version Number 98 - Amended Assembly 4/21/15

The people of the State of California do enact as follows:

SECTION 1. Article 6 (commencing with Section 14695.1) is added to Chapter 8.8 of Part 3 of Division 9 of the Welfare and Institutions Code, to read:

Article  6. Specialty Mental Health Services for Foster Children

14695.1. (a) (1) It is the intent of the Legislature to ensure that foster children who are placed outside of their county of original jurisdiction, are able to access mental health services in a timely manner, consistent with their individualized strengths and needs and the requirements of Early Periodic Screening Diagnosis and Treatment (EPSDT) program standards and requirements.

(2) It is the further intent of the Legislature to overcome the barriers to care that exist under existing law, which place responsibility for providing or arranging for mental health services to foster children who are placed outside of their county of original jurisdiction, on those same counties.

(b) In order to facilitate the receipt of medically necessary specialty mental health services by a foster child who is placed outside of his or her county of original jurisdiction, the California Health and Human Services Agency shall coordinate with the department and the State Department of Social Services to take all of the following actions:

(1) On or before July 1, 2016, all of the following shall occur:

(A) The department shall issue policy guidance, pursuant to Section 14716, that establishes the presumptive transfer of responsibility for providing or arranging for mental health services to foster youth, consistent with the requirements of EPSDT program standards and requirements, from the county of original jurisdiction to the foster child’s county of residence., and exceptions to presumptive transfer as defined in (d).

(B) The department shall establish the policy guidance conditions and exceptions to presumptive transfer and exceptions in consultation with the State Department of Social Services, and with the input of stakeholders that include the County Welfare Directors Association of California, the County Behavioral Health Directors Association of California, provider representatives, and family and youth advocates. The conditions and exceptions to presumptive transfer are intended to ensure that the transfer of responsibility improves access to mental health care services and does not impede the continuity of existing care.

(C) The department shall establish the procedures for implementing presumptive transfer that are consistent with the purposes and intent of this section and Early Periodic Screening Diagnosis and Treatment program standards and requirements, and shall include a procedure for expedited transfer within 48 hours.

(c) “Presumptive transfer” for the purposes of this section, means that absent any conditions or exceptions as established pursuant to this article, responsibility for providing or arranging for mental health services shall immediately transfer from the county of original jurisdiction to the county of residence, under the following conditions: when all of the following conditions occur:

(1) A foster child is placed in a county other than the county of original jurisdiction; or

(2) A foster child who resides in a county other than the county of jurisdiction is not receiving mental health services consistent with his or her treatment plan and the child’s caregiver with responsibility for healthcare decisions, in consultation with the county probation or child welfare agency with responsibility for the care and placement of the child, or the Child and Family Team if one exists, requests transfer of responsibility under this section.

(2) The transfer of responsibility is requested by the county child welfare services agency, county probation department, foster caregiver, or any other person authorized to make medical decisions on behalf of the foster child.

(d) Consistent with the conditions herein and exceptions to presumptive transfer established by the department pursuant to (d) (1), the person or agency responsible for healthcare decisions, in consultation with the child and family team, if one exists, may waive the presumptive transfer, and the responsibility for the provision of mental health services shall remain with the county of original jurisdiction.

(1) On a case by case basis, the presumptive transfer specified in (c) may be waived and the responsibility for provision of specialty mental health services may remain with the mental health plan in the county of original jurisdiction when any of the following conditions are met. Such exceptions shall be documented in the child’s case plan pursuant to Section 16501.1. Exceptions may include but are not limited to, the following:

(A) It is determined that the transfer of services would disrupt continuity of care or timely access to services provided to the child, as defined in paragraph (2).

(B) It is determined that the transfer would interfere with family reunification efforts.

(C) The child’s placement out of county is expected to last less than 9 months.

(2) Exceptions to the presumptive transfer shall be contingent upon the county mental health plan in the county with dependency or delinquency jurisdiction demonstrating an existing contract with a foster care provider, or the ability to enter into a contract within 30 days of the exception decision, and the ability to deliver timely services directly to the foster child. This shall be documented in the child’s case plan.

(e) If the county of jurisdiction mental health plan has completed an assessment of needed services for the foster child, the host county shall accept the assessment. The host county may conduct additional assessments if the child’s needs change.

(f) Upon presumptive transfer, the mental health plan in the county of residence shall assume liability for the authorization and provision of services, and payments for services.

(g) The department, in consultation with counties and through any administrative means within existing authority, will amend its contract with county mental health plans no later than July 1, 2016 to ensure a host county is reimbursed for services provided pursuant to this section within the fiscal year.

14695.2. By May 1, 2016, the Department of Finance shall set or adjust its allocation schedule of the Behavioral Health Subaccount pursuant to the requirements of Senate Bill 1020 (Chapter 40, Statutes of 2012), in order that counties that have paid, or will pay, for specialty mental health services for foster children placed out of county pursuant to this article, are fully reimbursed during the fiscal year in which the services are provided.

14695.3. (a) If the department determines it is necessary, it shall seek approval under the state’s Section 1915(b) Medicaid waiver from the United States Department of Health and Human Services, Centers for Medicare and Medicaid Services (CMS) prior to implementing this article.

(b) If the department makes the determination that it is necessary to seek CMS approval pursuant to subdivision (a), the department shall make an official request for approval from CMS no later than July 1, 2016, and shall do everything within its power necessary to secure an expeditious approval from CMS.

(c) The department shall not be required to implement any provision of this article that CMS determines is not permitted under the state’s waiver.

Add New Section

SECTION 14714 of the Welfare and Institutions Code is amended to read:

14714. (a) (1) Except as otherwise specified in this chapter, a contract entered into pursuant to this chapter shall include a provision that the mental health plan contractor shall bear the financial risk for the cost of providing medically necessary specialty mental health services to Medi-Cal beneficiaries.

(2) If the mental health plan is not administered by a county, the mental health plan shall not transfer the obligation for any specialty mental health services to Medi-Cal beneficiaries to the county. The mental health plan may purchase services from the county. The mental health plan shall establish mutually agreed-upon protocols with the county that clearly establish conditions under which beneficiaries may obtain non-Medi-Cal reimbursable services from the county. Additionally, the plan shall establish mutually agreed-upon protocols with the county for the conditions of transfer of beneficiaries who have lost Medi-Cal eligibility to the county for care under Part 2 (commencing with Section 5600), Part 3 (commencing with Section 5800), and Part 4 (commencing with Section 5850) of Division 5.

(3) The mental health plan shall be financially responsible for ensuring access and a minimum required scope of benefits and services, consistent with state and federal requirements, to Medi-Cal beneficiaries who are residents of that county regardless of where the beneficiary resides except as provided for and consistent with Section 14695.1. The department shall require that the same definition of medical necessity be used, and the minimum scope of benefits offered by each mental health plan be the same, except to the extent that prior federal approval is received and is consistent with state and federal laws.

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SENATE COMMITTEE ON HEALTH

Senator Ed Hernandez, O.D., Chair

BILL NO: AB 1299

SUBJECT: Medi-Cal: specialty mental health services: foster children.

SUMMARY:

Requires the California Health and Human Services Agency to coordinate with the Departments of Health Care Services (DHCS) and Social Services to facilitate the receipt of medically necessary specialty mental health services by foster youth, as specified, and for DHCS to meet specific conditions on or before July 1, 2016. Requires the Department of Finance to set or adjust its allocation schedule of the Behavioral Health Subaccount, as specified. Requires DHCS to seek federal approval, as specified, to implement the provisions in this bill.

Existing law:

1. Establishes California’s Medicaid program, Medi-Cal, through which eligible low-income individuals receive health care services.

2. Establishes the federal Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program to provide comprehensive and preventive health services, including preventive, dental, Mental Health (MH), developmental, and specialty services to Medi-Cal beneficiaries under the age of 21 who have full-scope Medi-Cal eligibility. Requires states to administer EPSDT as a condition of receiving federal Medicaid funds.

3. Requires county MH departments that receive full system of care funding, as specified, to provide children who are served by county social services and probation departments with MH screening, assessment, participation in multidisciplinary placement teams, and specialty MH treatment services for children placed out of home in group care, for those children who meet the definition of medical necessity, to the extent resources are necessary.

4. Requires each local MH plan to establish a procedure to ensure access to outpatient specialty MH services, as required by EPSDT program standards, for any child in foster care who has been placed outside his or her county of adjudication. Requires the local MH plan of the county of original jurisdiction for a foster youth to remain responsible for providing or arranging for specialty MH services, including the costs of services, unless there is a written contract in which the county of residence accepts responsibility for payment.

5. Establishes a state and local system of child welfare services, including foster care, for children who have been adjudged by the court to have been abused or neglected, or at risk of abuse or neglect, as specified.

6. Allows a juvenile court to adjudge a child a ward or a dependent of the court for specified reasons, including, but not limited to, if the child has been left without any provision for support, as specified.

7. States that the purpose of foster care law is to provide maximum safety and protection for children who are currently being physically, sexually, or emotionally abused, neglected, or exploited, and to ensure the safety, protection, and physical and emotional well-being of children who are at risk of harm.

8. Establishes rights of foster youth, including the right to receive medical, dental, vision, and MH services.

9. Establishes the Behavioral Health Subaccount, within the Support Services Account, which funds specialty MH, Drug Medi-Cal, residential perinatal drug services and treatment; drug court operations, and other non-Drug Medi-Cal programs.

This bill:

1. Requires the California Health and Human Services Agency (CHHSA) to coordinate with DHCS and Department of Social Services (DSS) to facilitate the receipt of medically necessary specialty MH services by foster youth placed outside his or her county of original jurisdiction. Requires DHCS to do the following on or before July 1, 2016:

1. Issue policy guidance that establishes the “presumptive transfer,” as defined, of responsibility for providing or arranging MH services to foster youth, consistent with EPSDT standards and requirements, from the county of original jurisdiction to the foster youth’s county of residence;

2. Establish conditions and exceptions to presumptive transfer in consultation with DSS and with input from stakeholders, including the County Welfare Directors Association of California, the California Behavioral Health Directors Association of California, provider representatives, and family and youth advocates. The conditions and exceptions to presumptive transfer are intended to ensure that the transfer or responsibility improves access to MH services and does not impede the continuity of existing care; and,

3. Establish procedures for implementing presumptive transfer that are consistent with the purpose and intent of the provisions of this bill and EPSDT standards and requirements. Requires DHCS to include a procedure for expedited transfer within 48 hours.

2. Defines “presumptive transfer” as responsibility for providing or arranging for MH services being immediately transferred from the county of original jurisdiction to the county of residence, when the following occur:

1. A foster child is placed in a county other than the county of original jurisdiction; and,

2. The transfer of responsibility is requested by the county child welfare services agency, county probation department, foster caregiver, or any other person authorized to make medical decisions on behalf of the foster child.

3. Requires Department of Finance (DOF), by May 1, 2016, to set or adjust its allocation schedule of the Behavioral Health Subaccount so that counties that have paid, or will pay, for specialty MH services for foster youth placed out-of-county, pursuant to the provisions in this bill, are fully reimbursed during the fiscal year in which the services were provided.

4. Requires DHCS, if it determines it is necessary, to seek approval under the state’s Section 1915(b) Medicaid Waiver from the Centers for Medicare and Medicaid Services (CMS) prior to implementing the provisions in this bill. Prohibits DHCS from implementing any provision that CMS determines is not permitted under the state’s 1915(b) waiver. (The state’s specialty MH services are operated under a section of the 1915(b) waiver.)

FISCAL EFFECT:

According to the Assembly Appropriations Committee, this bill will result in annual increased costs in the EPSDT program in the low millions (approximately 50% General Fund), possibly more to the extent this bill increases access to MH services for youth who face treatment and service barriers when placed out-of-county.

PRIOR VOTES:

COMMENTS:

1. Author’s statement. According to the author, foster youth are three to six times more likely than non-foster youth to experience emotional, behavioral, and developmental problems. When a foster youth’s MH needs are not met, the result is often placement instability; disruptions in permanency plans; school failure; costly care in group homes, residential treatment facilities, and psychiatric hospitals; delinquency; and even death. Especially at risk are foster youth placed across county lines, who often experience lengthy delays or denials in accessing MH services. According to the most recent data from the California Child Welfare Indicators Project at UC Berkeley, almost one-in-five foster youth statewide (an estimated 13,000) live in placements across county lines, or “out-of-county.” This disparity in access to MH services between in-county and out-of-county youth exists despite both having the same entitlement to MH services under federal and state law.

2. Background. The purpose of state’s Child Welfare Services (CWS) system is to protect children from abuse and neglect and provide for their health and safety. When children are identified as being at risk of abuse, neglect, or abandonment, county juvenile courts hold legal jurisdiction, and children are served by the CWS system through the appointment of a social worker. Through this system, there are multiple opportunities for the custody of the child, or his or her placement outside of the home, to be evaluated, reviewed, and determined by the judicial system, in consultation with the child's social worker, to help provide the best possible services to the child. The CWS system seeks to help children who have been removed from their homes reunify with their parents or guardians, whenever appropriate, or unite them with other individuals they consider to be family. There are currently close to 63,000 children in the state’s CWS.

California has a decentralized public MH system with most direct services provided through the county MH system. Counties (county MH plans) have the primary funding and programmatic responsibility for the majority of local MH programs. The state is required to meet certain federal requirements, including those set forth by Medicaid’s child health component, known as the EPSDT program. Federal law—including statutes, regulations, and guidelines—requires Medi-Cal to cover a very comprehensive set of benefits and services for children, different from adult benefits. EPSDT provides eligible children access to a range of MH services that include, but are not limited to, MH assessment and services, therapy, rehabilitation, medication support services, day rehabilitation, day treatment intensive, crisis intervention/stabilization, targeted case management, and therapeutic behavioral services.

3. MH needs of foster youth. Foster youth have a higher likelihood of experiencing emotional, behavioral, and developmental problems when compared to their non-foster peers. Abuse and neglect and unstable placements can contribute to and exacerbate MH issues. These problems can lead to other problems, like difficulty forming stable relationships and succeeding in school. Research underscores the need for improved access to health and MH services for foster youth, and points to the high incidence of behavioral or MH problems necessitating intervention among foster youth. The disproportionately high rates of emotional and behavioral health issues for youth placed in foster care, youth transitioning from foster care, and former foster youth can be correlated with other barriers foster youth face, such as higher rates of incarceration and homelessness, diminished rates of high school completion and college attendance, and disproportionate prescribing of antipsychotic and psychotropic medications, as highlighted in an 2014 exposé by the San Jose Mercury News.

There are indications that out-of-county foster youth may have higher needs and less access when it comes to MH treatment. A 2011 report issued by the California Child Welfare Council found that out-of-county foster youth were more likely to have been diagnosed with a serious MH disorder, yet were 10-15 percent less likely to have received any MH services compared to their in-county peers. And among those that did receive services, in-county foster youth fared better, receiving more care and more intensive treatment.

4. Double referral. This bill is double referred. Should it pass out of this committee, it will be referred to the Senate Human Services Committee.

5. Prior legislation. AB 1808 (Galgiani), of 2009, was substantially similar to this bill. AB 1808 was held on the suspense file of the Assembly Appropriations Committee.

SB 785 (Steinberg), Chapter 469, Statutes of 2007, facilitates the access to MH services for foster youth who are placed outside of the original county of jurisdiction, including those being adopted or entering into a guardianship with a relative.

6. Support. Supporters of this bill, largely behavioral health and family advocates, argue that the question of which MH plan is responsible for providing much-needed services to foster youth who have been placed outside of their counties of jurisdiction has vexed California for more than 20 years. They state that foster youth go through transitions where their mental stability takes a toll and that this bill will ensure that the MH needs of these foster youth will not be delayed or denied as the youth transition to a new county of residence. Supporters further argue that foster youth already have a rough start in life, and not being able to access MH services, which they are entitled to, in a timely and efficient manner puts them at an even greater risk of serious harm and potentially permanent negative outcomes.

SUPPORT AND OPPOSITION:

Support: California Alliance of Child and Family Services (co-sponsor)

Steinberg Institute (co-sponsor)

Women’s Foundation of California/Women’s Policy Institute (co-sponsor)

Accessing Health Services for California’s Children in Foster Care Task Force

Alameda County Faith Initiative Office Faith Advisory Council

Alameda County Foster Youth Alliance

Alternative Family Services

American Federation of State, County and Municipal Employees

Association of Community Human Services Agencies

Aviva Family and Children’s Services

Bienvenidos Children’s Center

Bill Wilson Center

California Council of Community Mental Health Agencies

California Mental Health Advocates for Children and Youth

California State PTA

Casa Pacifica Centers for Children and Families

ChildNet Youth and Family Services

Crittenton Services for Children and Families

David and Margaret Youth and Family Services

Ella Baker Center for Human Rights

EMQ Families First

Ettie Lee Youth and Family Services

Families Now

Family Care Network, Inc.

First Place for Youth

Fred Finch Youth Center

Hathaway-Sycamores Child and Family Services

Humboldt County Transition Age Youth Collaboration

Integral Community Solutions Institute

Junior Blind of America

Junior League of San Francisco

Junior Leagues of California State Public Affairs Committee

Lilliput Children’s Services

Lincoln Child Center

Maryvale

Mendocino County Health and Human Services Agency

National Association of Social Workers – California Chapter

North Star Family Center

Optimist Youth Homes and Family Services

Orange County Alliance for Children and Families

Sacramento Children’s Home

San Diego Center for Children

Seneca Family of Agencies

Sierra Forever Families

Stars Behavioral Health Group

Summitview Child & Family Services, Inc.

The Village Family Services

TLC Child and Family Services

Trinity Youth Services

United Advocates for Children and Families

Unity Care Group, Inc.

West Coast Children’s Clinic

Young Minds Advocacy Project

Youth Homes, Inc.

Oppose: None received.

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ASSEMBLY THIRD READING

ATR Bill Id:AB 1299

Author:(Ridley-Thomas)

As Amended Ver:April 21, 2015

Majority vote

SUMMARY: Transfers responsibility for providing or arranging mental health services for foster youth from the county of original jurisdiction to the foster child’s county of residence. Specifically, this bill:

1. States that it is the intent of the Legislature to ensure that foster children who are placed in their county of original jurisdiction are able to access mental health services, as specified. Further states the intent of the Legislature to overcome the barriers to mental health care existing in the current system for foster children who are placed outside their county of original jurisdiction.

2. Defines "presumptive transfer" to mean that responsibility for providing or arranging for mental health services shall immediately transfer from a foster youth’s county of original jurisdiction to his or her county of residence, provided he or she is placed in a county other than the county of original jurisdiction and the request is made by specified entities or individuals.

3. Requires the California Health and Human Services Agency to coordinate with the Department of Health Care Services (DHCS) and the Department of Social Services (DSS) to take the following actions by July 1, 2016:

1. Requires DHCS to issue policy guidance, as specified, that establishes the presumptive transfer of responsibility for mental health services for a foster youth from his or her county of original jurisdiction to his or her county of residence;

2. Requires DHCS, in consultation with DSS and with the input of specified stakeholders, to establish the conditions of and exceptions to presumptive transfer, intended to improve access to mental health care services and not impede the continuity of existing care; and

3. Requires DHCS to establish procedures for implementing presumptive transfer as specified and consistent with Early Periodic Screening, Diagnosis, and Treatment (EPSDT) program standards and requirements, and including a procedure for expedited transfer within 48 hours.

4. Requires the Department of Finance, by May 1, 2016, to set or adjust its allocation schedule of the Behavioral Health Subaccount, as specified, such that counties that pay or have paid for specialty mental health services for foster children placed out of county are fully reimbursed within the fiscal year the services are provided.

5. Requires DHCS, if it determines necessary, to seek approval under the state’s Section 1915(b) Medicaid waiver, as specified, by July 1, 2016. Further specifies that DHCS shall not be required to implement any provision of this bill that the Centers for Medicare and Medicaid Services (CMS) determines impermissible per the state’s waiver.

EXISTING LAW:

1. Establishes a state and local system of child welfare services, including foster care, for children who have been adjudged by the court to have been abused or neglected, or at risk of abuse or neglect, as specified. (Welfare and Institutions Code (WIC) Section 202)

2. States that the purpose of foster care law is to provide maximum safety and protection for children who are currently being physically, sexually, or emotionally abused, neglected, or exploited, and to ensure the safety, protection, and physical and emotional well-being of children who are at risk of harm. (WIC Section 300.2)

3. Establishes rights of foster children, including the right to receive medical, dental, vision, and mental health services. (WIC Section 16001.9)

4. Establishes the federal Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program to provide comprehensive and preventive health services, including preventive, dental, mental health, and developmental, and specialty services, to Medicaid beneficiaries under the age of 21. Requires states to administer EPSDT as a condition of receiving federal Medicaid funds. (42 United States Code Section 1396(d))

5. Requires county mental health departments that receive full system of care funding, as specified, to provide children served by county social services and probation departments mental health screening, assessment, participation in multidisciplinary placement teams and specialty mental health treatment services for children placed out of home in group care, for those children who meet the definition of medical necessity, to the extent resources are necessary. (WIC Section 5867.5)

6. Requires each local mental health plan to establish a procedure to ensure access to outpatient specialty mental health services, as required by EPSDT program standards, for any child in foster care who has been placed outside his or her county of adjudication. (WIC Section 14716)

7. Establishes the Behavioral Health Subaccount within the Support Services Account. (Government Code Section 30025)

FISCAL EFFECT: According to the Assembly Appropriations Committee, this bill will result in annual increased costs in the EPSDT program in the low millions (approximately 50% General Fund), possibly more to the extent this bill increases access to mental health services for youth who face treatment and service barriers when placed out-of-county.

COMMENTS:

Mental health needs of foster youth: Foster youth have a higher likelihood of experiencing emotional, behavioral, and developmental problems when compared to their non-foster peers. Abuse and neglect and unstable placements can contribute to, and exacerbate, mental health issues. These problems, in turn, can lead to other problems, like difficulty forming stable relationships and succeeding in school.

Research underscores the need for improved access to health and mental health services for foster children and youth, and points to the high incidence of behavioral or mental health problems necessitating intervention among foster youth. The disproportionately high rates of emotional and behavioral health issues for youth placed in foster care, youth transitioning from foster care, and former foster youth can be correlated with other barriers foster youth face (such as higher rates of incarceration and homelessness and diminished rates of high school completion and college attendance).

EPSDT: One in three children under the age of six in the United States is eligible for Medicaid. EPSDT is Medicaid’s child health component. Federal law requires a comprehensive set of benefits and services to be provided to children and youth under the age of 21 through Medicaid. On top of the standard benefits that Medi-Cal beneficiaries receive, children and youth are eligible for additional medically necessary services. Mental health services are recognized as an important component of children’s health care. Comprehensive well-child examinations including screening services through EPSDT, and screening for potential developmental, mental, behavioral, and/or substance use disorders are required by federal law.

Need for this bill: According to the author, foster children are three to six times more likely to experience emotional, behavioral, and developmental problems compared to non-foster children. When these mental health needs go unmet, placement instability, disruptions in permanency plans, barriers to educational attainment, and other consequences can result.

Youth dubbed "out-of-county" have been placed in a county other than the one in which they originally enter foster care (i.e., the "county of original jurisdiction"). The author reports that, as of July 2014, close to 20% of foster children (13,000) were considered "out-of-county." "Out-of-county" foster youth may be placed at greater risk because of lengthy delays or denials in accessing mental health services that can result from the way the system of care provision currently operates. This is because, when a youth in foster care is placed out of county, the county of original jurisdiction remains responsible for providing or arranging for necessary medical and mental health treatment for that youth. Mental health services – "Specialty Mental Health Medi-Cal" – are separate from other medical services and each county’s mental health plan must authorize and provide payment for the mental health services received by the child.

There are indications that out-of-county foster youth may have higher needs and less access when it comes to mental health care. A 2011 report issued by the California Child Welfare Council found that out-of-county foster youth were more likely to have been diagnosed with a serious mental health disorder, yet were 10% to 15% less likely to have received any mental health services compared to their in-county peers. And among those that did receive services, in-county foster youth fared better, receiving more care and more intensive treatment.

Analysis Prepared by: Daphne Hunt / HUM. S. / (916) 319-2089 FN: 0000626

Date of Hearing: May 27, 2015

ASSEMBLY COMMITTEE ON APPROPRIATIONS

Jimmy Gomez, Chair

ABPCA Bill Id:AB 1299

Author:(Ridley-Thomas) – As Amended Ver:April 21, 2015

Urgency: No State Mandated Local Program: No Reimbursable: No

SUMMARY:

This bill would shift responsibility for the provision of medically necessary mental health services for foster youth placed out-of-county, from the county of original jurisdiction to the foster youth's county of residence, in order to increase access to mental health services for youth.

FISCAL EFFECT:

Annual increased costs in the medical Early Periodic Screening Treatment and Diagnosis Program (EPSDT) in the low millions (approx 50% GF), possibly more to the extent this bill increases access to mental health services for youth who face treatment and service barriers when placed out-of-county.

COMMENTS:

1. Purpose. This bill moves responsibility for the provision of mental health services for foster youth from the county-of-origin to the host county. The author indicates current law arrangements result in treatment delays and denials when a child is placed out-of-county and the host county must recover mental health funding from the county from which the child was removed.

2. Background. There are indications that out-of-county foster youth may have higher needs and less access to mental health care. A 2011 report issued by the California Child Welfare Council found that out-of-county foster youth were more likely to have been diagnosed with a serious mental health disorder, yet were 10% to 15% less likely to have received any mental health services compared to their in-county peers. And among those that did receive services, in-county foster youth fared better, receiving more care and more intensive treatment. As of July 2014, nearly 20% of foster children (13,000) were considered out-of-county.

The Early and Periodic Screening, Diagnosis and Treatment Program (EPSDT), is a federally-mandated benefit under Medi-Cal. States must provide medically necessary services to specified children. If a physician screening determines a child needs additional treatment, Medi-Cal must provide the services according the federal mandate. EPSDT is the source of funding for a majority of mental health treatment for children in foster care. Mental health services provided to foster youth include outpatient services, medication support, behavioral therapy, and 24-hour care.

3. Prior Legislation.

1. AB 1808 (Galgiani) of 2009 was substantially similar to this bill. AB 1808 was held on this Committee’s Suspense File.

2. SB 785 (Steinberg), Chapter 469, Statutes of 2007, required the California Department of Mental Health 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.

Analysis Prepared by: Jennifer Swenson / APPR. / (916) 319-2081

Date of Hearing: April 28, 2015

ASSEMBLY COMMITTEE ON HEALTH

Rob Bonta, Chair

ABPCA Bill Id:AB 1299

Author:(Ridley-Thomas) – As Amended Ver:April 21, 2015

SUBJECT: Medi-Cal: specialty mental health services: foster children.

SUMMARY: Transfers responsibility for providing or arranging mental health services for foster youth from the county of original jurisdiction to the foster child’s county of residence. Specifically, this bill:

1. Requires the California Health and Human Services Agency to coordinate with the Department of Health Care Services (DHCS) and the Department of Social Services (DSS) to take the following actions by July 1, 2016:

1. Requires DHCS to issue policy guidance, as specified, that establishes the presumptive transfer of responsibility for mental health services for a foster youth from his or her county of original jurisdiction to his or her county of residence;
   
   

2. Requires DHCS, in consultation with DSS and with the input of specified stakeholders, to establish the conditions of and exceptions to presumptive transfer, intended to improve access to mental health care services and not impede the continuity of existing care; and,
   
   

3. Requires DHCS to establish procedures for implementing presumptive transfer as specified and consistent with Early Periodic Screening, Diagnosis, and Treatment (EPSDT) program standards and requirements, and including a procedure for expedited transfer within 48 hours.

2. Defines “presumptive transfer” to mean that responsibility for providing or arranging for mental health services must immediately transfer from a foster youth’s county of original jurisdiction to his or her county of residence, provided he or she is placed in a county other than the county of original jurisdiction and the request is made by specified entities or individuals.

3. Requires the Department of Finance, by May 1, 2016, to set or adjust its allocation schedule of the Behavioral Health Subaccount, as specified, such that counties that pay or have paid for specialty mental health services for foster children placed out of county are fully reimbursed within the fiscal year the services are provided.

4. Requires DHCS, if it determines necessary, to seek approval under the state’s Section 1915(b) Medicaid waiver, as specified. Further specifies that DHCS is not required to implement any provision of this bill that the Centers for Medicare and Medicaid Services (CMS) determines impermissible per the state’s waiver.

EXISTING LAW:

1. Establishes California’s Medicaid program, Medi-Cal, through which eligible low-income individuals receive health care services.

2. Establishes the federal EPSDT program to provide comprehensive and preventive health services, including preventive, dental, mental health, developmental, and specialty services to Medicaid beneficiaries under the age of 21. Requires states to administer EPSDT as a condition of receiving federal Medicaid funds.

3. Requires county mental health departments that receive full system of care funding, as specified, to provide children served by county social services and probation departments mental health screening, assessment, participation in multidisciplinary placement teams and specialty mental health treatment services for children placed out of home in group care, for those children who meet the definition of medical necessity, to the extent resources are necessary.

4. Requires each local mental health plan to establish a procedure to ensure access to outpatient specialty mental health services, as required by EPSDT program standards, for any child in foster care who has been placed outside his or her county of adjudication.

5. Establishes the Behavioral Health Subaccount within the Support Services Account.

6. Establishes a state and local system of child welfare services, including foster care, for children who have been adjudged by the court to have been abused or neglected, or at risk of abuse or neglect, as specified.

7. Allows a juvenile court to adjudge a child a ward or a dependent of the court for specified reasons, including but not limited to if the child has been left without any provision for support, as specified.

8. States that the purpose of foster care law is to provide maximum safety and protection for children who are currently being physically, sexually, or emotionally abused, neglected, or exploited, and to ensure the safety, protection, and physical and emotional well-being of children who are at risk of harm.

9. Establishes rights of foster children, including the right to receive medical, dental, vision, and mental health services.

FISCAL EFFECT: This bill has not been analyzed by a fiscal committee.

COMMENTS:

1. PURPOSE OF THIS BILL. According to the author, foster children are three to six times more likely to experience emotional, behavioral, and developmental problems compared to non-foster children. The author explains that when these mental health needs go unmet, placement instability, disruptions in permanency plans, barriers to educational attainment, and other consequences can result. Youth dubbed “out-of-county” have been placed in a county other than the one in which they originally enter foster care (i.e., the “county of original jurisdiction”). The author reports that, as of July 2014, close to 20% of foster children (13,000) were considered out-of-county and that out-of-county foster youth may be placed at greater risk because of lengthy delays or denials in accessing mental health services that can result from the way the system of care provision currently operates. This problem results, the author explains because, when a youth in foster care is placed out of county, the county of original jurisdiction remains responsible for providing or arranging for necessary medical and mental health treatment for that youth. Mental health services in Medi-Cal are provided differently from other medical services and each county’s mental health plan must authorize and provide payment for the mental health services received by the child.

2. BACKGROUND.

   1. Child Welfare Services. The purpose of California's Child Welfare Services (CWS) system is to protect children from abuse and neglect and provide for their health and safety. When children are identified as being at risk of abuse, neglect, or abandonment, county juvenile courts hold legal jurisdiction and children are served by the CWS system through the appointment of a social worker. Through this system, there are multiple opportunities for the custody of the child, or his or her placement outside of the home, to be evaluated, reviewed and determined by the judicial system, in consultation with the child's social worker, to help provide the best possible services to the child. The CWS system seeks to help children who have been removed from their homes reunify with their parents or guardians, whenever appropriate, or unite them with other individuals they consider to be family. There are currently close to 63,000 children in California’s child welfare system.

2. Mental health needs of foster youth. Foster youth have a higher likelihood of experiencing emotional, behavioral, and developmental problems when compared to their non-foster peers. Abuse and neglect and unstable placements can contribute to, and exacerbate, mental health issues. These problems, in turn, can lead to other problems, like difficulty forming stable relationships and succeeding in school.

Research underscores the need for improved access to health and mental health services for foster children and youth, and points to the high incidence of behavioral or mental health problems necessitating intervention among foster youth. The disproportionately high rates of emotional and behavioral health issues for youth placed in foster care, youth transitioning from foster care, and former foster youth can be correlated with other barriers foster youth face (such as higher rates of incarceration and homelessness and diminished rates of high school completion and college attendance).

There are indications that out-of-county foster youth may have higher needs and less access when it comes to mental health care. A 2011 report issued by the California Child Welfare Council found that out-of-county foster youth were more likely to have been diagnosed with a serious mental health disorder, yet were 10% to 15% less likely to have received any mental health services compared to their in-county peers. And among those that did receive services, in-county foster youth fared better, receiving more care and more intensive treatment.

3. County Mental Health Programs. California has a decentralized public mental health system with most direct services provided through the county mental health system. Counties (i.e., county mental health plans) have the primary funding and programmatic responsibility for the majority of local mental health programs. The state is required to meet certain federal requirements, including those set forth by Medicaid’s child health component, known as the EPSDT program. EPSDT is a Medi-Cal benefit for individuals under the age of 21 who have full-scope Medi-Cal eligibility.  Federal law – including statutes, regulations, and guidelines – requires that Medi-Cal cover a very comprehensive set of benefits and services for children, different from adult benefits. EPSDT provides eligible children access to a range of mental health services that include, but are not limited to:
   
   

1. Mental health assessment;

2. Therapy;

3. Rehabilitation;

4. Mental health services;

5. Medication support services;

6. Day rehabilitation;

7. Day treatment intensive;

8. Crisis intervention/stabilization;

9. Targeted case management

10. Therapeutic behavioral services.

3. SUPPORT. Supporters state the question of which county mental health plan is responsible for providing children and youth in foster care placed outside their counties of jurisdiction the behavioral health services they need and to which they are entitled has vexed California for over 20 years. According to supporters, as a result, foster children and youth placed across county lines often experience lengthy delays in accessing behavioral health services or are denied service altogether.

Supporters argue that this bill would ensure that foster children and youth who are placed outside of their county of jurisdiction, are able to access mental health services in a timely manner responsive to their individual needs and strengths, and consistent with the requirements of the Medi-Cal EPSDT and Specialty Mental Health Services program standards and requirements.

4. PREVIOUS LEGISLATION.

   1. AB 1808 (Galgiani) of 2009 was substantially similar to this bill. AB 1808 was held on the Suspense File of the Assembly Appropriations Committee.

   2. SB 785 (Steinberg), Chapter 469, Statutes of 2007 facilitates the access to mental health services for foster children who are placed outside of the original county of jurisdiction, including those being adopted or entering into a guardianship with a relative.

DOUBLE REFERRAL. This bill has been double referred. It passed the Assembly Committee on Human Services with a vote of 7-0 on April 14, 2015..

REGISTERED SUPPORT / OPPOSITION:

Support

California Alliance of Child and Family Services, (co sponsor

California Mental Health Advocates for Children and Youth, (co-sponsor)

Women's Foundation of California (co-sponsor)

Alameda County Foster Youth Alliance

American Federation of State, County and Municipal employees, AFL-CIO

Aviva Family and Children's Services

Bill Wilson Center

California Council of Community Mental Health Agencies

California Primary Care Association

Crittenton Services for Children and Families

David & Margaret Youth and Family Services

EMQ Families First

Ettie Lee Youth & Family Services

Families NOW

Family Care Network, Inc.

First Place for Youth

Foster Youth Alliance

Fred Finch Youth Center

Hathaway Sycamores

Integral Community Solutions Group

Junior Blind of America

Lilliput Children's Services

Lincoln Child Center

Maryvale

Mendocino County Health and Human Services Agency

National Association of Social Workers, CA Chapter

North Star Family Center

OPTIMIST

Orange County Alliance for Children and Families

San Diego Center for Children

Seneca Family of Agencies

Sierra Forever Families

Steinberg Institute

Sunny Hills Services

The Association of Community Human Services Agencies

The Edgewood Center for Children and Families

The Village Family Services

The Women's Foundation of California

TLC Child and Family Services

Trinity Youth Services

United Advocates for Children and Families

Unity Care Group, Inc.

Valley Teen Ranch

WestCoast Children's Clinic

Young Minds Advocacy Project

Youth Homes Inc.

Opposition

None on file.

Analysis Prepared by: Roger Dunstan / HEALTH / (916) 319-2097

Date of Hearing: April 14, 2015

ASSEMBLY COMMITTEE ON HUMAN SERVICES

Kansen Chu, Chair

ABPCA Bill Id:AB 1299

Author:(Ridley-Thomas) – As Introduced Ver:February 27, 2015

SUBJECT: Medi-Cal: specialty mental health services: foster children

SUMMARY: Transfers responsibility for providing or arranging mental health services for foster youth from the county of original jurisdiction to the foster child’s county of residence.

Specifically, this bill:

1. States that it is the intent of the Legislature to ensure that foster children who are placed in their county of original jurisdiction are able to access mental health services, as specified. Further states the intent of the Legislature to overcome the barriers to mental health care existing in the current system for foster children who are placed outside their county of original jurisdiction.

2. Defines “presumptive transfer” to mean that responsibility for providing or arranging for mental health services shall immediately transfer from a foster youth’s county of original jurisdiction to his or her county of residence, provided he or she is placed in a county other than the county of original jurisdiction and the request is made by specified entities or individuals.

3. Requires the California Health and Human Services Agency to coordinate with the Department of Health Care Services (DHCS) and the Department of Social Services (DSS) to take the following actions by July 1, 2016:

1. Requires DHCS to issue policy guidance, as specified, that establishes the presumptive transfer of responsibility for mental health services for a foster youth from his or her county of original jurisdiction to his or her county of residence;
   
   

2. Requires DHCS, in consultation with DSS and with the input of specified stakeholders, to establish the conditions of and exceptions to presumptive transfer, intended to improve access to mental health care services and not impede the continuity of existing care; and
   
   

3. Requires DHCS to establish procedures for implementing presumptive transfer as specified and consistent with Early Periodic Screening, Diagnosis, and Treatment (EPSDT) program standards and requirements, and including a procedure for expedited transfer within 48 hours.

4. Requires the Department of Finance, by May 1, 2016, to set or adjust its allocation schedule of the Behavioral Health Subaccount, as specified, such that counties that pay or have paid for specialty mental health services for foster children placed out of county are fully reimbursed within the fiscal year the services are provided.

5. Requires DHCS, if it determines necessary, to seek approval under the state’s Section 1915(b) Medicaid waiver, as specified. Further specifies that DHCS shall not be required to implement any provision of this bill that the Centers for Medicare and Medicaid Services (CMS) determines impermissible per the state’s waiver.

EXISTING LAW:

1. Establishes a state and local system of child welfare services, including foster care, for children who have been adjudged by the court to have been abused or neglected, or at risk of abuse or neglect, as specified. (WIC 202)

2. Allows a juvenile court to adjudge a child a ward or a dependent of the court for specified reasons, including but not limited to if the child has been left without any provision for support, as specified. (WIC 300)

3. States that the purpose of foster care law is to provide maximum safety and protection for children who are currently being physically, sexually, or emotionally abused, neglected, or exploited, and to ensure the safety, protection, and physical and emotional well-being of children who are at risk of harm. (WIC 300.2)

4. Establishes rights of foster children, including the right to receive medical, dental, vision, and mental health services. (WIC 16001.9)

5. Establishes the federal Medicaid program to provide health benefits to low-income individuals. (42 U.S.C. Section 1396 et seq.) 

6. Establishes California’s Medicaid program, Medi-Cal, through which eligible low-income individuals receive health care services. (WIC 14000 et seq.)

7. Establishes the federal Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program to provide comprehensive and preventive health services, including preventive, dental, mental health, and developmental, and specialty services, to Medicaid beneficiaries under the age of 21. Requires states to administer EPSDT as a condition of receiving federal Medicaid funds. (42 USC Section 1396d)

8. Requires county mental health departments that receive full system of care funding, as specified, to provide children served by county social services and probation departments mental health screening, assessment, participation in multidisciplinary placement teams and specialty mental health treatment services for children placed out of home in group care, for those children who meet the definition of medical necessity, to the extent resources are necessary. (WIC 5867.5)

9. Requires each local mental health plan to establish a procedure to ensure access to outpatient specialty mental health services, as required by EPSDT program standards, for any child in foster care who has been placed outside his or her county of adjudication. (WIC 14716)

10. Establishes the Behavioral Health Subaccount within the Support Services Account. (GOV 30025)

FISCAL EFFECT: Unknown

COMMENTS:

Child Welfare Services: The purpose of California's Child Welfare Services (CWS) system is to protect children from abuse and neglect and provide for their health and safety. When children are identified as being at risk of abuse, neglect or abandonment, county juvenile courts hold legal jurisdiction and children are served by the CWS system through the appointment of a social worker. Through this system, there are multiple opportunities for the custody of the child, or his or her placement outside of the home, to be evaluated, reviewed and determined by the judicial system, in consultation with the child's social worker, to help provide the best possible services to the child. The CWS system seeks to help children who have been removed from their homes reunify with their parents or guardians, whenever appropriate, or unite them with other individuals they consider to be family. There are currently close to 63,000 children in California’s child welfare system.

Mental health needs of foster youth: Foster youth have a higher likelihood of experiencing emotional, behavioral, and developmental problems when compared to their non-foster peers. Abuse and neglect and unstable placements can contribute to, and exacerbate, mental health issues. These problems, in turn, can lead to other problems, like difficulty forming stable relationships and succeeding in school.

Research underscores the need for improved access to health and mental health services for foster children and youth, and points to the high incidence of behavioral or mental health problems necessitating intervention among foster youth. The disproportionately high rates of emotional and behavioral health issues for youth placed in foster care, youth transitioning from foster care, and former foster youth can be correlated with other barriers foster youth face (such as higher rates of incarceration and homelessness and diminished rates of high school completion and college attendance).

EPSDT: One in three children under the age of six in the United States is eligible for Medicaid. Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) is Medicaid’s child health component. Federal law requires a comprehensive set of benefits and services to be provided to children and youth under the age of 21 through Medicaid. On top of the standard benefits that Medi-Cal beneficiaries receive, children and youth are eligible for additional medically necessary services. Mental health services are recognized as an important component of children’s health care. Comprehensive well-child examinations including screening services through EPSDT, and screening for potential developmental, mental, behavioral, and/or substance use disorders are required by federal law.

Need for this bill: According to the author, foster children are three to six times more likely to experience emotional, behavioral, and developmental problems compared to non-foster children. When these mental health needs go unmet, placement instability, disruptions in permanency plans, barriers to educational attainment, and other consequences can result.

Youth dubbed “out-of-county” have been placed in a county other than the one in which they originally enter foster care (i.e., the “county of original jurisdiction”). The author reports that, as of July 2014, close to 20% of foster children (13,000) were considered “out-of-county.” “Out-of-county” foster youth may be placed at greater risk because of lengthy delays or denials in accessing mental health services that can result from the way the system of care provision currently operates. This is because, when a youth in foster care is placed out of county, the county of original jurisdiction remains responsible for providing or arranging for necessary medical and mental health treatment for that youth. Mental health services – “Specialty Mental Health Medi-Cal” – are separate from other medical services and each county’s mental health plan must authorize and provide payment for the mental health services received by the child.

There are indications that out-of-county foster youth may have higher needs and less access when it comes to mental health care. A 2011 report issued by the California Child Welfare Council found that out-of-county foster youth were more likely to have been diagnosed with a serious mental health disorder, yet were 10 to 15% less likely to have received any mental health services compared to their in-county peers. And among those that did receive services, in-county foster youth fared better, receiving more care and more intensive treatment.

The author states that:

“The disparity in access to mental health services between in-county and out-of-county children exists despite both having the same entitlement to mental health services under federal and state law.

The problem stems from California’s county-based system of mental health delivery. Medi-Cal Specialty Mental Health Services are provided using a system of county-based managed care agencies or Mental Health Plans (MHPs) under contract with the Department of Health Care Services. Each MHP, in turn, contracts with local private mental health service providers (or uses county mental health staff) to deliver services.

This system works efficiently for many children and youth. However, the county-based MHPs face substantial administrative barriers when services must be provided to children placed out-of-county, that is, outside the service area for its network of providers. These problems include difficulty: 1) finding providers and services in the child’s county of residence; 2) contracting for care; 3) getting treatment authorizations; 4) coordinating and monitoring care; and 5) securing adequate reimbursements from responsible parties including federal, state, and local agencies.”

Recommended amendments:

1. Committee staff recommends the following technical amendments, beginning on line 21 of page 2 of the bill:

8 (b) In order to facilitate the receipt of medically necessary

9 specialty mental health services by a foster child who is placed

10 outside of his or her county of original jurisdiction, the California

11 Health and Human Services Agency shall coordinate with the

12 department and the State Department of Social Services to take

13 all of the following actions:

14 (1) On or before July 1, 2016, all of the following shall occur:

15 (A) The department shall issue policy guidance, pursuant to

16 Section 14716, that establishes the presumptive transfer of

17 responsibility for providing or arranging for mental health services

18 to foster youth, consistent with the requirements of EPSDT

19 program standards and requirements, from the county of original

20 jurisdiction to the foster child's county of residence.

21 (B) "Presumptive transfer" for the purposes of this section means

22 that absent any conditions or exceptions as established pursuant

23 to this article, responsibility for providing or arranging for mental

24 health services shall immediately transfer from the county of

25 original jurisdiction to the county of residence, when the all of the

26 following conditions occur:

27 (i) A foster child is placed in a county other than the county of

28 original jurisdiction.

29 (ii) The transfer of responsibility is requested by the county

30 child welfare services agency, county probation department, foster

31 caregiver, or any other person authorized to make medical decisions

32 on behalf of the foster child.

33 (C) (B) The department shall establish the conditions and exceptions

34 to presumptive transfer in consultation with the State Department

35 of Social Services, and with the input of stakeholders that include

36 the County Welfare Directors Association of California, the County

37 Behavioral Health Directors Association of California, provider

38 representatives, and family and youth advocates. The conditions

39 and exceptions to presumptive transfer are intended to ensure that

1 the transfer of responsibility improves access to mental health care

2 services and does not impede the continuity of existing care.

3 (D) (C) The department shall establish the procedures for

4 implementing presumptive transfer that are consistent with the

5 purposes and intent of this section and Early Periodic Screening

6 Diagnosis and Treatment program standards and requirements,

7 and shall include a procedure for expedited transfer within 48

8 hours.

(c) “Presumptive transfer” for the purposes of this section means

that absent any conditions or exceptions as established pursuant

to this article, responsibility for providing or arranging for mental

health services shall immediately transfer from the county of

original jurisdiction to the county of residence, when all of the

following conditions occur:

(1) A foster child is place in a county other than the county of

original jurisdiction.

(2) The transfer of responsibility is requested by the county

child welfare services agency, county probation department, foster

caregiver, or any other person authorized to make medical decisions

on behalf of the foster child.

9 14695.2. By May 1, 2016, the Department of Finance shall set

10 or adjust its allocation schedule of the Behavioral Health

11 Subaccount pursuant to the requirements of Senate Bill 1020

12 (Chapter 40, Statutes of 2012), in order that counties that have

13 paid, or will pay, for specialty mental health services for foster

14 children placed out of county pursuant to this article, are fully

15 reimbursed during the fiscal year in which the services are

16 provided.

2. In order to clarify the deadline for seeking CMS waiver approval being placed upon DHCS, committee staff recommends the following amendment be made on line 25 of page 4 of the bill:

17 14695.3. (a) If the department determines it is necessary, it

18 shall seek approval under the state's Section 1915(b) Medicaid

19 waiver from the United States Department of Health and Human

20 Services, Centers for Medicare and Medicaid Services (CMS) prior

21 to implementing this article.

22 (b) If the department makes the determination that it is necessary

23 to seek CMS approval pursuant to subdivision (a), the department

24 shall make an official request for approval from CMS no later than

25 July 1, 2016, and shall do everything within its power necessary to secure

26 an expeditious approval from CMS.

27 (c) The department shall not be required to implement any

28 provision of this article that CMS determines is not permitted under

29 the state's waiver.

DOUBLE REFERRAL. This bill has been double-referred. Should this bill pass out of this committee, it will be referred to the Assembly Committee on Health.

REGISTERED SUPPORT / OPPOSITION:

Support

California Alliance of Child and Family Services, co-sponsor

California Mental Health Advocates for Children and Youth (CMHACY), co-sponsor

Women's Foundation of California (co-sponsor)

American Federation of State, County and Municipal employees (AFSCMEE), AFL-CIO

Aviva Family and Children's Services

Bill Wilson Center

California Council of Community Mental Health Agencies

California Primary Care Association (CPCA)

Crittenton Services for Children and Families

David &Margaret Youth and Family Services

EMQ Families First

Ettie Lee Youth & Family Services

Families NOW

Family Care Network, Inc.

Foster Youth Alliance

Fred Finch Youth Center (FFYC)

Hathaway Sycamores

Junior Blind of America

Maryvale

Mendocino County Health and Human Services Agency

National Association of Social Workers, CA Chapter (NASW-CA)

OPTIMIST

Orange County Alliance for Children and Families

San Diego Center for Children (the Center)

Seneca Family of Agencies

Sierra Forever Families

Steinberg Institute

Sunny Hills Services

The Association of Community Human Services Agencies (ACHSA)

The Village Family Services

The Women's Foundation of California

TLC Child and Family Services

Trinity Youth Services

United Advocates for Children and Families (UACF)

Valley Teen Ranch

Young Minds Advocacy Project

Youth Homes Inc.

Opposition

None on file.

Analysis Prepared by: Daphne Hunt / HUM. S. / (916) 319-2089