Existing law provides for the Medi-Cal program, which is administered by the State Department of Health Care Services and under which qualified low-income individuals receive health care services, including Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) for any individual under 21 years of age who is covered under Medi-Cal consistent with the requirements under federal law. The Medi-Cal program is, in part, governed and funded by federal Medicaid program provisions.

Existing federal law provides that EPSDT services include periodic 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.

This bill would require, consistent with federal law, that screening services under the EPSDT program include developmental screening services for individuals zero to 3 years of age, inclusive. Until July 1, 2023, the bill would require an external quality review organization entity to annually review, survey, and report on managed care plan reporting and compliance with specified developmental screening tools and schedules. The bill would also make legislative findings and declarations relating to child development.

Existing law provides for the Medi-Cal program, which is administered by the State Department of Health Care Services and under which qualified low-income individuals receive health care services, including Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) for any individual under 21 years of age who is covered under Medi-Cal consistent with the requirements under federal law. The Medi-Cal program is, in part, governed and funded by federal Medicaid program provisions.

Existing federal law provides that EPSDT services include periodic 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.

This bill would require, consistent with federal law, that screening services under the EPSDT program include developmental screening services for individuals zero to 3 years of age, inclusive, and be in compliance with the periodicity schedule and the standardized and validated developmental screening tools that are established by the Bright Futures/American Academy of Pediatrics Recommendations for Preventive Pediatric Health Care and by any future updates to those recommendations. The bill would require that screening tools be administered in their entirety and in adherence to the specific tools recommended guidelines. inclusive. Until July 1, 2023, the bill would require an external quality review organization entity to annually review, survey, and report on managed care plan reporting and compliance with specified developmental screening tools and schedules. The bill would also make legislative findings and declarations relating to child development.

Existing law provides for the Medi-Cal program, which is administered by the State Department of Health Care Services and under which qualified low-income individuals receive health care services, including Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) for any individual under 21 years of age who is covered under Medi-Cal consistent with the requirements under federal law. The Medi-Cal program is, in part, governed and funded by federal Medicaid program provisions.

Existing federal law provides that EPSDT services include periodic 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.

This bill would require, consistent with federal law, that screening services under the EPSDT program include developmental screening services for individuals zero to 3 years of age, inclusive, and be in compliance with the periodicity schedule and the standardized and validated developmental screening tools that are established by the Bright Futures/American Academy of Pediatrics Recommendations for Preventive Pediatric Health Care and by any future updates to those recommendations. The bill would require that screening tools be administered in their entirety and in adherence to the specific tools recommended guidelines. The bill would also make legislative findings and declarations relating to child development.

Existing law provides for the Medi-Cal program, which is administered by the State Department of Health Care Services and under which qualified low-income individuals receive health care services, including Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) for any individual under 21 years of age who is covered under Medi-Cal consistent with the requirements under federal law. The Medi-Cal program is, in part, governed and funded by federal Medicaid program provisions.

Existing federal law provides that EPSDT services include periodic 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.

This bill would require, consistent with federal law, that screening services under the EPSDT program include developmental screening services for individuals zero to 3 years of age, inclusive, in compliance with the periodicity schedule and the standardized and validated screening tool tools that are established by the Bright Futures/American Academy of Pediatrics Recommendations for Preventive Pediatric Health Care and by any future updates to those recommendations. The bill would also make legislative findings and declarations relating to child development.

The Child Care and Development Services Act has a purpose to provide a comprehensive, coordinated, and cost-effective system of child care and development services for children from infancy to 13 years of age and their parents, including a full range of supervision, health, and support services through full- and part-time programs. Existing law requires the Superintendent of Public Instruction to advise local educational agencies of the federal requirements relating to the Head Start Program. Existing law requires the Governor to appoint an advisory committee composed of representatives from various entities and requires the advisory committee to, among other things, assist the State Department of Education in developing a state plan for child development programs pursuant to the act. Existing law requires the advisory committee to continually evaluate the effectiveness of these programs and to provide reports to the Legislature.

The Child Care and Development Services Act has a purpose to provide a comprehensive, coordinated, and cost-effective system of child care and development services for children from infancy to 13 years of age and their parents, including a full range of supervision, health, and support services through full- and part-time programs. Existing law requires the Superintendent of Public Instruction to advise local educational agencies of the federal requirements relating to the Head Start Program.

This bill would make various findings and declarations regarding child care and would provide that it is the intent of the Legislature to enact legislation that would establish the Early Head Start-Child Care-Early Intervention Partnership and provide funding to establish classroom-based early intervention services to Early Head Start-Child Care programs.

GOVERNOR'S VETO

GV Bill Id:AB 11

Author:(McCarty and Bonta)

As Enrolled Ver:September 11, 2018

2/3 vote

Original Committee Reference: HEALTH

SUMMARY: Requires that screening services available under the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Program, consistent with federal law, include developmental screening services for individuals zero to three years of age, inclusive.

The Senate amendments require an external quality review organization (EQRO) to review, survey, and report, as currently part of the federally required EQRO review of Medi-Cal managed care plans (MCPs), on compliance by MCPs of the use of validated developmental screening tools and periodicity schedules recommended by the American Academy of Pediatrics for children zero to three years of age, inclusive, for EQRO contract periods commencing on or after July 1, 2018 until July 1, 2023.

FISCAL EFFECT: According to the Senate Appropriations Committee, possible increased administrative costs of $500,000 total funds ($250,000 General Fund (GF)) to $1 million ($500,000 GF) in fiscal year (FY) 2019-20 through FY 2022-23 and unknown local assistance costs (up to low millions) to the extent that the EQRO study results in increased screenings.

COMMENTS: According to the author, research has shown that toxic stress affects the development of young children, especially infants and toddlers, and we must start earlier to make a positive impact on our youngest learners. Early identification and intervention can improve a child's long-term outcome, and minimize the need for costly health care, special education, juvenile justice, and child welfare services in the future. This bill further implements the Bright Futures Guidelines by ensuring that developmental screenings, with a validated tool, are routinely occurring for infants and toddlers during Medi-Cal health care visits.

EPSDT. EPSDT services are a benefit of the State's Medicaid program (Medi-Cal) that provide comprehensive, preventative, diagnostic, and treatment services to eligible children under the age of 21, as specified in Section 1905(r) of the Federal Social Security Act. This benefit is designed to ensure that children receive early detection and care, so that health problems are averted or diagnosed and treated as early as possible. EPSDT allows for periodic screenings to determine health care needs and based upon the identified health care need and diagnosis, treatment services are provided. EPSDT services include all services otherwise covered by Medi-Cal and EPSDT beneficiaries can receive additional medically necessary services.

Screening Services. Federal law defines the term "early and periodic screening, diagnostic, and treatment services" to mean screening services which are provided at intervals that meet reasonable standards of medical and dental practice, as determined by the State, that at a minimum include:

1. A comprehensive health and developmental history, including assessment of both physical and mental health development;
2. A comprehensive unclothed physical exam;
3. Appropriate immunizations;
4. Laboratory tests, including lead blood level assessment appropriate for age and risk factors; and,
5. Health education, including anticipatory guidance.

Federal law defers screening intervals to the implementing states and California state regulations define "screening services" as an initial, periodic, or additional health assessment, but do not directly discuss developmental screening services, intervals, or tools.

Children Now, cosponsors of this bill, states that this bill takes the first critical step to help ensure that every California child, especially those who are low-income, has the opportunity to reach his or her full potential by having timely developmental screenings in Medi-Cal. Early identification of developmental delays through screening is the first step to connecting children with the supports they need for healthy development. When children with (or at risk of) developmental or other delays are not identified early, they may not receive the timely care and intervention services they need to address those developmental delays or concerns. Unidentified delays during the child's first years of life can significantly impact a child's school readiness and have long-term effects on their overall well-being. Children Now also states that less than one in three California kids are actually receiving timely developmental screenings, further delaying any referrals to needed early intervention services. Additionally, California ranks 43rd in the nation in the rate of young kids who receive timely screenings, and puts California children at a serious disadvantage.

First 5 Association of California, cosponsors of this bill, state that currently, pediatricians are relying on surveillance rather than using a validated screening tool to identify children at-risk for developmental delays. When they do screen, pediatricians are not consistent in their use of validated tools. For example, many do not use the entire tool or follow its intended directions. Subsequently, pediatricians believe they are properly implementing developmental screening and following the American Academy of Pediatrics recommendations, when in fact they are not.

The California Right to Life Committee, Inc., states in opposition that this bill would be the beginning step in a system to further impinge on the privacy of families. Under the guise of developing an extensive healthcare system for the betterment of California children and families, this bill would encompass more than early childhood healthcare programs and services and would result in a sizeable data collection of family life and "toxic stress" factors. Therefore, family privacy could be jeopardized and what appears to be for the betterment of the family could result in more stress for individual family members as various agencies determine how family members interact with each other.

GOVERNOR'S VETO MESSAGE:

This bill would require developmental screening of children from birth to age three in Medi-Cal and impose annual reporting requirements to assess managed care plan compliance.

The Medi-Cal State Plan already requires providers to screen children for developmental delays according to the schedule recommended by the American Academy of Pediatrics. Codifying this requirement and producing another costly report is not necessary.

Analysis Prepared by: Paula Villescaz / HEALTH / (916) 319-2097 FN: 0005282

 THIRD READING  

Bill No: AB 11

Author:

:

Vote:

SENATE HEALTH COMMITTEE: 9-0, 6/27/18

AYES: Pan, Nguyen, Beall, Hernandez, Leyva, Mitchell, Monning, Nielsen, Roth

SENATE APPROPRIATIONS COMMITTEE: 7-0, 8/16/18

AYES: Portantino, Bates, Beall, Bradford, Hill, Nielsen, Wiener

ASSEMBLY FLOOR: 77-0, 1/29/18 - See last page for vote

SUBJECT:

SOURCE: Children Now

First 5 Association of California

First 5 LA

DIGEST:

This bill requires, consistent with federal law, screening services provided under the Early and Periodic Screening, Diagnosis, and Treatment program to include developmental screening services for individuals zero to three years of age. Requires the federally required external quality review organization to annually review, survey, and report on Medi-Cal managed care plan reporting and compliance with the use of the validated developmental screening tools and periodicity schedule recommended for children zero to three years of age.

ANALYSIS:

Existing law:

1. Establishes the Medi-Cal program, which is administered by the Department of Health Care Services (DHCS) and under which qualified low-income individuals receive health care services. [WIC §14000, et seq.]
   
2. Makes children age 18 and under with incomes up to 266% of the federal poverty level (FPL) eligible for Medi-Cal. [WIC §14005.26 and 14005.64]
3. Establishes a schedule of benefits in the Medi-Cal program, which includes the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program for any individual under 21 years of age, consistent with the requirements of a specified EPSDT provision of federal Medicaid law. [WIC §14132, 42 U.S.C. §1396d]
   
4. Requires DHCS, in consultation with the Department of Social Services, county mental health experts, managed care plan experts, behavioral health experts, child welfare experts, and stakeholders, to convene an advisory working group to update, amend, or develop, if appropriate, tools and protocols for the screening of children for trauma, within the EPSDT benefit, consistent with existing law. [WIC §14132.19]
   
5. Requires the advisory working group to consider both of the following:
6. Existing screening tools used in the Medi-Cal program, including, but not limited to, the Staying Healthy Assessment developed by DHCS, the U.S. Preventive Services Task Force grade “A” or “B” recommendations, and the American Academy of Pediatrics (AAP) Bright Futures periodicity schedule and anticipatory guidance; and,
7. The efficacy and appropriateness of the types of providers authorized to administer screenings. [WIC §14132.19]
8. Requires DHCS to convene the advisory working group by May 1, 2018, and requires the advisory working group to report its findings and recommendations, as well as any appropriations necessary to implement those recommendations, to DHCS and to the Legislature’s budget subcommittees on health and human services no later than May 1, 2019. Disbands the advisory working group on December 31, 2019. [WIC §14132.19]
   
9. Prohibits findings or recommendations of the advisory working group that cannot be implemented without a subsequent appropriation by the Legislature, as determined by DHCS from being implemented until the appropriation is made. [WIC §14132.19]
   
10. Requires, under federal Medicaid law, EPSDT services to include screening, vision, dental, hearing and other Medicaid health care, diagnostic services, treatment, and other measures to correct or ameliorate defects and physical and mental illnesses and conditions discovered by the screening services. [42 U.S.C. §1396d]
    

This bill:

1. Requires, consistent with federal law, screening services provided under EPSDT benefit to include developmental screening services for individuals ages 0-3, inclusive.
   
2. Requires, as part of the federally required external quality review organization (EQRO) review of Medi-Cal managed care plans in the annual detailed technical report required by federal regulation, effective for contract periods commencing on or after July 1, 2018, the EQRO entity to annually review, survey, and report on Medi-Cal managed care plan reporting and compliance with the use of the validated developmental screening tools and periodicity schedule recommended by the AAP for children zero to three years of age, inclusive. Sunsets this requirements on July 1, 2023.
3. Makes legislative findings and declarations regarding identification of developmental concerns, the low rate of screening and inconsistent use of validated screening tools, that children at risk are not identified due to environmental or development factors are not identified, that the Bright Futures Guidelines by the AAP provides evidence-driven guidance, including recommending that developmental surveillance include the periodic administration of a standardized developmental screening test, and that early access to appropriate intervention for children with developmental delays and disabilities is critically important for healthy and optimal development.

Comments

1. Author’s statement. According to the author, research has shown that we must start earlier to make a positive impact on our youngest learners. Toxic stress can affect young children’s development, especially among infants and toddlers. However, early identification and intervention can improve a child’s long-term outcome, and minimize the need for costly health care, special education, juvenile justice, and child welfare services in the future. This bill further implements the Bright Futures Guidelines by ensuring that developmental screenings, with a validated tool, are routinely occurring for infants and toddlers during Medi-Cal health care visits.
2. EPSDT. The purpose of EPSDT is to discover and treat childhood health conditions before they become serious or disabling. States must inform all Medicaid-eligible families about the benefit, screen children at reasonable intervals, diagnose and treat any health problems found, and report certain data regarding EPSDT participation annually to the Centers for Medicare & Medicaid Services. The EPSDT benefit is more robust than the Medi-Cal benefit package provided to adults. For example, services that are optional benefits under federal law for adults in Medi-Cal (such as dental, eyeglasses, physical and occupational therapy and pharmacy) are required goods and services under EPSDT. The EPSDT benefit is designed to ensure that eligible members receive early detection and preventive care in addition to medically necessary treatment services, so that health problems are averted or diagnosed and treated as early as possible.
   
3. Bright Futures. The Child Health and Disability Prevention Program (CHDP) is responsible for the screening component of the EPSDT benefit of the Medi-Cal program, including the health assessments, immunizations, and laboratory screening procedures for Medi-Cal children. CHDP issues guidelines to set CHDP provider standards for pediatric health assessments for children served by the CHDP Program. DHCS indicates these guidelines are consistent with the AAP Bright Futures Guidelines and provide guidance to ensure compliance with California state specific regulations, and that all CHDP providers are required to comply with the most recent AAP Bright Futures Guidelines and the AAP Bright Futures Recommendations for Preventive Pediatric Health Care. DHCS indicates that the CHDP Program is continuing to update the CHDP Guidelines to meet Bright Futures Guidelines, as well as state regulations that may supersede some of the Bright Futures periodicity requirements for screening and testing. As a result, there may be some differences between the CHDP Guidelines and Bright Futures Guidelines.
   
4. Focused study on development screening. In 2016, DHCS contracted with its EQRO to conduct a focused study to help DHCS determine if Common Procedural Terminology Code 96110 (CPT Code 96110 is a code for developmental screening) could be used to evaluate plans’ rates for the Developmental Screening in the First Three Years of Life measure in California as DHCS considered the potential inclusion of this measure in its External Accountability Set. DHCS indicated statewide coding rate for CPT 96110 at one, two, and three years of age was 54.8%, 41.1% and 30.8 respectively, with a total over three years of 36.4% DHCS indicated the questionnaires identified similar barriers, including lack of education on the importance of children receiving development screening (provider and beneficiary), resource constrains, lack of referral services and/or pathways, inconsistent use of standardized tools, inconsistent use of CPT 96110, and data reporting issues so that it cannot be accurately assessed whether or not a child has received developmental screening.

FISCAL EFFECT: Appropriation: Fiscal Com.: Local:

According to the Senate Appropriations Committee, staff notes the following estimate is predicated on similar estimates for costs related to scope of work expansions performed by external quality review organizations:

• Possible increased administrative costs of $500,000 total funds ($250,000 General Fund) to $1 million ($500,000 General Fund) in fiscal year 2019-2020 through fiscal year 2022-23.
• Unknown local assistance costs (up to low millions) to the extent that the EQRO study results in increased screenings.

SUPPORT: (Verified 8/14/18)

Children Now (co-source)

First 5 Association of California (co-source)

First 5 LA (co-source)

Alameda County Board of Supervisors

Alliance for Children’s Rights

American Academy of Pediatrics, California

Association of California School Administrators

California Academy of Child and Adolescent Psychiatry

California Alternative Payment Program Association

California Association of Clinical Nurse Specialists

California Coverage and Health Initiatives

California Maternal, Child, and Adolescent Health Directors

California School Employees Association

California School-Based Health Alliance

California State PTA

Center for Autism and Related Disorders

Children and Families Commission of Orange County

Children’s Defense Fund

Children’s Specialty Care Coalition

City and County of San Francisco

Common Sense Kids Action

County Health Executives Association of California

Family Voices of California

First 5 California

First 5 Contra Costa

First 5 Kern

First 5 Marin Children and Families Commission

First 5 Mono County

First 5 Nevada County

First 5 Placer Children and Families Commission

First 5 Sacramento

First 5 San Bernardino

First 5 San Francisco

First 5 Santa Clara County

First 5 Santa Cruz County

First 5 Solano Children and Families Commission

First 5 Sonoma County Commission

First 5 Tehama

Gatepath

Health Access California

Health Officers Association of California

Help Me Grow San Mateo County

Help Me Grow Ventura County

Kalmanovitz Child Development Center at California Pacific Medical Center

Kidango

LA Trust for Children’s Health

Lucile Packard Children’s Hospital

North Los Angeles County Regional Center

Sonoma County Board of Supervisors

The Arc and United Cerebral Palsy California Collaboration

The Children’s Partnership

United Ways of California

WestEd Center for Prevention & Early Intervention

Western Center on Law and Poverty

OPPOSITION: (Verified 8/23/18)

California Right to Life Committee

Department of Finance

Department of Health Care Services

ARGUMENTS IN SUPPORT: This bill is jointly sponsored by Children Now and the First 5 Association of California. Children Now writes that this bill will clarify that all infants and toddlers in Medi-Cal should receive routine developmental screenings with a validated tool during a health care visit, as recommended by pediatricians. The Bright Futures Preventive Health Guidelines from the AAP recommends that all infants and toddlers under the age of three should receive routine developmental screenings as part of a well-child visit. Early identification of developmental delays through screening is the first step to connecting children with the supports they need for healthy development. When children with (or at risk of) developmental or other delays are not identified early, they may not receive the timely care and intervention services they need to address those developmental delays or concerns. Unidentified delays during the child’s first years of life can significantly impact a child’s school readiness and have long-term effects on their overall well-being. Children Now cites a National Survey of Children’s Health, which found that fewer than one in three California kids are actually receiving timely developmental screenings, further delaying any referrals to needed early intervention services. Additionally, California ranks 43rd in the nation in the rate of young kids who receive timely screenings, which puts California children at a serious disadvantage. Children Now concludes that this bill takes the first critical step to help ensure that every California child, especially those who are low-income, has the opportunity to reach his or her full potential by having timely developmental screenings in Medi-Cal.

The First 5 Association of California states that currently, pediatricians are relying on surveillance rather than using a validated screening tool to identify children at-risk for developmental delays. When they do screen, pediatricians are not consistent in their use of validated tools. For example, many do not use the entire tool or follow its intended directions. Subsequently, pediatricians believe they are properly implementing developmental screening and following the AAP recommendations, when in fact they are not.

ARGUMENTS IN OPPOSITION: The California Right to Life Committee (CRLC) writes that it has concerns about this bill and its potential for invasion of privacy of families through the collection of data on these families. CRLC also expresses concern with the requirement that development screening tools must be administered in their entirety and in adherence to the specific tools’ guidelines. CRLC writes that this does not allow for parental permission or refusal of the use of certain tools, and the recommended guidelines are open to future changes from AAP. CRLC writes that it appears to them that this bill is opening a pathway to a mandated yearly presentation of the child before a health committee to check on the compliance of parents with the state health plan for children.

The Department of Finance is opposed to this bill, arguing it will result in increased General Fund costs for the EQRO entity to report on compliance for screening, and DHCS is already undertaking administrative efforts to improve screening levels and this bill duplicates data collected from a 2016 study, which DHCS’ EQRO completed. Based on the study results, which showed a low percentage of providers billing for these screenings, DHCS is updating its policy manual to provide more clear guidance to increase provider awareness of the requirement for developmental screenings. Additionally, DHCS is working with managed care plans to identify ways to collaborate on developmental screenings with the goal of improving screening rates.

ASSEMBLY FLOOR: 77-0, 1/29/18

AYES: Acosta, Aguiar-Curry, Travis Allen, Arambula, Baker, Berman, Bigelow, Bloom, Bonta, Brough, Burke, Caballero, Calderon, Carrillo, Cervantes, Chau, Chávez, Chen, Chiu, Choi, Chu, Cooley, Cooper, Cunningham, Dahle, Daly, Eggman, Flora, Fong, Frazier, Friedman, Gallagher, Cristina Garcia, Eduardo Garcia, Gipson, Gloria, Gonzalez Fletcher, Gray, Grayson, Harper, Holden, Irwin, Jones-Sawyer, Kalra, Kiley, Lackey, Levine, Limón, Low, Maienschein, Mathis, Mayes, McCarty, Medina, Melendez, Mullin, Muratsuchi, Nazarian, Obernolte, O'Donnell, Patterson, Quirk, Quirk-Silva, Reyes, Rodriguez, Rubio, Salas, Santiago, Steinorth, Mark Stone, Thurmond, Ting, Voepel, Waldron, Weber, Wood, Rendon

Prepared by:
8/23/18 11:56:38

**** END ****

CONCURRENCE IN SENATE AMENDMENTS

CSA1 Bill Id:AB 11

Author:(McCarty and Bonta)

As Amended Ver:July 3, 2018

Majority vote

Original Committee Reference: HEALTH

SUMMARY: Requires that screening services available under the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Program, consistent with federal law, include developmental screening services for individuals zero to three years of age, inclusive.

The Senate amendments require an external quality review organization (EQRO) to review, survey, and report, as currently part of the federally required EQRO review of Medi-Cal managed care plans (MCPs), on compliance by MCPs of the use of validated developmental screening tools and periodicity schedules recommended by the American Academy of Pediatrics for children zero to three years of age, inclusive, for EQRO contract periods commencing on or after July 1, 2018 until July 1, 2023.

FISCAL EFFECT: According to the Senate Appropriations Committee, possible increased administrative costs of $500,000 total funds ($250,000 General Fund (GF)) to $1 million ($500,000 GF) in fiscal year (FY) 2019-20 through FY 2022-23 and unknown local assistance costs (up to low millions) to the extent that the EQRO study results in increased screenings.

COMMENTS: According to the author, research has shown that toxic stress affects the development of young children, especially infants and toddlers, and we must start earlier to make a positive impact on our youngest learners. Early identification and intervention can improve a child's long-term outcome, and minimize the need for costly health care, special education, juvenile justice, and child welfare services in the future. This bill further implements the Bright Futures Guidelines by ensuring that developmental screenings, with a validated tool, are routinely occurring for infants and toddlers during Medi-Cal health care visits.

EPSDT. EPSDT services are a benefit of the State's Medicaid program (Medi-Cal) that provide comprehensive, preventative, diagnostic, and treatment services to eligible children under the age of 21, as specified in Section 1905(r) of the Federal Social Security Act. This benefit is designed to ensure that children receive early detection and care, so that health problems are averted or diagnosed and treated as early as possible. EPSDT allows for periodic screenings to determine health care needs and based upon the identified health care need and diagnosis, treatment services are provided. EPSDT services include all services otherwise covered by Medi-Cal and EPSDT beneficiaries can receive additional medically necessary services.

Screening Services. Federal law defines the term "early and periodic screening, diagnostic, and treatment services" to mean screening services which are provided at intervals that meet reasonable standards of medical and dental practice, as determined by the State, that at a minimum include:

1. A comprehensive health and developmental history, including assessment of both physical and mental health development;
2. A comprehensive unclothed physical exam;
3. Appropriate immunizations;
4. Laboratory tests, including lead blood level assessment appropriate for age and risk factors; and,
5. Health education, including anticipatory guidance.

Federal law defers screening intervals to the implementing states and California state regulations define "screening services" as an initial, periodic, or additional health assessment, but do not directly discuss developmental screening services, intervals, or tools.

Children Now, cosponsors of this bill, states that this bill takes the first critical step to help ensure that every California child, especially those who are low-income, has the opportunity to reach his or her full potential by having timely developmental screenings in Medi-Cal. Early identification of developmental delays through screening is the first step to connecting children with the supports they need for healthy development. When children with (or at risk of) developmental or other delays are not identified early, they may not receive the timely care and intervention services they need to address those developmental delays or concerns. Unidentified delays during the child's first years of life can significantly impact a child's school readiness and have long-term effects on their overall well-being. Children Now also states that less than one in three California kids are actually receiving timely developmental screenings, further delaying any referrals to needed early intervention services. Additionally, California ranks 43rd in the nation in the rate of young kids who receive timely screenings, and puts California children at a serious disadvantage.

First 5 Association of California, cosponsors of this bill, state that currently, pediatricians are relying on surveillance rather than using a validated screening tool to identify children at-risk for developmental delays. When they do screen, pediatricians are not consistent in their use of validated tools. For example, many do not use the entire tool or follow its intended directions. Subsequently, pediatricians believe they are properly implementing developmental screening and following the American Academy of Pediatrics recommendations, when in fact they are not.

The California Right to Life Committee, Inc., states in opposition that this bill would be the beginning step in a system to further impinge on the privacy of families. Under the guise of developing an extensive healthcare system for the betterment of California children and families, this bill would encompass more than early childhood healthcare programs and services and would result in a sizeable data collection of family life and "toxic stress" factors. Therefore, family privacy could be jeopardized and what appears to be for the betterment of the family could result in more stress for individual family members as various agencies determine how family members interact with each other.

Analysis Prepared by: Paula Villescaz / HEALTH / (916) 319-2097 FN: 0004264

Date of Hearing: January 9, 2018

ASSEMBLY COMMITTEE ON HEALTH

Jim Wood, Chair

ABPCA Bill Id:AB 11

Author:(McCarty) – As Amended Ver:January 3, 2018

SUBJECT: Early and Periodic Screening, Diagnosis, and Treatment Program: screening services.

SUMMARY: Requires that screening services available under the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Program include screening services for individuals zero to three years of age, inclusive, in compliance with the periodicity schedule and the standardized and validated screening tool that are established by the Bright Futures/American Academy of Pediatrics (AAP) Recommendations for Preventive Pediatric Health Care and by any future updates to those recommendations.

EXISTING LAW:

1. Establishes the Medi-Cal program, administered by the Department of Health Care Services (DHCS), under which qualified low-income individuals receive health care services.
   
2. Establishes a schedule of benefits under the Medi-Cal program, which includes EPSDT for any individual under 21 years of age, consistent with federal Medicaid requirements. Defines, through regulation, “screening services” for purposes of EPSDT to mean:
   
   1. An initial, periodic, or additional health assessment of a Medi-Cal eligible individual under 21 years of age provided in accordance with the requirements of the Child Health and Disability Prevention (CHDP) program;
      
   2. A health assessment, examination, or evaluation of a Medi-Cal eligible individual under 21 years of age by a licensed health care professional acting within his or her scope of practice, at intervals other than the CHDP intervals, to determine the existence of physical or mental illnesses or conditions; or,
      
   3. Any other encounter with a licensed health care professional that results in the determination of the existence of a suspected illness or condition or a change or complication in a condition for a Medi-Cal eligible person under 21 years of age.
3. Requires mental health plans to provide specialty mental health services to eligible Medi-Cal beneficiaries, including both adults and children. Includes EPSDT within the scope of specialty mental health services for eligible Medi-Cal beneficiaries under 21 years of age pursuant to federal Medicaid law.
   

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

COMMENTS:

1. PURPOSE OF THIS BILL. According to the author, research has shown that toxic stress affects the development of young children, especially infants and toddlers, and we must start earlier to make a positive impact on our youngest learners. Early identification and intervention can improve a child’s long-term outcome, and minimize the need for costly health care, special education, juvenile justice, and child welfare services in the future. This bill further implements the Bright Futures Guidelines by ensuring that developmental screenings, with a validated tool, are routinely occurring for infants and toddlers during Medi-Cal health care visits.
2. BACKGROUND.
   1. EPSDT. EPSDT services are a benefit of the State’s Medicaid program (Medi-Cal) that provide comprehensive, preventative, diagnostic, and treatment services to eligible children under the age of 21, as specified in Section 1905(r) of the Federal Social Security Act. This benefit is designed to ensure that children receive early detection and care, so that health problems are averted or diagnosed and treated as early as possible. EPSDT allows for periodic screenings to determine health care needs and based upon the identified health care need and diagnosis, treatment services are provided. EPSDT services include all services otherwise covered by Medi-Cal and EPSDT beneficiaries can receive additional medically necessary services.
   2. Screening Services. Federal law defines the term “early and periodic screening, diagnostic, and treatment services” to mean screening services which are provided at intervals that meet reasonable standards of medical and dental practice, as determined by the State, that at a minimum include:
      1. A comprehensive health and developmental history, including assessment of both physical and mental health development;
         
      2. A comprehensive unclothed physical exam;
         
      3. Appropriate immunizations;
         
      4. Laboratory tests, including lead blood level assessment appropriate for age and risk factors; and,
         
      5. Health education, including anticipatory guidance.

As discussed above, federal law defers screening intervals to the implementing states and California state regulations define "screening services" as an initial, periodic, or additional health assessment, but do not directly discuss developmental screening services, intervals, or tools.

• 1. Bright Futures/AAP Recommendations. Bright Futures is a national health promotion and prevention initiative, led by the AAP and supported, in part, by the U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau. The Bright Futures Guidelines provide theory-based and evidence-driven guidance for all preventive care screenings and well-child visits. Bright Futures content can be incorporated into many public health programs such as home visiting, child care, school-based health clinics, and many others. The Bright Futures/AAP periodicity schedule recommends an initial developmental screening at nine months, and additional screenings at 18 months and 30 months of age and that developmental surveillance be incorporated at every well-child preventive care visit. AAP validated developmental screening tools include the Ages and Stages Questionnaire, Parents' Evaluation of Developmental Status, FirstSTEp Screening Test for Evaluating Preschooler, and Developmental Assessment of Young Children, among others.

1. SUPPORT. Children Now, cosponsors of this bill, states that this bill takes the first critical step to help ensure that every California child, especially those who are low-income, has the opportunity to reach his or her full potential by having timely developmental screenings in Medi-Cal. Early identification of developmental delays through screening is the first step to connecting children with the supports they need for healthy development. When children with (or at risk of) developmental or other delays are not identified early, they may not receive the timely care and intervention services they need to address those developmental delays or concerns. Unidentified delays during the child’s first years of life can significantly impact a child’s school readiness and have long-term effects on their overall well-being. Children Now also states that fewer than one in three California kids are actually receiving timely developmental screenings, further delaying any referrals to needed early intervention services. Additionally, California ranks 43rd in the nation in the rate of young kids who receive timely screenings, which puts California children at a serious disadvantage.

First 5 Association of California, cosponsors of this bill, state that currently, pediatricians are relying on surveillance rather than using a validated screening tool to identify children at-risk for developmental delays. When they do screen, pediatricians are not consistent in their use of validated tools. For example, many do not use the entire tool or follow its intended directions. Subsequently, pediatricians believe they are properly implementing developmental screening and following the AAP recommendations, when in fact they are not.

1. OPPOSITION. The California Right to Life Committee, Inc., states in opposition that this bill would be the beginning step in a system to further impinge on the privacy of families. Under the guise of developing an extensive healthcare system for the betterment of California children and families, this bill would encompass more than early childhood healthcare programs and services and would result in a sizeable data collection of family life and "toxic stress" factors. Therefore, family privacy could be jeopardized and what appears to be for the betterment of the family could result in more stress for individual family members as various agencies determine how family members interact with each other.
2. PREVIOUS LEGISLATION.
   1. AB 340 (Arambula), Chapter 700, Statutes of 2017, requires that screening services provided under the EPSDT Program include screening for trauma, defines trauma for the purpose of screening, and requires the DHCS, in consultation with the Department of Social Services, behavioral health experts, child welfare experts, and stakeholders, to adopt, employ, and develop tools and protocols for the screening of children for trauma, as specified.
   2. AB 470 (Arambula), Chapter 550, Statutes of 2017, requires the DHCS to consult with specified stakeholders to inform the updates to the performance outcomes system for specialty mental health services (SMHS) developed for the EPSDT Program and under the Special Terms and Conditions of the Medi-Cal SMHS Waiver.
   3. SB 1466 (Mitchell) of 2016 would have required screening services provided under the EPSDT Program to include screening for trauma, as defined, at all screenings. SB 1446 was vetoed by the Governor. The Governor's veto message stated:

I am returning Senate Bill 1466 without my signature. This bill establishes a new trauma screening entitlement for every child on Medi-Cal. Medi-Cal has grown from 8 million to 14 million beneficiaries since our implementation of the federal Affordable Care Act and provides coverage for over 5 million children. Given this dramatic expansion, I am reluctant to create another entitlement as required by this bill.

1. SUGGESTED AMENDMENTS. The Committee suggests amendments to clarify provisions regarding the future implementation of Bright Futures/AAP Recommendations and clarify that the screening services include developmental screening services.

REGISTERED SUPPORT / OPPOSITION:

Support

Children Now (cosponsor)

First 5 Association of California (cosponsor)

American Academy of Pediatrics, California

California Association of Clinical Nurse Specialists

California Coverage & Health Initiatives

California School-Based Health Alliance

Center for Autism and Related Disorders

Children's Defense Fund California

Common Sense Kids Action

Family Connections

Family Voices of California

First 5 Alameda County

First 5 Contra Costa

First 5 Fresno County

First 5 Kern

First 5 Kings County

First 5 LA

First 5 Lake County

First 5 Marin

First 5 Merced County

First 5 Mono County

First 5 Monterey County

First 5 Napa County

First 5 Placer

First 5 Riverside County

First 5 Sacramento

First 5 San Bernardino

First 5 San Diego

First 5 San Luis Obispo County

First 5 San Mateo County

First 5 Santa Clara County

First 5 Santa Cruz County

First 5 Shasta

First 5 Siskiyou County

First 5 Solano County

First 5 Sonoma County

First 5 Tehama County

First 5 Ventura County

Gatepath

Help Me Grow Orange County

Help Me Grow Ventura County

Kalmanovitz Child Development Center at California Pacific Medical Center

Los Angeles Trust for Children's Health

Lucile Packard Children's Hospital Stanford

Maternal and Child Health Access

MCAH Action

The Children's Partnership

United Ways of California

WestEd Center for Prevention & Early Intervention

Western Center on Law and Poverty

Opposition

California Right to Life Committee, Inc.

Analysis Prepared by: Paula Villescaz / HEALTH / (916) 319-2097

SENATE COMMITTEE ON APPROPRIATIONS

Senator Anthony Portantino, Chair

2017 - 2018 Regular Session

AB 11 (McCarty) - Early and Periodic Screening, Diagnosis, and Treatment Program: screening services

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

Bill Summary:

Requires, consistent with federal law, screening services provided under the Early and Periodic Screening, Diagnosis, and Treatment program to include developmental screening services for individuals zero to three years of age.

Fiscal Impact:

Staff notes the following estimate is predicated on similar estimates for costs related to scope of work expansions performed by external quality review organizations:

• Possible increased administrative costs of $500,000 total funds ($250,000 General Fund) to $1 million ($500,000 General Fund) in fiscal year 2019-2020 through fiscal year 2022-23.
• Unknown local assistance costs (up to low millions) to the extent that the EQRO study results in increased screenings.

Background:

DHCS administers the state’s Medi-Cal program, which provides health care services to qualified individuals who are low-income, including children aged 18 and under and those under incomes up to 266 percent of the federal poverty level. Federal Medicaid law requires early and periodic screening, diagnostic, and treatment (EPSDT) services to include screening, vision, dental, hearing and other Medicaid health care, diagnostic services, treatment, and other measures to correct or ameliorate defects and physical and mental illnesses and conditions discovered by the screening services. Existing screening tools used in the Medi-Cal program, include the Staying Healthy Assessment developed by DHCS, the U.S. Preventive Services Task Force grade “A” or “B” recommendations, and the American Academy of Pediatrics (AAP) Bright Futures periodicity schedule and anticipatory guidance. EPSDT is a Medi-Cal benefit for individuals under the age of 21 who have full-scope Medi-Cal eligibility. The EPSDT benefit is designed to ensure that eligible members receive early detection and preventive care in addition to medically necessary treatment services, so that health problems are averted or diagnosed and treated as early as possible.

Proposed Law:

The bill includes the following provisions:

• Requires Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) to include developmental screening services for individuals zero to three years of age, inclusive.
• Requires the external quality review organization (EQRO) to conduct an annual review, survey, and report on managed care plan compliance with developmental screening tools and screening scheduled, as recommended by the American Academy of Pediatrics, for children zero to three, inclusive, for contract periods commencing on or after July 1, 2018 and until July 1, 2023.

Related Legislation:

• SB 1287 (Hernandez) defines in state law, for individuals under age 21 years of age enrolled in Medi-Cal, a service as medically necessary or a medical necessity when it would correct or ameliorate defects and physical and mental illnesses and conditions, including substance use disorders. SB 1287 is pending consideration in the Assembly Appropriations Committee.
• AB 340 (Arambula, Chapter 700, Statutes of 2017) requires DHCS, in consultation with specified entities, to convene an advisory working group to update, amend, or develop, if appropriate, tools and protocols for the screening of children for trauma, within the EPSDT benefit, consistent with existing law.
• AB 470 (Arambula, Chapter 550, Statutes of 2017) requires the DHCS to consult with specified stakeholders to inform the updates to the performance outcomes system for specialty mental health services (SMHS) developed for the EPSDT Program and under the Special Terms and Conditions of the Medi-Cal SMHS Waiver.
• SB 1466 (Mitchell of 2016) would have required screening services provided under the EPSDT Program to include screening for trauma, as defined, at all screenings. SB 1446 was vetoed by the Governor. In his veto message, the Governor stated this bill establishes a new trauma screening entitlement for every child on Medi-Cal, that Medi-Cal has grown from 8 million to 14 million beneficiaries since Affordable Care Act implementation, and given this dramatic expansion, he was reluctant to create another entitlement.

Staff Comments:

1. In 2016, DHCS contracted with its EQRO to conduct a focused study to help DHCS determine if Common Procedural Terminology Code 96110 (CPT Code 96110 is a code for developmental screening) could be used to evaluate plans’ rates for the Developmental Screening in the First Three Years of Life measure in California as Of the 23 plans that received the questionnaire, the EQRO received 20 distinct responses, with two plans not responding and two plans submitting a combined response due to their contractual setup. DHCS reported the Focus Study Results at a September 17, 2017 meeting of the Medi-Cal Managed Care Advisory Group. DHCS indicated statewide coding rate for CPT 96110 at 1, 2, and 3 years of age was 54.8 percent, 41.1 percent and 30.8 percent respectively, with a total over three years of 36.4 percent. The questionnaire indicated similar barriers: lack of education on the importance of children receiving development screening (provider and beneficiary), resource constrains, lack of referral services and/or pathways, inconsistent use of standardized tools, inconsistent use of CPT 96110, and data reporting issues so that it cannot be accurately assessed whether or not a child has received developmental screening.

-- END --

SENATE COMMITTEE ON HEALTH

Senator Dr. Richard Pan, Chair

BILL NO: AB 11

SUBJECT: Early and Periodic Screening, Diagnosis, and Treatment Program: screening services

SUMMARY:

Requires, consistent with federal law, screening services provided under the Early and Periodic Screening, Diagnosis, and Treatment program to include developmental screening services for individuals zero to three years of age. Requires these developmental screenings to be in compliance with the periodicity schedule and the standardized and validated screening tools that are established by the Bright Futures/American Academy of Pediatrics Recommendations for Preventive Pediatric Health Care and by any future updates to those recommendations.

Existing law:

1. Establishes the Medi-Cal program, which is administered by the Department of Health Care Services (DHCS) and under which qualified low-income individuals receive health care services. [WIC §14000, et seq.]
   
2. Makes children age 18 and under with incomes up to 266% of the federal poverty level (FPL) eligible for Medi-Cal. [WIC §14005.26 and 14005.64]
3. Establishes a schedule of benefits in the Medi-Cal program, which includes the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program for any individual under 21 years of age, consistent with the requirements of a specified EPSDT provision of federal Medicaid law. [WIC §14132, 42 U.S.C. §1396d]
   
4. Requires DHCS, in consultation with the Department of Social Services, county mental health experts, managed care plan experts, behavioral health experts, child welfare experts, and stakeholders, to convene an advisory working group to update, amend, or develop, if appropriate, tools and protocols for the screening of children for trauma, within the EPSDT benefit, consistent with existing law. [WIC §14132.19]
5. Requires the advisory working group to consider both of the following:
6. Existing screening tools used in the Medi-Cal program, including, but not limited to, the Staying Healthy Assessment developed by DHCS, the U.S. Preventive Services Task Force grade “A” or “B” recommendations, and the American Academy of Pediatrics (AAP) Bright Futures periodicity schedule and anticipatory guidance; and,
7. The efficacy and appropriateness of the types of providers authorized to administer screenings. [WIC §14132.19]
8. Requires DHCS to convene the advisory working group by May 1, 2018, requires the advisory working group to report its findings and recommendations, as well as any appropriations necessary to implement those recommendations, to DHCS and to the Legislature’s budget subcommittees on health and human services no later than May 1, 2019. Disbands the advisory working group on December 31, 2019. [WIC §14132.19]
9. Prohibits findings or recommendations of the advisory working group that cannot be implemented without a subsequent appropriation by the Legislature, as determined by DHCS from being implemented until the appropriation is made. [WIC §14132.19]
10. Requires DHCS, on or before May 1, 2019, to identify an existing advisory working group to periodically review and consider the protocols for the screening of trauma in children. Requires the advisory working group identified by DHCS to review and consider the protocols for the screening of trauma in children at least once every five years, or upon the request of DHCS. [WIC §14132.19]
11. Requires, under federal Medicaid law, EPSDT services to include screening, vision, dental, hearing and other Medicaid health care, diagnostic services, treatment, and other measures to correct or ameliorate defects and physical and mental illnesses and conditions discovered by the screening services. [42 U.S.C. §1396d]
    

This bill:

1. Requires, consistent with federal law, screening services provided under EPSDT benefit to include developmental screening services for individuals zero to three years of age, inclusive.
   
2. Requires these developmental screenings to be in compliance with the periodicity schedule and the standardized and validated screening tools that are established by the Bright Futures/AAP Recommendations for Preventive Pediatric Health Care and by any future updates to those recommendations.
   
3. Requires developmental screening tools to be administered in their entirety and in adherence to the specific tools’ guidelines.
   
4. Makes legislative findings and declarations regarding identification of developmental concerns, the low rate of screening and inconsistent use of validated screening tools, that children at risk are not identified due to environmental or development factors are not identified, that the Bright Futures Guidelines by the AAP provides evidence-driven guidance, including recommending that developmental surveillance include the periodic administration of a standardized developmental screening test, and that early access to appropriate intervention for children with developmental delays and disabilities is critically important for healthy and optimal development.

FISCAL EFFECT:

According to the Assembly Appropriations committee analyses of the previous version of this bill, none, as this bill appears to codify existing federal requirements.

PRIOR VOTES:

COMMENTS:

1. Author’s statement. According to the author, research has shown that we must start earlier to make a positive impact on our youngest learners. Toxic stress can affect young children’s development, especially among infants and toddlers. However, early identification and intervention can improve a child’s long-term outcome, and minimize the need for costly health care, special education, juvenile justice, and child welfare services in the future. This bill further implements the Bright Futures Guidelines by ensuring that developmental screenings, with a validated tool, are routinely occurring for infants and toddlers during Medi-Cal health care visits.
2. EPSDT. The purpose of EPSDT is to discover and treat childhood health conditions before they become serious or disabling. States must inform all Medicaid-eligible families about the benefit, screen children at reasonable intervals, diagnose and treat any health problems found, and report certain data regarding EPSDT participation annually to the Centers for Medicare & Medicaid Services. The EPSDT benefit is more robust than the Medi-Cal benefit package provided to adults. For example, services that are optional benefits under federal law for adults in Medi-Cal (such as dental, eyeglasses, physical and occupational therapy and pharmacy) are required goods and services under EPSDT. The EPSDT benefit is designed to ensure that eligible members receive early detection and preventive care in addition to medically necessary treatment services, so that health problems are averted or diagnosed and treated as early as possible.
   
3. Bright Futures. The Child Health and Disability Prevention Program (CHDP) is responsible for the screening component of the EPSDT benefit of the Medi-Cal program, including the health assessments, immunizations, and laboratory screening procedures for Medi-Cal children. CHDP issues guidelines to set CHDP provider standards for pediatric health assessments for children served by the CHDP Program. DHCS indicates these guidelines are consistent with the AAP Bright Futures Guidelines and provide guidance to ensure compliance with California state specific regulations, and that all CHDP providers are required to comply with the most recent AAP Bright Futures Guidelines and the AAP Bright Futures Recommendations for Preventive Pediatric Health Care. DHCS indicates that the CHDP Program is continuing to update the CHDP Guidelines to meet Bright Futures Guidelines, as well as state regulations that may supersede some of the Bright Futures periodicity requirements for screening and testing. As a result, there may be some differences between the CHDP Guidelines and Bright Futures Guidelines.
   
4. Focused study on development screening. In 2016, DHCS contracted with its External Quality Review Organization (EQRO) to conduct a focused study to help DHCS determine if Common Procedural Terminology Code 96110 (CPT Code 96110 is a code for developmental screening) could be used to evaluate plans’ rates for the Developmental Screening in the First Three Years of Life measure in California as DHCS considered the potential inclusion of this measure in its External Accountability Set (EAS). The objective of the focus study was to determine to what extent can CPT Code 96110 be used to evaluate Medi-Cal managed plans’ rates for at “Developmental Screening in the First Three Years of Life” measure in California. DHCS had concerns that the rates for this measure would be artificially low due to provider lack of use of the CPT Code 96110 (for example, providers who are capitated or working in FQHCs have no incentive to use the code as it does not result in additional payment).
   
   The EQRO distributed the Developmental Screening in the First Three Years of Life measure questionnaire to 23 Medi-Cal managed care plans in February 2017. The EQRO then reviewed Medi-Cal managed care plans’ questionnaire responses and followed up with them, if necessary, in March and April 2017. Of the 23 plans that received the questionnaire, the EQRO received 20 distinct responses, with two plans not responding and two plans submitting a combined response due to their contractual setup. DHCS reported the Focus Study Results at a September 17, 2017 meeting of the Medi-Cal Managed Care Advisory Group. DHCS indicated statewide coding rate for CPT 96110 at 1, 2, and 3 years of age was 54.8%, 41.1% and 30.8 respectively, with a total over three years of 36.4% DHCS indicated the questionnaires identified similar barriers, including lack of education on the importance of children receiving development screening (provider and beneficiary), resource constrains, lack of referral services and/or pathways, inconsistent use of standardized tools, inconsistent use of CPT 96110, and data reporting issues so that it cannot be accurately assessed whether or not a child has received developmental screening.
   
5. Related legislation. SB 1287 (Hernandez) defines in state law, for individuals under age 21 years of age enrolled in Medi-Cal, a service as medically necessary or a medical necessity when it would correct or ameliorate defects and physical and mental illnesses and conditions, including substance use disorders. SB 1287 is set for hearing on June 26, 2018 in the Assembly Health Committee.
6. Prior legislation. AB 340 (Arambula, Chapter 700, Statutes of 2017) requires DHCS, in consultation with specified entities, to convene an advisory working group to update, amend, or develop, if appropriate, tools and protocols for the screening of children for trauma, within the EPSDT benefit, consistent with existing law.

AB 470 (Arambula, Chapter 550, Statutes of 2017) requires the DHCS to consult with specified stakeholders to inform the updates to the performance outcomes system for specialty mental health services (SMHS) developed for the EPSDT Program and under the Special Terms and Conditions of the Medi-Cal SMHS Waiver.

SB 1466 (Mitchell of 2016) would have required screening services provided under the EPSDT Program to include screening for trauma, as defined, at all screenings. SB 1446 was vetoed by the Governor. In his veto message, the Governor stated this bill establishes a new trauma screening entitlement for every child on Medi-Cal, that Medi-Cal has grown from 8 million to 14 million beneficiaries since implementation of the federal Affordable Care Act and provides coverage for over five million children, and given this dramatic expansion, he was reluctant to create another entitlement as required by the bill.

1. Support. This bill is jointly sponsored by Children Now and the First 5 Association of California. Children Now writes that this bill will clarify that all infants and toddlers in Medi-Cal should receive routine developmental screenings with a validated tool during a health care visit, as recommended by pediatricians. The Bright Futures Preventive Health Guidelines from the AAP recommends that all infants and toddlers under the age of three should receive routine developmental screenings as part of a well-child visit. Early identification of developmental delays through screening is the first step to connecting children with the supports they need for healthy development. When children with (or at risk of) developmental or other delays are not identified early, they may not receive the timely care and intervention services they need to address those developmental delays or concerns. Unidentified delays during the child’s first years of life can significantly impact a child’s school readiness and have long-term effects on their overall well-being. Children Now cites a National Survey of Children’s Health, which found that fewer than one in three California kids are actually receiving timely developmental screenings, further delaying any referrals to needed early intervention services. Additionally, California ranks 43rd in the nation in the rate of young kids who receive timely screenings, which puts California children at a serious disadvantage. Children Now concludes that this bill takes the first critical step to help ensure that every California child, especially those who are low-income, has the opportunity to reach his or her full potential by having timely developmental screenings in Medi-Cal.

The First 5 Association of California states that currently, pediatricians are relying on surveillance rather than using a validated screening tool to identify children at-risk for developmental delays. When they do screen, pediatricians are not consistent in their use of validated tools. For example, many do not use the entire tool or follow its intended directions. Subsequently, pediatricians believe they are properly implementing developmental screening and following the APP recommendations, when in fact they are not.

1. Concerns. The California Right to Life Committee (CRLC) writes that it has concerns about this bill and its potential for invasion of privacy of families through the collection of data on these families. CRLC also expresses concern with the requirement that development screening tools must be administered in their entirety and in adherence to the specific tools’ guidelines. CRLC writes that this does not allow for parental permission or refusal of the use of certain tools, and the recommended guidelines are open to future changes from the American Academy of Pediatrics. CRLC writes that it appears to them that this bill is opening a pathway to a mandated yearly presentation of the child before a health committee to check on the compliance of parents with the state health plan for children.
2. Policy questions:
3. Is this bill premature? While its focus is on trauma, the advisory group convened pursuant to AB 340 (Arambula, Chapter 700, Statutes of 2017) is required to consider both:
4. Existing screening tools used in the Medi-Cal program, including, but not limited to, the Staying Healthy Assessment developed by DHCS, the US Preventive Services Task Force grade “A” or “B” recommendations, and the AAP Bright Futures periodicity schedule and anticipatory guidance; and,
5. The efficacy and appropriateness of the types of providers authorized to administer screenings.

The advisory group has is required to report its findings and recommendations, as well as any appropriations necessary to implement those recommendations, no later than May 1, 2019. Given that this advisory group is working on the type of screening tools to be used in EPSDT, should this bill require compliance with the Bright Futures recommendations? Or should the Legislature wait for the results of the advisory body before codifying a particular screening tool (or allow the tool to be established administratively by DHCS on the basis of DHCS’ review of the medical evidence supporting a screening tool)?

1. Coverage requirement for compliance with Bright Futures and health care provider treatment mandate. This bill requires developmental screenings to be in compliance with the periodicity schedule and the standardized and validated screening tools that are established by the Bright Futures/AAP Recommendations for Preventive Pediatric Health Care. In addition, this bill requires developmental screening tools to be administered in their entirety and in adherence to the specific tools’ guidelines. This language appears to both statutorily require compliance developmental screenings to be in compliance with of the Bright Futures tools, and to require health care providers to follow the developmental screening tools in Bright Futures in their entirety and in adherence to the specific tools’ recommended guidelines. However, these guidelines are intended for use by health care providers based on medical evidence, as opposed to being codified in law.
2. Bright Futures currently in use. CHDP issues guidelines to set CHDP provider standards for pediatric health assessments for children served by the program. DHCS indicates these guidelines are consistent with the AAP Bright Futures Guidelines, that all CHDP providers are required to comply with the most recent AAP Bright Futures Guidelines and the AAP Bright Futures Recommendations for Preventive Pediatric Health Care. Given the current use of Bright Futures and the work of the AB 340 advisory group, it is unclear why statutory codification is needed.

SUPPORT AND OPPOSITION:

Support: Children Now (co-sponsor)

First 5 Association of California (co-sponsor)

First 5 LA (co-sponsor)

Alameda County Board of Supervisors

Alliance for Children’s Rights

American Academy of Pediatrics, California

Association of California School Administrators

California Academy of Child and Adolescent Psychiatry

California Association of Clinical Nurse Specialists

California Alternative Payment Program Association

California Coverage and Health Initiatives

California School-Based Health Alliance

California School Employees Association

California Maternal, Child, and Adolescent Health Directors

California State PTA

Children and Families Commission of Orange County

Children’s Defense Fund

Children’s Specialty Care Coalition

Center for Autism and Related Disorders

City and County of San Francisco

Common Sense Kids Action

County Health Executives Association of California

Family Voices of California

First 5 California

First 5 Contra Costa

First 5 Kern

First 5 Marin Children and Families Commission

First 5 Mono County

First 5 Nevada County

First 5 Placer Children and Families Commission

First 5 Santa Clara County

First 5 Sacramento

First 5 San Bernardino

First 5 San Francisco

First 5 Santa Cruz County

First 5 Solano Children and Families Commission

First 5 Sonoma County Commission

First 5 Tehama

Gatepath

Health Access California

Health Officers Association of California

Help Me Grow San Mateo County

Help Me Grow Ventura County

Kalmanovitz Child Development Center at California Pacific Medical Center

Kidango

LA Trust for Children’s Health

Lucile Packard Children’s Hospital

North Los Angeles County Regional Center

Sonoma County Board of Supervisors
The Arc and United Cerebral Palsy California Collaboration

The Children’s Partnership

United Ways of California

Western Center on Law and Poverty

WestEd Center for Prevention & Early Intervention

Oppose: None received

-- END --

ASSEMBLY THIRD READING

ATR Bill Id:AB 11

Author:(McCarty and Bonta)

As Amended Ver:January 10, 2018

Majority vote

SUMMARY: Requires that screening services available under the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Program specifically include screening services for individuals zero to three years of age, inclusive, in compliance with the periodicity schedule and the standardized and validated screening tool that are established by the Bright Futures/American Academy of Pediatrics (AAP) Recommendations for Preventive Pediatric Health Care and by any future updates to those recommendations.

FISCAL EFFECT: According to the Assembly Appropriations committee, none, as this bill appears to codify existing federal requirements.

COMMENTS: According to the author, research has shown that toxic stress affects the development of young children, especially infants and toddlers, and we must start earlier to make a positive impact on our youngest learners. Early identification and intervention can improve a child's long-term outcome, and minimize the need for costly health care, special education, juvenile justice, and child welfare services in the future. This bill further implements the Bright Futures Guidelines by ensuring that developmental screenings, with a validated tool, are routinely occurring for infants and toddlers during Medi-Cal health care visits.

BACKGROUND.

1. EPSDT. EPSDT services are a benefit of the State's Medicaid program (Medi-Cal) that provide comprehensive, preventative, diagnostic, and treatment services to eligible children under the age of 21, as specified in Section 1905(r) of the Federal Social Security Act. This benefit is designed to ensure that children receive early detection and care, so that health problems are averted or diagnosed and treated as early as possible. EPSDT allows for periodic screenings to determine health care needs and based upon the identified health care need and diagnosis, treatment services are provided. EPSDT services include all services otherwise covered by Medi-Cal and EPSDT beneficiaries can receive additional medically necessary services.
2. Screening Services. Federal law defines the term "early and periodic screening, diagnostic, and treatment services" to mean screening services which are provided at intervals that meet reasonable standards of medical and dental practice, as determined by the State, that at a minimum include:
   1. A comprehensive health and developmental history, including assessment of both physical and mental health development;
   2. A comprehensive unclothed physical exam;
   3. Appropriate immunizations;
   4. Laboratory tests, including lead blood level assessment appropriate for age and risk factors; and,
   5. Health education, including anticipatory guidance.

Federal law defers screening intervals to the implementing states and California state regulations define "screening services" as an initial, periodic, or additional health assessment, but do not directly discuss developmental screening services, intervals, or tools.

1. Bright Futures/AAP Recommendations. Bright Futures is a national health promotion and prevention initiative, led by the AAP and supported, in part, by the United States Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau. The Bright Futures Guidelines provide theory-based and evidence-driven guidance for all preventive care screenings and well-child visits. Bright Futures content can be incorporated into many public health programs such as home visiting, child care, school-based health clinics, and many others. The Bright Futures/AAP periodicity schedule recommends an initial developmental screening at nine months, and additional screenings at 18 months and 30 months of age and that developmental surveillance be incorporated at every well-child preventive care visit. AAP validated developmental screening tools include the Ages and Stages Questionnaire, Parents' Evaluation of Developmental Status, FirstSTEp Screening Test for Evaluating Preschooler, and Developmental Assessment of Young Children, among others.
2. SUPPORT. Children Now, cosponsors of this bill, states that this bill takes the first critical step to help ensure that every California child, especially those who are low-income, has the opportunity to reach his or her full potential by having timely developmental screenings in Medi-Cal. Early identification of developmental delays through screening is the first step to connecting children with the supports they need for healthy development. When children with (or at risk of) developmental or other delays are not identified early, they may not receive the timely care and intervention services they need to address those developmental delays or concerns. Unidentified delays during the child's first years of life can significantly impact a child's school readiness and have long-term effects on their overall well-being. Children Now also states that fewer than one in three California kids are actually receiving timely developmental screenings, further delaying any referrals to needed early intervention services. Additionally, California ranks 43rd in the nation in the rate of young kids who receive timely screenings, which puts California children at a serious disadvantage.

First 5 Association of California, cosponsors of this bill, state that currently, pediatricians are relying on surveillance rather than using a validated screening tool to identify children at-risk for developmental delays. When they do screen, pediatricians are not consistent in their use of validated tools. For example, many do not use the entire tool or follow its intended directions. Subsequently, pediatricians believe they are properly implementing developmental screening and following the APP recommendations, when in fact they are not.

1. OPPOSITION. The California Right to Life Committee, Inc., states in opposition that this bill would be the beginning step in a system to further impinge on the privacy of families. Under the guise of developing an extensive healthcare system for the betterment of California children and families, this bill would encompass more than early childhood healthcare programs and services and would result in a sizeable data collection of family life and "toxic stress" factors. Therefore, family privacy could be jeopardized and what appears to be for the betterment of the family could result in more stress for individual family members as various agencies determine how family members interact with each other.

Analysis Prepared by: Paula Villescaz/Lara Flynn / HEALTH / (916) 319-2097 FN: 0002560

Date of Hearing: January 18, 2018

ASSEMBLY COMMITTEE ON APPROPRIATIONS

Lorena Gonzalez Fletcher, Chair

ABPCA Bill Id:AB 11

Author:(McCarty) – As Amended Ver:January 10, 2018

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

SUMMARY:

This bill requires screening services available under the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit for children in Medi-Cal to include developmental screening services for individuals zero to three years of age according to specified expert recommendations.

FISCAL EFFECT:

No fiscal effect is expected, as this bill appears to codify existing federal requirements.

COMMENTS:

1. Purpose. This bill is intended to ensure developmental screenings, with a standardized and validated tool, are routinely occurring for infants and toddlers during Medi-Cal health care visits. According to the bill sponsors, although it is a federal requirement, screenings are routinely either not occurring or not being conducted as required.
2. Background. Medi-Cal coverage for children includes enumerated preventive health and developmental screenings. This bill requires screenings to include those established by the Bright Futures/ American Academy of Pediatrics (AAP) Periodicity Schedule. Bright Futures is a national health promotion and prevention initiative, led by the AAP and supported, in part, by the federal governmental health agencies. The periodicity schedule provides evidence-based guidance for preventive care screenings and well-child visits. It includes recommended procedures, measurements, and exams for each visit according to a child's age, and includes developmental screenings at 9, 18, and 30 months.

It should be noted Medi-Cal already requires EPSDT to include the screenings in accordance with the Bright Futures periodicity schedule. A Medi-Cal state plan amendment effective October 1, 2015, approved by the federal Centers for Medicare and Medicaid Services March 17, 2016, states EPSDT screening includes "preventive care and screening for infants and children recommended by Health Resources and Services Administration’s (HRSA) Bright Futures program/project." Thus, the bill is codifying existing practice.

1. Support and opposition. This bill is co-sponsored by Children Now and the First 5 Association of California, and is supported by a large number of children's advocacy organizations and local First 5 agencies, as well as AAP-California, because it will improve early identification of developmental delays. The California Right to Life Committee, Inc., opposes the bill, indicating it jeopardizes family privacy.

1. Staff comment. It does not appear this bill will, itself, increase provider adherence to standardized and validated developmental screening tools. It simply restates current practice. To accomplish the stated intent, the author may wish to consider enhancing provider accountability requirements or improving provider education about the required practices.

Analysis Prepared by: Lisa Murawski / APPR. / (916) 319-2081