Existing law establishes the Medi-Cal program, administered by the State Department of Health Care Services, under which basic health care services are provided to qualified low-income persons. The Medi-Cal program is, in part, governed and funded by federal Medicaid program provisions. Existing law provides that specialty mental health services are covered under the Medi-Cal program for eligible Medi-Cal beneficiaries, including both adults and children, and coverage for those services is provided through mental health managed care plans. Existing law requires the department to develop a performance outcome system for Early and Periodic Screening, Diagnosis, and Treatment mental health services provided to eligible Medi-Cal beneficiaries under 21 years of age.

This bill would require the department, commencing no later than January 15, 2018, and as needed thereafter, in consultation with specified stakeholders, to inform the updates to, and build upon, the performance outcomes system reports for specialty mental health services developed for Early and Periodic Screening, Diagnosis, and Treatment mental health services provided to eligible Medi-Cal beneficiaries under 21 years of age and under the Special Terms and Conditions of the Medi-Cal Specialty Mental Health Services Waiver in order to provide data to inform strategies to reduce mental health disparities for specialty mental health services provided to all eligible Medi-Cal beneficiaries. The bill would require the department to consider specified objectives, including high-quality, culturally and linguistically competent, and accessible specialty mental health services for all eligible beneficiaries, in building upon the performance outcomes reports for specialty mental health services, and would require the performance outcomes report for specialty mental health services to be produced using existing data collected by the state, stratified at statewide and county levels and by specified data elements in certain areas, including, among others, access and quality.

This bill would require the department to publish, by December 31, 2018, the performance outcomes reports based on available data for specialty mental health services on the departments Internet Web site, and to provide the performance outcomes reports to the Legislature by December 31, 2018. The bill would require the department, commencing January 1, 2019, and on an as-needed basis thereafter, to consult with specified stakeholders to incorporate additional components into the performance outcomes reports and to make recommendations for statewide quality improvement and efforts to reduce mental health disparities, as specified. The bill, commencing January 1, 2019, and annually thereafter, would require the department to update the performance outcomes reports for specialty mental health services and to post the updated reports on the departments Internet Web site. The bill would authorize the department to implement, interpret, or make specific the requirements of the bill by all-county letters, plan letters, plan or provider bulletins, or similar instructions.

Existing law establishes the Medi-Cal program, administered by the State Department of Health Care Services, under which basic health care services are provided to qualified low-income persons. The Medi-Cal program is, in part, governed and funded by federal Medicaid program provisions. Existing law provides that specialty mental health services are covered under the Medi-Cal program for eligible Medi-Cal beneficiaries, including both adults and children, and coverage for those services is provided through mental health managed care plans. Existing law requires the department to develop a performance outcome system for Early and Periodic Screening, Diagnosis, and Treatment mental health services provided to eligible Medi-Cal beneficiaries under 21 years of age.

This bill would require the department, commencing no later than January 15, 2018, and as needed thereafter, in consultation with specified stakeholders, to inform the updates to, and build upon, the performance outcomes system reports for specialty mental health services developed for Early and Periodic Screening, Diagnosis, and Treatment mental health services provided to eligible Medi-Cal beneficiaries under 21 years of age and under the Special Terms and Conditions of the Medi-Cal Specialty Mental Health Services Waiver in order to provide data to inform strategies to reduce mental health disparities for specialty mental health services provided to all eligible Medi-Cal beneficiaries. The bill would require the department to consider specified objectives, including high-quality, culturally and linguistically competent, and accessible specialty mental health services for all eligible beneficiaries, in building upon the performance outcomes reports for specialty mental health services, and would require the performance outcomes report for specialty mental health services to be produced using existing data collected by the state, stratified at statewide and county levels and by specified data elements in certain areas, including, among others, access and quality.

This bill would require the department to publish, by December 31, 2018, the performance outcomes reports based on available data for specialty mental health services on the departments Internet Web site, and to provide the performance outcomes reports to the Legislature by December 31, 2018. The bill would require the department, commencing January 1, 2019, and on an as-needed basis thereafter, to consult with specified stakeholders to incorporate additional components into the performance outcomes reports and to make recommendations for statewide quality improvement and efforts to reduce mental health disparities, as specified. The bill, commencing January 1, 2019, and annually thereafter, would require the department to update the performance outcomes reports for specialty mental health services and to post the updated reports on the departments Internet Web site. The bill would authorize the department to implement, interpret, or make specific the requirements of the bill by all-county letters, plan letters, plan or provider bulletins, or similar instructions.

Existing law establishes the Medi-Cal program, administered by the State Department of Health Care Services, under which basic health care services are provided to qualified low-income persons. The Medi-Cal program is, in part, governed and funded by federal Medicaid program provisions. Existing law provides that speciality mental health services are covered under the Medi-Cal program for eligible Medi-Cal beneficiaries, including both adults and children, and coverage for those services is provided through mental health managed care plans. Existing law requires the department to develop a performance outcome system for Early and Periodic Screening, Diagnosis, and Treatment mental health services provided to eligible Medi-Cal beneficiaries under 21 years of age.

This bill would require the department, in collaboration with the California Health and Human Services Agency, to create a performance outcome dashboard, as specified, commencing no later than January 15, 2018, and as needed thereafter, in consultation with specified stakeholders, to inform the updates to, and build upon, the performance outcomes system reports developed for Early and Periodic Screening, Diagnosis, and Treatment mental health services provided to eligible Medi-Cal beneficiaries under 21 years of age and under the Special Terms and Conditions of the Medi-Cal Specialty Mental Health Services Waiver in order to provide data to inform strategies to reduce mental health disparities for specialty mental health services provided to all eligible Medi-Cal beneficiaries. The bill would require the department, commencing no later than January 15, 2018, and quarterly thereafter, to convene a stakeholder advisory committee comprised of specified representatives, including representatives of providers, consumers, and counties, to inform the creation of the performance outcome dashboard for specialty mental health services. The bill would require the department to consider specified objectives, including high-quality, trauma-informed, culturally and linguistically competent, and accessible specialty mental health services for all eligible beneficiaries, in developing the performance outcome dashboard, building upon the performance outcomes reports for specialty mental health services, and would require the dashboard to include both statewide and plan-specific data, disaggregated performance outcomes report for specialty mental health services to be produced using existing data collected by the state, stratified at statewide and county levels and by specified categories, data elements in certain areas, including, among others, mental health disparities and quality indicators. access and quality.

This bill would require the department to provide the dashboard to all fiscal committees and appropriate policy committees of the Legislature no later than December 31, 2018. publish, by December 31, 2018, the performance outcomes reports based on available data for specialty mental health services on the departments Internet Web site, and to provide the performance outcomes reports to the Legislature by December 31, 2018. The bill would require the department, commencing January 1, 2019, and on an as-needed basis thereafter, to consult with the stakeholder advisory committee specified stakeholders to incorporate additional components into the dashboard performance outcomes reports and to make recommendations for statewide quality improvement and efforts to reduce mental health disparities, as specified. The bill, commencing January 1, 2019, and annually thereafter, would require the department to provide quarterly updates to the dashboard update the performance outcomes reports for specialty mental health services and to post the updated report reports on the departments Internet Web site. The bill would authorize the department to implement, interpret, or make specific the requirements of the bill by all-county letters, plan letters, plan or provider bulletins, or similar instructions.

Existing law establishes the Medi-Cal program, administered by the State Department of Health Care Services, under which basic health care services are provided to qualified low-income persons. The Medi-Cal program is, in part, governed and funded by federal Medicaid program provisions. Existing law provides that speciality mental health services are covered under the Medi-Cal program for eligible Medi-Cal beneficiaries, including both adults and children, and coverage for those services is provided through mental health managed care plans. Existing law requires the department to develop a performance outcome system for Early and Periodic Screening, Diagnosis, and Treatment mental health services provided to eligible Medi-Cal beneficiaries under 21 years of age.

This bill would require the department, in collaboration with the California Health and Human Services Agency, to create a performance outcome dashboard, as specified, for specialty mental health services provided to eligible Medi-Cal beneficiaries. The bill would require the department, commencing no later than January 15, 2018, and quarterly thereafter, to convene a stakeholder advisory committee comprised of specified representatives, including representatives of providers, consumers, and counties, to inform the creation of the performance outcome dashboard for specialty mental health services. The bill would require the department to consider specified objectives, including high-quality high-quality, trauma-informed, and accessible specialty mental health services for eligible adults, beneficiaries, in developing the performance outcome dashboard, and would require the dashboard to include both statewide and plan-specific data, disaggregated by specified categories, in certain areas, including, among others, mental health disparities and quality indicators.

This bill would require the department to provide the dashboard to all fiscal committees and appropriate policy committees of the Legislature no later than December 31, 2018. The bill would require the department, commencing January 1, 2019, to consult with the stakeholder advisory committee to incorporate additional components into the dashboard and to make recommendations for statewide quality improvement and efforts to reduce mental health disparities, as specified. The bill, commencing January 1, 2019, would require the department to provide quarterly updates to the dashboard and to post the updated report on the departments Internet Web site. The bill would authorize the department to implement, interpret, or make specific the requirements of the bill by all-county letters, plan letters, plan or provider bulletins, or similar instructions.

Existing law establishes the Medi-Cal program, administered by the State Department of Health Care Services, under which basic health care services are provided to qualified low-income persons. The Medi-Cal program is, in part, governed and funded by federal Medicaid program provisions. Existing law provides that speciality mental health services are covered under the Medi-Cal program for eligible Medi-Cal beneficiaries, including both adults and children, and coverage for those services is provided through mental health managed care plans. Existing law requires the department to develop a performance outcome system for Early and Periodic Screening, Diagnosis, and Treatment mental health services provided to eligible Medi-Cal beneficiaries under 21 years of age.

This bill would require the department, in collaboration with the California Health and Human Services Agency, to create a performance outcome dashboard, as specified, for specialty mental health services provided to eligible Medi-Cal beneficiaries 20 years of age and older. beneficiaries. The bill would require the department, commencing no later than January 15, 2018, and quarterly thereafter, to convene a stakeholder advisory committee comprised of specified representatives, including representatives of providers, consumers, and counties, to inform the creation of the performance outcome dashboard for specialty mental health services. The bill would require the department to consider specified objectives, including high-quality and accessible specialty mental health services for eligible adults, in developing the performance outcome dashboard, and would require the dashboard to include both statewide and plan-specific data, disaggregated by specified categories, in certain areas, including, among others, mental health disparities and quality indicators.

This bill would require the department to provide the dashboard to all fiscal committees and appropriate policy committees of the Legislature no later than December 31, 2018. The bill would require the department, commencing January 1, 2019, to consult with the stakeholder advisory committee to incorporate additional components into the dashboard and to make recommendations for statewide quality improvement and efforts to reduce mental health disparities, as specified. The bill, commencing January 1, 2019, would require the department to provide quarterly updates to the dashboard and to post the updated report on the departments Internet Web site. The bill would authorize the department to implement, interpret, or make specific the requirements of the bill by all-county letters, plan letters, plan or provider bulletins, or similar instructions.

Existing law establishes the Medi-Cal program, administered by the State Department of Health Care Services, under which basic health care services are provided to qualified low-income persons. The Medi-Cal program is, in part, governed and funded by federal Medicaid program provisions. Existing law provides that speciality mental health services are covered under the Medi-Cal program for eligible Medi-Cal beneficiaries, including both adults and children, and coverage for those services is provided through mental health managed care plans. Existing law requires the department to develop a performance outcome system for Early and Periodic Screening, Diagnosis, and Treatment mental health services provided to eligible Medi-Cal beneficiaries under 21 years of age.

This bill would require the department to develop department, in collaboration with the California Health and Human Services Agency, to create a performance outcome system dashboard, as specified, for specialty mental health services provided to eligible Medi-Cal beneficiaries 21 20 years of age and older. The bill would require the department, in collaboration with the California Health and Human Services Agency, to create a plan for a performance outcome system for specialty mental health services, and commencing no later than January 15, 2018, would require the department and quarterly thereafter, to convene a stakeholder advisory committee comprised of specified representatives, including consumer advocates representatives of providers, consumers, and counties, to help create a plan for a performance outcomes system inform the creation of the performance outcome dashboard for specialty mental health services. The bill would require the department to consider specified objectives, including high-quality and accessible specialty mental health services for eligible adults, in developing the plan for a performance outcome system, dashboard, and would require the plan dashboard to include metrics of timely access to services, language access, quality, and utilization. The both statewide and plan-specific data, disaggregated by specified categories, in certain areas, including, among others, mental health disparities and quality indicators.

This bill would require the department to provide the plan dashboard to all fiscal committees and appropriate policy committees of the Legislature no later than December 31, 2018, and would require the department, no later than December 31, 2018, to propose how to implement the plan. The bill, commencing January 1, 2018, and at least quarterly thereafter, would require the department to convene a 2018. The bill would require the department, commencing January 1, 2019, to consult with the stakeholder advisory group committee to incorporate additional components into the dashboard and to make recommendations to the department regarding additional performance and outcome measures, for statewide quality improvement and efforts to reduce mental health disparities, as specified. The bill, commencing January 1, 2019, would require the department to provide quarterly updates to the performance outcome system and would require the department to post those updates dashboard and to post the updated report on the departments Internet Web site. The bill would authorize the department to implement, interpret, or make specific the requirements of the bill by all-county letters, plan letters, plan or provider bulletins, or similar instructions.

Existing law establishes the Medi-Cal program, administered by the State Department of Health Care Services, under which basic health care services are provided to qualified low-income persons. The Medi-Cal program is, in part, governed and funded by federal Medicaid program provisions. Existing law provides that speciality mental health services are covered under the Medi-Cal program for eligible Medi-Cal beneficiaries, including both adults and children, and coverage for those services is provided through mental health managed care plans. Existing law requires the department to develop a performance outcome system for Early and Periodic Screening, Diagnosis, and Treatment mental health services provided to eligible Medi-Cal beneficiaries under 21 years of age.

This bill would require the department to develop a performance outcome system for specialty mental health services provided to eligible Medi-Cal beneficiaries 21 years of age and older. The bill would require the department, in collaboration with the California Health and Human Services Agency, to create a plan for a performance outcome system for specialty mental health services, and commencing no later than January 15, 2018, would require the department to convene a stakeholder advisory committee comprised of specified representatives, including consumer advocates and counties, to help create a plan for a performance outcomes system for specialty mental health services. The bill would require the department to consider specified objectives, including high-quality and accessible specialty mental health services for eligible adults, in developing the plan for a performance outcome system, and would require the plan to include metrics of timely access to services, language access, quality, and utilization. The bill would require the department to provide the plan to all fiscal committees and appropriate policy committees of the Legislature no later than December 31, 2018, and would require the department, no later than December 31, 2018, to propose how to implement the plan. The bill, commencing January 1, 2018, and at least quarterly thereafter, would require the department to convene a stakeholder advisory group to make recommendations to the department regarding additional performance and outcome measures, as specified. The bill, commencing January 1, 2019, would require the department to provide quarterly updates to the performance outcome system and would require the department to post those updates on the departments Internet Web site.

CONCURRENCE IN SENATE AMENDMENTS

CSA1 Bill Id:AB 470

Author:(Arambula)

As Amended Ver:September 1, 2017

Majority vote

Original Committee Reference: HEALTH

SUMMARY: Requires the Department of Health Care Services (DHCS) to consult with specified stakeholders to inform the updates to the performance outcomes system for specialty mental health services (SMHS) developed for Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) and under the Special Terms and Conditions (STCs) of the Medi-Cal SMHS Waiver. Specifically, this bill:

1. Requires DHCS, commencing on January 15, 2018, and as needed thereafter, to consult with stakeholders, including but not limited to, subject-matter experts who represent providers, consumer advocates, consumers, family members, counties and the Legislature to inform the updates to the performance outcomes report for SMHS developed for EPSDT and the STCs.
2. Requires DHCS, in building upon the performance outcomes reports for SMHS, to consider both of the following objectives, among others:
   1. High-quality, culturally informed and linguistically competent and accessible SMHS for all eligible beneficiaries, consistent with federal law; and,
   2. Strategies to reduce mental health disparities.
3. Requires the performance outcome dashboard for SMHS to also consider the STCs and the Medicaid Managed Care Quality Rating System, as specified.
4. Requires, in order to identify mental health disparities, at a minimum, the performance outcomes reports for SMHS to be produced using existing data collected by the state, stratified by both the statewide and county levels in the following areas:
   1. Access, such as of timely access to services, including waiting time to assessment and waiting time to first appointment;
   2. Language capacity and language access;
   3. Quality
   4. Utilization and penetration.
5. Requires data collected under 4), above, to be stratefied by age, sex, gender identity, race, ethnicity, primary language, sexual orientation, and any other data elements for which there is peer-reviewed evidence to assess performance outcomes related to mental health disparities.
6. Prohibits DHCS from reporting any demographic data under 5), above, that would permit identification of individuals.
7. Requires DHCS to publish the performance outcomes reports based on available data for SMHS on the department's Internet Web site by December 31, 2018. Requires DHCS to provide the performance outcomes reports to the Legislature by December 31, 2018.
8. Requires DHCS, commencing January 1, 2019, and annually thereafter, to update the performance outcomes reports and post the updated report on its Internet Web site.
9. Requires DHCS, commencing on January 1, 2019, and annually thereafter, to consult, as needed, with the stakeholders specified in 1) above to do both of the following:
   1. Incorporate additional components into performance outcomes reports, including but not limited to: components concerning the reduction of mental health disparities, timely access to services, language access, and quality and utilization measures relating to mental health services obtained through Medi-Cal managed care (MCMC) plans; and,
   2. Make recommendations for statewide quality improvement and efforts to reduce mental health disparities based on information reported in the performance outcomes reports.
10. Specifies that upon completion of the activities specified in 9) above, the department shall consult with the stakeholders on an as-needed bases.

The Senate amendments clarify that the reporting requirements in this bill are an extension of the reporting requirements for EPSDT and the STCs and not a new reporting system; remove the requirement for DHCS to convene a formal advisory committee and require DHCS to consult with stakeholders instead; and make other technical, conforming and clarifying changes.

FISCAL EFFECT: According to the Senate Appropriations Committee, ongoing costs, likely in the hundreds of thousands, for additional data analysis and reporting by DHCS (General Fund and federal funds). The bill requires DHCS to disaggregate data related to access to services and quality indicators by various demographic characteristics of the beneficiaries served by county mental health plans. DHCS generally has the kind of demographic data required in the bill. However, DHCS would likely incur administrative costs to cross match existing demographic data with claims data submitted by counties.

COMMENTS: According to the author, providing consistency in the mental health services throughout the state is necessary to ensure equity and access to everyone. Current mental health plans (MHPs) show major disparities in language access and timely access for underserved communities who are in need of quality SMHS.

Mental health services under Medi-Cal are delivered through a unique system that involves MCMC plans, county MHPs, and fee for service Medi-Cal. When the state adopted the Patient Protection and Affordable Care Act in 2014, California was required to provide behavioral health services, including mental health services to the Medicaid expansion population and the same scope of behavioral services are currently provided to all Medi-Cal beneficiaries. Currently, MCMC plans are required to provide mental health benefits covered in the state plan, except those benefits provided by county MHPs under the Specialty Mental Health Services Waiver (discussed below). MCMC plans cover the following mental health services: individual and group mental health evaluation and treatment (psychotherapy), psychological testing (when clinically indicated) outpatient services for the purposes of monitoring drug therapy, outpatient laboratory, drugs, supplies and supplements, and psychiatric consultation. MCMC plans are also obligated to cover outpatient mental health services to beneficiaries with mild to moderate impairment of mental, emotional or behavioral functioning, and for this reason, the scope of services provided by MCMC plans is often referred to as "mild to moderate."

Under Section 1915 (b) of the Specialty Mental Health Services Waiver, California continues to provide SMHS to Medi-Cal beneficiaries through the MHPs. SMHS are those mental health services which are provided to Medi-Cal beneficiaries who meet medical necessity criteria (a person must have a listed diagnosis, and meet specified impairment and intervention criteria). SMHS include rehabilitative mental health services, medication support, day treatment intervention, crisis stabilization, adult residential treatment, crisis residential treatment, psychiatric health facility services, psychologist services, and psychiatric nursing facility services.

Analysis Prepared by: Rosielyn Pulmano / HEALTH / (916) 319-2097 FN: 0001882

 THIRD READING  

Bill No: AB 470

Author:

: 9/1/17

Vote:

SENATE HEALTH COMMITTEE: 9-0, 6/21/17

AYES: Hernandez, Nguyen, Atkins, Leyva, Mitchell, Monning, Newman, Nielsen, Roth

SENATE APPROPRIATIONS COMMITTEE: 6-0, 9/1/17

AYES: Lara, Beall, Bradford, Hill, Nielsen, Wiener

NO VOTE RECORDED: Bates

ASSEMBLY FLOOR: 72-5, 5/31/17 - See last page for vote

SUBJECT: Medi-Cal: specialty mental health services: performance outcome reports

SOURCE: California Pan-Ethnic Health Network

DIGEST:

This bill requires the Department of Health Care Services (DHCS) to create a performance outcome report for specialty mental health services, as specified, and to make it available to specified entities no later than December 31, 2018. Requires DHCS to consult with stakeholders, as specified, for purposes of creating the report, and to update the report, as specified.

ANALYSIS:

Existing law:

1. Establishes the Medi-Cal program, which is administered by the DHCS, under which qualified low-income individuals receive health care services. Establishes a schedule of benefits under the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) program for any individual under 21 years of age consistent with federal Medicaid requirements.
2. Requires DHCS to implement managed mental health care for Medi-Cal beneficiaries through contracts with mental health plans (MHPs), which may include individual counties, counties acting jointly, or an organization or nongovernmental entity determined by DHCS to meet MHP standards.
3. Requires MHPs to provide specialty mental health services (SMHS) to eligible Medi-Cal beneficiaries, including both adults and children. Includes EPSDT within the scope of SMHS.

This bill:

1. Requires DHCS to create a performance outcome report for SMHS provided to Medi-Cal beneficiaries, developed pursuant to the Center for Medicare and Medicaid’s Special Terms and Conditions (CMS STCs).
2. Requires DHCS, commencing no later than January 15, 2018, and as needed thereafter, to consult stakeholders comprised of representatives of providers, consumer advocates, consumer, family members, counties, and the Legislature to inform the updates of the performance outcome report for SMHS.
3. Requires DHCS, in developing the performance outcome report, to consider the following objectives:
   1. High-quality culturally and linguistically competent and accessible SMHS for all eligible beneficiaries, consistent with federal law; and
   2. Strategies to reduce mental health disparities.
4. Requires the SMHS performance outcome report to also consider CMS’s STCs and the Medicaid Managed Care Quality Rating System.
5. Requires the SMHS performance outcome report to be produced using existing data collected by the state, stratified by both the statewide and county levels in the following areas:
   1. Access, such as timely access to services, including waiting time to assessment and waiting time to first appointment;
   2. Language capacity and language access;
   3. Quality; and,
   4. Utilization and penetration.
6. Requires data specified in 5) above to be stratified by age, sex, gender identity, race, ethnicity, languages available from the Medi-Cal Eligibility Data System, sexual orientation, and any other data elements for which there is peer-reviewed evidence to assess performance outcomes related to mental health disparities. Prohibits DHCS from reporting demographic data that would permit identification of individuals.
7. Requires DHCS to publish the SMHS performance outcome report based on available date to DHCS’s Web site by December 31, 2018, and to provide the report to the Legislature by that date.
8. Requires DHCS, commencing January 1, 2019, to consult, as needed, with the stakeholders in 2) above to do both of the following:
   1. Incorporate additional components into the SMHS report, including languages not previously reported, and components concerning the reduction of mental health disparities, such as timely access to services, language access, and quality and utilization measures, as specified; and,
   2. Make recommendations for statewide quality improvement and efforts to reduce mental health disparities, as specified.
9. Permits DHCS to implement, interpret, or make specific the provisions in this bill by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions, without taking regulatory action.

Comments

1. Author’s statement. According to the author, providing consistency in our mental health services throughout the state is necessary in order to ensure equity and access to everyone. Current MHPs show major disparities in language access and timely access for underserved communities who are in need of quality adult SMHS. Communities of color have rates of serious mental illness above the state average, yet there are major disparities in access to mental health treatment for Medi-Cal beneficiaries. Additionally, limited English proficient communities and the lesbian, gay, bisexual, and transgender (LGBT) community have historically been underserved by California’s public mental health system. Creating metrics and compiling data on what services we provide is one of the first steps towards ensuring that we are doing our due diligence to improve mental health outcomes and reduce disparities for our constituency.
2. SMHS. The Medi-Cal SMHS program is carved out of the broader Medi-Cal program and is administered by DHCS under the 1915(b) SMHS Waiver approved by CMS. DHCS contracts with MHPs in each county to provide or arrange for the provision of Medi-Cal SMHS. All MHPs are county mental health departments. SMHS are Medi-Cal entitlement services for adults and children that meet medical necessity criteria, which consist of having a specific covered diagnosis, functional impairment, and meeting intervention criteria. MHPs must certify that they incurred a cost before seeking federal reimbursement through claims to the state. MHPs are responsible for the nonfederal share of Medi-Cal SMHS. Mental health services for Medi-Cal beneficiaries who do not meet the criteria for SMHS are provided under the broader Medi-Cal program either through Medi-Cal Managed Care (MCMC) plans or the fee-for-service Medi-Cal program for beneficiaries not enrolled in a MCMC plan. The following Medi-Cal SMHS are available for adults: adult residential treatment services, crisis intervention, crisis stabilization, crisis residential treatment services, day rehabilitation, day treatment intensive, medication support services, psychiatric health facility services, psychiatric inpatient hospital services, targeted case management, and therapy and other service activities. The responsibility for SMHS was realigned to the counties in 2011 as part of 2011 Public Safety Realignment. Pursuant to Proposition 30, state requirements enacted after September 30, 2012, that have an overall effect of increasing the costs already borne by a local agency for programs or levels of service mandated by 2011 Realignment apply to local agencies only to the extent that the state provides annual funding for the cost increase.
3. CMS’s STCs. In a letter to DHCS dated June 24, 2015, CMS approved the renewal of the 1915(b) SMHS Waiver for a five-year term, which to date is the longest renewal term CMS has granted to DHCS for this particular waiver. As a condition of the renewal, CMS required DHCS to adhere to several STCs, as there continued to be overarching concern about program integrity and compliance. The first STC required by CMS requires DHCS to make readily available to beneficiaries, providers, and other interested stakeholders, an MHP dashboard that is based on performance data of each county MHP included in the external quality review organization’s (EQRO) annual technical report and/or other appropriate resources. Each county MHP dashboard is required to be posted on DHCS’s and the MHP’s Web site. Each dashboard is required to present an easily understandable summary of quality, access, timeliness, and translation and interpretation capabilities regarding the performance of each participating MHP. The dashboards must also include the performance of subcontracted providers. DHCS has the authority to determine how the data on the performance of subcontracted providers will be collected and the associated timeframe. DHCS is required to update CMS on this process. The first dashboard was due on September 1, 2016, and CMS specified that it may initially not include information on the subcontracted providers; however, that information is required to be included in subsequent dashboards.

The first dashboard made available on DHCS’s Web site did not include all of the information required in the first STC, particularly timeliness, translation/interpretation capabilities, and quality. According to DHCS, CMS was aware, through frequent conversations, that the initial dashboard would not include specific information and that DHCS would produce the initial dashboard containing information that it currently has. DHCS stated that it does not have the capability to collect the missing information, and that they are currently working on mechanisms for capturing the information. DHCS further stated that competing priorities and changes to technological systems contributed to missing information. Additionally, MPHs have technological systems that also are incapable of capturing required information. DHCS stated that they are working with the EQRO to develop a baseline metric. According to DHCS, CMS is notified frequently regarding their progress.

The second STC requires DHCS to require each county MHP to commit to having a system in place for tracking and measuring timeliness of care, including wait times to assessments and wait time to providers. DHCS is required to establish a baseline of each and all counties that includes the number of days and an average range of time it takes to access services in their county. This information also was not made available in the first released dashboard, particularly because of existing DHCS and county MHP technological capabilities.

SB 1009 (Committee on Budget and Fiscal Review, Chapter 34, Statutes of 2012) expressed the intent of the Legislature to develop a performance outcome dashboard for EPSDT services that would improve outcomes at the individual and systems levels and inform fiscal decision making related to the purchase of services. This bill codifies CMS’s STC requirements related to timeliness, translation and interpretation capabilities and language access, and quality of services. This bill also goes further in requiring the dashboard to include disaggregated data about beneficiaries, like race, age, sex, primary language, and gender identity, and other data, including mental health disparities; measurement of timely access to services, including waiting time to assessment and waiting time to first appointment; language capacity and access; quality indicators, including beneficiary experience and clinical outcomes; and utilization and penetration rates, including, at a minimum, reporting the subcomponents of services utilized by assessments, contacts, and therapy or other services provided. DHCS’s current dashboard for EPSDT services contains more data that aligns with the requirements in this bill than the SMHS dashboard it initially released.

FISCAL EFFECT: Appropriation: Fiscal Com.: Local:

According to the Senate Appropriations Committee, ongoing costs, likely in the hundreds of thousands, for additional data analysis and reporting by DHCS (General Fund and federal funds). The bill requires DHCS to disaggregate data related to access to services and quality indicators by various demographic characteristics of the beneficiaries served by county mental health plans. DHCS generally has the kind of demographic data required in the bill. However, DHCS would likely incur administrative costs to cross match existing demographic data with claims data submitted by counties.

SUPPORT: (Verified 9/1/17)

California Pan-Ethnic Health Network (source)

Alliance for Boys and Men of Color

Asian Law Alliance

California Access Coalition

California Children’s Hospital Association

California Immigrant Policy Center

California Latinas for Reproductive Justice

California LGBT Health & Human Services Network

California Rural Legal Assistance Foundation

California School-Based Health Alliance

Consumers Union

Disability Rights California

Fathers & Families of San Joaquin

Gender Health Center

Having Our Say Coalition

Health Access California

LGBT Community Center of the Desert

Los Angeles LGBT Center

Mental Health America of California

Mental Health America of Northern California

Mixteco/Indígena Community Organizing Project

National Alliance on Mental Illness California

National Help Law Program

Southeast Asia Resource Action Center

Steinberg Institute

Street Level Health

Western Center on Law and Poverty

OPPOSITION: (Verified 9/1/17)

None received

ARGUMENTS IN SUPPORT: The California Pan-Ethnic Health Network (CPEHN), the sponsor of this bill, states that prevalence rates of serious mental illness in adults vary by income and race and ethnicity. Adults who live in poverty have significantly higher rates of mental illness than those who do not. On average, 4.3% of adult Californians are diagnosed with serious mental illness. However, 9.3% of California adults living below the poverty limit are diagnosed with a serious mental illness, and Latino, African-American, Native-American, and multi-racial adults have rates of serious mental illness above the state average. CPEHN and other supporters, largely advocates of underrepresented groups, argue that CMS’s STCs require DHCS to annually produce a dashboard to report on statewide and plan-specific performance in timely access, language access, and quality. However, the dashboard does not currently provide this required information. Supporters argue that this bill adds disparities reduction as a required performance measure, and codifies the requirement that DHCS produce the annual dashboard, building on the resources already devoted to the dashboard. Supporters state that it is important to ensure that Medi-Cal beneficiaries have timely access to care than meet their cultural and language needs, including mental health services.

ASSEMBLY FLOOR: 72-5, 5/31/17

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

NOES: Brough, Dahle, Fong, Gallagher, Harper

NO VOTE RECORDED: Choi, Eggman, Melendez

Prepared by:

9/4/17 12:33:30

**** END ****

SENATE COMMITTEE ON

Senator Ricardo Lara, Chair

2017 - 2018 Regular Session

AB 470 (Arambula) - Medi-Cal: specialty mental health services: performance outcome dashboard

Bill Summary:

AB 470 would require the Department of Health Care Services to create a performance outcome dashboard for specialty mental health services provided in the Medi-Cal program.

*********** ANALYSIS ADDENDUM – SUSPENSE FILE ***********

The following information is revised to reflect amendments

adopted by the committee on September 1, 2017

Fiscal Impact:

The Department of Health Care Services is required by the federal government to develop a performance outcome dashboard for specialty mental health services. Many of the specific requirements in this bill mirror existing federal requirements. However, there are some elements of the bill that would impose additional cost on the Department and county mental health plans.

• Ongoing costs, likely in the hundreds of thousands, for additional data analysis and reporting by the Department of Health Care Services (General Fund and federal funds). The bill would require the Department to disaggregate data related to access to services and quality indicators by various demographic characteristics of the beneficiaries served by county mental health plans. The Department generally has the kind of demographic data required in the bill. However, the Department would likely incur administrative costs to cross match existing demographic data with claims data submitted by counties.

Author Amendments:

revise the information required to be provided by the Department, generally to limit reporting to data already collected by the Department.

-- END --

SENATE COMMITTEE ON APPROPRIATIONS

Senator Ricardo Lara, Chair

2017 - 2018 Regular Session

AB 470 (Arambula) - Medi-Cal: specialty mental health services: performance outcome dashboard

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

Bill Summary:

AB 470 would require the Department of Health Care Services to create a performance outcome dashboard for specialty mental health services provided in the Medi-Cal program.

Fiscal Impact:

The Department of Health Care Services is required by the federal government to develop a performance outcome dashboard for specialty mental health services. Many of the specific requirements in this bill mirror existing federal requirements. However, there are some elements of the bill that would impose additional cost on the Department and county mental health plans.

• Unknown information technology costs, potentially in the hundreds of thousands to low millions, to allow the Department to collect data on the subcomponents of services provided by county mental health plans (General Fund and federal funds). Under current practice, county mental health plans submit claims information to the Department, in order to draw down federal funding for specialty mental health services provided by the county mental health plan or its contractors. The information in the claim is limited and does not include a level of specificity that would be reported under the bill. The Department would likely either need to make changes to the information technology system that processes claims or create some other mechanism for counties to provide more detailed information on the services provided.
• Unknown costs to county mental health plans to report more detailed data on services provided (General Fund). Similar to the issue above, if county mental health plans need to revise their systems for tracking and reporting services provided at a higher level of detail, there could be substantial costs to counties. Under Proposition 30, those costs would likely be a state responsibility.
• Ongoing costs, likely in the hundreds of thousands, for additional data analysis and reporting by the Department of Health Care Services (General Fund and federal funds). The bill would require the Department to disaggregate data related to access to services and quality indicators by various demographic characteristics of the beneficiaries served by county mental health plans. The Department generally has the kind of demographic data required in the bill. However, the Department would likely incur substantial administrative costs to cross match existing demographic data with claims data submitted by counties and then report the claims data in the disaggregated manner required in the bill.

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.

In the Medi-Cal program, provision of mental health services is divided by the severity of the enrollee’s mental health needs. Services for mild to moderate mental illness are provided by Medi-Cal managed care plans (or the fee-for-service system for about 20% of Medi-Cal enrollees not in managed care). Services for severe mental illness, known as specialty mental health services, are provided by county mental health plans. County mental health plans contract with the Department of Health Care Services. Specialty mental health services are paid for with local funds (primarily realignment funds) and federal matching funds. The state has a “waiver” of federal law that allows the state to provide specialty mental health services in this manner. The federal government has imposed “special terms and conditions” upon approval of the state’s waiver. Included in those special terms and conditions is a requirement that the Department develop a mental health plan dashboard that includes performance data for each county mental health plan, including information on quality, access, timeliness, and translation/interpretation capabilities.

Proposed Law:

AB 470 would require the Department of Health Care Services to create a performance outcome dashboard for specialty mental health services provided in the Medi-Cal program.

Specific provisions of the bill would:

• Require the Department of Health Care Services to create a performance outcome dashboard for specialty mental health services;
• Require the Department to convene a stakeholder advisory committee to inform the creation of the required dashboard;
• Specify objectives to be considered by the Department in developing the dashboard;
• Require the dashboard to include, at a minimum, specified information at the statewide and plan level – including information on mental health disparities, measurements of timely access to care, language access, quality indicators, and utilization and penetration rates (including reporting on subcomponents of services);
• Require the data to be reported to be disaggregated by specified demographic characteristics, including gender, ethnic, primary language, and zip code;
• Beginning January 1, 2019, require quarterly updates to the dashboard on its website;
• Beginning January 1, 2019, require the Department to consult with the stakeholder advisory committee to incorporate additional components into the dashboard and consider recommendations for statewide quality improvement efforts to reduce mental health disparities;
• Authorize the Department to implement the bill without taking regulatory action under the Administrative Procedure Act.

Staff Comments:

As noted above, the Department is required by the federal government to develop a performance dashboard system that is consistent with the requirements of this bill. The Department provided the first iteration of the Dashboard in late 2016. That dashboard did not include much of the information required by the federal government, including information on timely access to services, translation, and quality.

Proposition 30 of 2012 provides that any legislation enacted after September 30, 2012 that has an overall effect of increasing the costs already borne by a local agency for realigned services applies 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. The provision of specialty mental health services in Medi-Cal is a realigned program. To the extent that this bill would impose additional costs on county mental health plans, they would only be required to perform those duties to the extent that the state provided funding.

-- END --

SENATE COMMITTEE ON HEALTH

Senator Ed Hernandez, O.D., Chair

BILL NO: AB 470

SUBJECT: Medi-Cal: specialty mental health services: performance outcome dashboard

SUMMARY:

Requires the Department of Health Care Services (DHCS) to create a performance outcome dashboard for specialty mental health services, as specified, and to make it available to specified entities no later than December 31, 2018. Requires DHCS to convene a stakeholder advisory committee, as specified, for purposes of creating the dashboard, and to make frequent updates to the dashboard, as specified. Requires the dashboard to contain specified information, including mental health disparities, measurements of timely access, and language capacity and access.

Existing law:

1. Establishes the Medi-Cal program, which is administered by the DHCS, under which qualified low-income individuals receive health care services. Establishes a schedule of benefits under the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) program for any individual under 21 years of age consistent with federal Medicaid requirements.
2. Requires DHCS to implement managed mental health care for Medi-Cal beneficiaries through contracts with mental health plans (MHPs), which may include individual counties, counties acting jointly, or an organization or nongovernmental entity determined by DHCS to meet MHP standards.
3. Requires MHPs to provide specialty mental health services (SMHS) to eligible Medi-Cal beneficiaries, including both adults and children. Includes EPSDT within the scope of SMHS.

This bill:

1. Requires DHCS, in collaboration with the California Health and Human Services Agency, to create a performance outcome dashboard for SMHS provided to Medi-Cal beneficiaries, consistent with the Center for Medicare and Medicaid’s Special Terms and Conditions (CMS STCs).
2. Requires DHCS, commencing no later than January 15, 2018, and quarterly thereafter, to convene a stakeholder advisory committee comprised of representatives of providers, consumer advocates, consumer, family members, counties, and the Legislature to inform the creation of the performance outcome dashboard for SMHS.
3. Requires DHCS, in developing the performance outcome dashboard, to consider, at a minimum, the following objectives:
   1. High-quality, trauma informed, and accessible SMHS for eligible beneficiaries, consistent with federal law;
   2. Information that improves practice at the individual, program, and system levels;
   3. Minimization of costs by building upon existing resources to the fullest extent possible;
   4. Reliable data that are collected and analyzed in a timely fashion; and,
   5. Elimination or reduction of mental health disparities and strategies for addressing the social determinants of mental health.
4. Requires the SMHS performance outcome dashboard to consider evidence-based models for performance outcomes systems, federal requirements, including CMS’s STCs, the review by the EQRO, and the Medicaid Managed Care Quality Rating System, and the timelines for implementation at the provider, county, and state levels.
5. Requires, at a minimum, the SMHS performance outcome dashboard to include both statewide and plan-specific data in the following areas:
   1. Mental health disparities;
   2. Measurement of timely access to services, including waiting time to assessment and waiting time to first appointment;
   3. Language capacity and access;
   4. Quality indicators, including beneficiary experience and clinical outcomes; and,
   5. Utilization and penetration rates, including, at a minimum, reporting the subcomponents of services utilized by assessments, contacts, and therapy or other services provided.
6. Requires data specified in 5) above to be disaggregated by age, sex, gender identity, race, ethnicity, primary language, sexual orientation, ZIP Code, and any other factors for which there is peer-reviewed evidence of mental health disparities. Prohibits DHCS from reporting demographic data that would permit identification of individuals.
7. Requires DHCS to provide the SMHS performance outcome dashboard to all fiscal committees and appropriate policy committees of the Legislature no later than December 31, 2018.
8. Requires DHCS, commencing January 1, 2019, to provide quarterly updates to the SMHS dashboard and to post the updated report on its Internet Web site.
9. Requires DHCS, commencing January 1, 2019, to consult with the stakeholder advisory committee in 2) above to do both of the following:
   1. Incorporate additional components into the SMHS dashboard, including components concerning the reduction of mental health disparities, timely access, language access, and quality, as specified; and,
   2. Make recommendations for statewide quality improvement and efforts to reduce mental health disparities, as specified.
10. Permits DHCS to implement, interpret, or make specific the provisions in this bill by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions, without taking regulatory action.

FISCAL EFFECT: According to the Assembly Appropriations Committee:

1. One-time costs to convene stakeholders and develop an implementation plan, in the range of $100,000 (General Fund [GF]/federal monies).
2. Ongoing costs, potentially in the range of low hundreds of thousands (GF/federal), to make changes to the current dashboard system to address additional requirements, such as data on disparities. Because stakeholder input will be used to inform the design of the dashboard, exact cost estimates will be based on the number and availability of data sources used and the number and type of additions to the current dashboard design. Costs could be higher if measures or data sources need to be developed by DHCS, versus publishing data that is already collected and validated. The bill requires DHCS to consider "minimization of costs by building upon existing resources to the fullest extent possible." DHCS has received funds for related activities, such as monitoring and complying with federal requirements for a dashboard as described in 3) below, and requests funds in 2017-18 to implement a new federal rule that requires greater monitoring of MHPs. However, new requirements added by this bill are in addition to current and planned workload identified by DHCS.
3. This bill could result in unknown additional costs in future years from the bill's requirement for DHCS to incorporate additional components into the performance outcome dashboard based on consultation with the stakeholder advisory committee, and to make recommendations for quality improvement and reduction of mental health disparities.

PRIOR VOTES:

COMMENTS:

1. Author’s statement. According to the author, providing consistency in our mental health services throughout the state is necessary in order to ensure equity and access to everyone. Current MHPs show major disparities in language access and timely access for underserved communities who are in need of quality adult SMHS. Communities of color have rates of serious mental illness above the state average, yet there are major disparities in access to mental health treatment for Medi-Cal beneficiaries. Additionally, limited English proficient communities and the lesbian, gay, bisexual, and transgender (LGBT) community have historically been underserved by California’s public mental health system. Creating metrics and compiling data on what services we provide is one of the first steps towards ensuring that we are doing our due diligence to improve mental health outcomes and reduce disparities for our constituency.
2. SMHS. The Medi-Cal SMHS program is carved out of the broader Medi-Cal program and is administered by DHCS under the 1915(b) SMHS Waiver approved by CMS. DHCS contracts with MHPs in each county to provide or arrange for the provision of Medi-Cal SMHS. All MHPs are county mental health departments. SMHS are Medi-Cal entitlement services for adults and children that meet medical necessity criteria, which consist of having a specific covered diagnosis, functional impairment, and meeting intervention criteria. MHPs must certify that they incurred a cost before seeking federal reimbursement through claims to the state. MHPs are responsible for the nonfederal share of Medi-Cal SMHS. Mental health services for Medi-Cal beneficiaries who do not meet the criteria for SMHS are provided under the broader Medi-Cal program either through Medi-Cal Managed Care (MCMC) plans or the fee-for-service Medi-Cal program for beneficiaries not enrolled in a MCMC plan. The following Medi-Cal SMHS are available for adults: adult residential treatment services, crisis intervention, crisis stabilization, crisis residential treatment services, day rehabilitation, day treatment intensive, medication support services, psychiatric health facility services, psychiatric inpatient hospital services, targeted case management, and therapy and other service activities. The responsibility for SMHS was realigned to the counties in 2011 as part of 2011 Public Safety Realignment. Pursuant to Proposition 30, state requirements enacted after September 30, 2012, that have an overall effect of increasing the costs already borne by a local agency for programs or levels of service mandated by 2011 Realignment apply to local agencies only to the extent that the state provides annual funding for the cost increase.
3. CMS’s STCs. In a letter to DHCS dated June 24, 2015, CMS approved the renewal of the 1915(b) SMHS Waiver for a five-year term, which to date is the longest renewal term CMS has granted to DHCS for this particular waiver. As a condition of the renewal, CMS required DHCS to adhere to several STCs, as there continued to be overarching concern about program integrity and compliance. The first STC required by CMS requires DHCS to make readily available to beneficiaries, providers, and other interested stakeholders, an MHP dashboard that is based on performance data of each county MHP included in the external quality review organization’s (EQRO) annual technical report and/or other appropriate resources. Each county MHP dashboard is required to be posted on DHCS’s and the MHP’s Web site. Each dashboard is required to present an easily understandable summary of quality, access, timeliness, and translation and interpretation capabilities regarding the performance of each participating MHP. The dashboards must also include the performance of subcontracted providers. DHCS has the authority to determine how the data on the performance of subcontracted providers will be collected and the associated timeframe. DHCS is required to update CMS on this process. The first dashboard was due on September 1, 2016, and CMS specified that it may initially not include information on the subcontracted providers; however, that information is required to be included in subsequent dashboards.

The first dashboard made available on DHCS’s Web site did not include all of the information required in the first STC, particularly timeliness, translation/interpretation capabilities, and quality. According to DHCS, CMS was aware, through frequent conversations, that the initial dashboard would not include specific information and that DHCS would produce the initial dashboard containing information that it currently has. DHCS stated that it does not have the capability to collect the missing information, and that they are currently working on mechanisms for capturing the information. DHCS further stated that competing priorities and changes to technological systems contributed to missing information. Additionally, MPHs have technological systems that also are incapable of capturing required information. DHCS stated that they are working with the EQRO to develop a baseline metric. According to DHCS, CMS is notified frequently regarding their progress.

The second STC requires DHCS to require each county MHP to commit to having a system in place for tracking and measuring timeliness of care, including wait times to assessments and wait time to providers. DHCS is required to establish a baseline of each and all counties that includes the number of days and an average range of time it takes to access services in their county. This information also was not made available in the first released dashboard, particularly because of existing DHCS and county MHP technological capabilities.

SB 1009 (Committee on Budget and Fiscal Review, Chapter 34, Statutes of 2012) expressed the intent of the Legislature to develop a performance outcome dashboard for EPSDT services that would improve outcomes at the individual and systems levels and inform fiscal decision making related to the purchase of services. This bill would codify CMS’s STC requirements related to timeliness, translation and interpretation capabilities and language access, and quality of services. This bill would also go further in requiring the dashboard to include disaggregated data about beneficiaries, like race, age, sex, primary language, and gender identity, and other data, including mental health disparities; measurement of timely access to services, including waiting time to assessment and waiting time to first appointment; language capacity and access; quality indicators, including beneficiary experience and clinical outcomes; and utilization and penetration rates, including, at a minimum, reporting the subcomponents of services utilized by assessments, contacts, and therapy or other services provided. DHCS’s current dashboard for EPSDT services contains more data that aligns with the requirements in this bill than the SMHS dashboard it initially released.

1. EQRO. Federal Medicaid regulations require states to contract with an EQRO to perform external quality review activities. The EQRO must have staff with demonstrated experience and knowledge of (a) Medicaid beneficiaries, policies, data systems, and processes; (b) managed care delivery systems, organizations, and financing; (c) quality assessment and improvement methods; and (d) research design and methodology, including statistical analysis. The EQRO and its subcontractors are independent from DHCS and the MHPs that they review. States must ensure that the EQRO’s review produces at least the following information:

1. A detailed technical report that describes the manner in which the data from all activities conducted were aggregated and analyzed and conclusions were drawn as to the quality, timeliness, and access to the care furnished by the plan;
2. An assessment of each plan’s strengths and weaknesses with respect to the quality, timeliness, and access to health care services furnished to Medicaid beneficiaries;
3. Recommendations for improving the quality of health care services furnished by each plan;
4. As DHCS determines methodologically appropriate, comparative information about all MHPs; and,
5. An assessment of the degree to which each MHP has addressed effectively the recommendations for quality improvement made by the EQRO during the previous year's review.
6. Related legislation. AB 340 (Arambula) requires, consistent with federal law, that screening services under the EPSDT program include screening for trauma, as specified. Requires DHCS, in consultation with the Department of Social Services and others, to adopt, employ, and develop, as appropriate, tools and protocols for screening children for trauma, as specified. AB 340 is set for hearing on June 28, 2017, in this committee.
7. Prior legislation. SB 1009 (Committee on Budget and Fiscal Review, Chapter 34, Statutes of 2012) expressed the intent of the Legislature to develop a performance outcome system for EPSDT that would improve outcomes at the individual and systems levels and inform fiscal decision making related to the purchase of services.
8. Support. CPEHN, the sponsor of this bill, states that prevalence rates of serious mental illness in adults vary by income and race and ethnicity. Adults who live in poverty have significantly higher rates of mental illness than those who do not. On average, 4.3% of adult Californians are diagnosed with serious mental illness. However, 9.3% of California adults living below the poverty limit are diagnosed with a serious mental illness, and Latino, African-American, Native-American, and multi-racial adults have rates of serious mental illness above the state average. CPEHN and other supporters, largely advocates of underrepresented groups, argue that CMS’s STCs require DHCS to annually produce a dashboard to report on statewide and plan-specific performance in timely access, language access, and quality. However, the dashboard does not currently provide this required information. Supporters argue that this bill adds disparities reduction as a required performance measure, and codifies the requirement that DHCS produce the annual dashboard, building on the resources already devoted to the dashboard. Supporters state that it is important to ensure that Medi-Cal beneficiaries have timely access to care than meet their cultural and language needs, including mental health services.

SUPPORT AND OPPOSITION:

Support: California Pan-Ethnic Health Network (sponsor)

Alliance for Boys and Men of Color

Asian Law Alliance

California Access Coalition

California Children’s Hospital Association

California Immigrant Policy Center

California Latinas for Reproductive Justice

California LGBT Health & Human Services Network

California Rural Legal Assistance Foundation

California School-Based Health Alliance

Consumers Union

Disability Rights California

Fathers & Families of San Joaquin

Gender Health Center

Having Our Say Coalition

Health Access California

LGBT Community Center of the Desert

Los Angeles LGBT Center

Mental Health America of California

Mental Health America of Northern California

Mixteco/Indígena Community Organizing Project

National Alliance on Mental Illness California

National Help Law Program

Southeast Asia Resource Action Center

Steinberg Institute

Street Level Health

Western Center on Law and Poverty

Oppose: None received

-- END -

ASSEMBLY THIRD READING

ATR Bill Id:AB 470

Author:()

As Amended Ver:

Majority vote

SUMMARY: Requires the Department of Health Care Services (DHCS), in collaboration with the California Health and Human Service Agency, to create a plan for a performance outcome system for specialty mental health services (SMHS) provided to eligible Medi-Cal beneficiaries. Specifically, this bill:

1. Requires DHCS, commencing on January 15, 2018, to convene a stakeholder advisory committee every quarter comprised of representatives of consumer advocates, consumers, family members, counties and the Legislature to inform the creation of a plan for a performance outcome system for SMHS. Provides that the consultation will inform the creation of the performance outcome dashboard for SMHS.
2. Requires DHCS, in developing a plan for a performance outcome system to consider the following objectives:
   1. High-quality and accessible SMHS for eligible adults, consistent with federal law;
   2. Information that improves practice at the individual, program, and system levels;
   3. Minimization of costs by building upon existing resources to the fullest extent possible;
   4. Reliable data that are collected and analyzed in a timely fashion; and,
   5. Elimination or reduction of mental health disparities and strategies for addressing the social determinants of mental health.
3. Requires the performance outcome dashboard for SMHS to consider evidence-based models for performance outcome systems, federal requirements, as specified, a review by the External Quality Review Organization, and the Medicaid Managed Care Quality Rating System, and timelines for implementation at the provider, county, and state levels.
4. Requires the performance outcome dashboard for SMHS to include both statewide and plan-specific data in the following areas:
   1. Mental health disparities;
   2. Measurement of timely access to services, including waiting time to assessment and waiting time to first appointment;
   3. Language capacity and access;
   4. Quality indicators, including beneficiary experience and clinical outcomes; and,
   5. Utilization and penetration rates.
5. Requires data collected under 4) above to be disaggregated by age, sex, gender identity, race, ethnicity, primary language, sexual orientation, ZIP Code, and any other factors for which there is peer-reviewed evidence of mental health disparities.
6. Prohibits DHCS from reporting any demographic data under 5) above that would permit identification of individuals.
7. Requires DHCS to provide the performance outcome dashboard to specified committees of the Legislature no later than December 31, 2018.
8. Requires DHCS, commencing no later than January 1, 2019, to provide quarterly updates to the performance outcome dashboard and post the updated report on its Internet Web site.
9. Requires DHCS, commencing on January 1, 2019, to consult with the stakeholder advisory committee to do both of the following:
   1. Incorporate additional components into the dashboard including but not limited to: components concerning the reduction of mental health disparities, timely access to services, language access, and quality and utilization measures relating to mental health services obtained through Medi-Cal managed care (MCMC) plans; and,
   2. Make recommendations for statewide quality improvement and efforts to reduce mental health disparities based on information reported in the performance outcome dashboard.

FISCAL EFFECT: According to the Assembly Appropriations Committee:

1. One-time costs to convene stakeholders and develop an implementation plan, in the range of $100,000 (General Fund (GF)/federal).
2. Ongoing costs, potentially in the range of low hundreds of thousands (GF/federal), to make changes to the current dashboard system to address additional requirements, such as data on disparities. Because stakeholder input will be used to inform the design of the dashboard, exact cost estimates will be based on the number and availability of data sources used and the number and type of additions to the current dashboard design. Costs could be higher if measures or data sources need to be developed by the department, versus publishing data that is already collected and validated. The bill requires DHCS to consider "minimization of costs by building upon existing resources to the fullest extent possible." DHCS has received funds for related activities, such as monitoring and complying with federal requirements for a dashboard as described in Comment #3, and requests funds in 2017-18 to implement a new federal rule that requires greater monitoring of health plans. However, new requirements added by this bill are in addition to current and planned workload identified by the department.
3. This bill could result in unknown additional costs in future years from the bill's requirement for DHCS to incorporate additional components into the performance outcome dashboard based on consultation with the stakeholder advisory committee, and to make recommendations for quality improvement and reduction of mental health disparities.

COMMENTS: According to the author, providing consistency in the mental health services throughout the state is necessary to ensure equity and access to everyone. Current mental health plans (MHPs) show major disparities in language access and timely access for underserved communities who are in need of quality SMHS.

Mental health services under Medi-Cal are delivered through a unique system that involves MCMC plans, county MHPs, and fee for service Medi-Cal. When the state adopted the Patient Protection and Affordable Care Act in 2014, California was required to provide behavioral health services, including mental health services to the Medicaid expansion population and the same scope of behavioral services are currently provided to all Medi-Cal beneficiaries. Currently, MCMC plans are required to provide mental health benefits covered in the state plan, except those benefits provided by county MHPs under the Specialty Mental Health Services Waiver (discussed below). MCMC plans cover the following mental health services: individual and group mental health evaluation and treatment (psychotherapy), psychological testing (when clinically indicated) outpatient services for the purposes of monitoring drug therapy, outpatient laboratory, drugs, supplies and supplements, and psychiatric consultation. MCMC plans are also obligated to cover outpatient mental health services to beneficiaries with mild to moderate impairment of mental, emotional or behavioral functioning, and for this reason, the scope of services provided by MCMC plans is often referred to as "mild to moderate."

Under Section 1915 (b) of the Specialty Mental Health Services Waiver, California continues to provide SMHS to Medi-Cal beneficiaries through the MHPs. SMHS are those mental health services which are provided to Medi-Cal beneficiaries who meet medical necessity criteria (a person must have a listed diagnosis, and meet specified impairment and intervention criteria). SMHS include rehabilitative mental health services, medication support, day treatment intervention, crisis stabilization, adult residential treatment, crisis residential treatment, psychiatric health facility services, psychologist services, and psychiatric nursing facility services.

The California Pan-Ethnic Health Network (the sponsor of this bill), the Asian Law Alliance, Southeast Asia Resource Action Center and the California Immigrant Policy Center state that approximately one in five Californians live with a mental health condition, and one in 20 lives with a mental health condition that impacts daily functioning. While mental health challenges impact all communities, communities of color, immigrant and refugee communities, the LGBT community, and limited English proficient communities have experienced decades of trauma that also impact mental health and well-being. These communities have lower rates of accessing necessary mental health services. Including specific measures of mental health disparities, timely access to services, quality, and utilization will assist in addressing the causes of mental health disparities and barriers to access for historically underserved communities.

There is no known opposition to this bill.

Analysis Prepared by: Rosielyn Pulmano / HEALTH / (916) 319-2097 FN: 0000778

Date of Hearing: April 26, 2017

ASSEMBLY COMMITTEE ON APPROPRIATIONS

Lorena Gonzalez Fletcher, Chair

ABPCA Bill Id:AB 470

Author:(Arambula) – As Amended Ver:March 28, 2017

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

SUMMARY:

This bill requires the Department of Health Care Services (DHCS), in collaboration with the California Health and Human Services Agency (CHHSA), to create a performance outcome dashboard for specialty mental health services provided by county mental health plans. It also establishes parameters for the dashboard, and requires DHCS to:

1. Convene a stakeholder advisory committee to inform creation of the dashboard.
2. Update the dashboard quarterly, starting in 2019.
3. Make recommendations for quality improvement and reduction of mental health disparities based on information reported in the dashboard, starting in 2019.

FISCAL EFFECT:

1. One-time costs to convene stakeholders and develop an implementation plan, in the range of $100,000 (GF/federal).
2. Ongoing costs, potentially in the range of low hundreds of thousands (GF/federal), to make changes to the current dashboard system to address additional requirements, such as data on disparities. Because stakeholder input will be used to inform the design of the dashboard, exact cost estimates will be based on the number and availability of data sources used and the number and type of additions to the current dashboard design. Costs could be higher if measures or data sources need to be developed by the department, versus publishing data that is already collected and validated. The bill requires DHCS to consider "minimization of costs by building upon existing resources to the fullest extent possible." DHCS has received funds for related activities, such as monitoring and complying with federal requirements for a dashboard as described in Comment #3, and requests funds in 2017-18 to implement a new federal rule that requires greater monitoring of health plans. However, new requirements added by this bill are in addition to current and planned workload identified by the department.
3. This bill could result in unknown additional costs in future years from the bill's requirement for DHCS to incorporate additional components into the performance outcome dashboard based on consultation with the stakeholder advisory committee, and to make recommendations for quality improvement and reduction of mental health disparities.

COMMENTS:

1. Purpose. Building on an existing performance dashboard system, this bill is intended to help the state ensure access to quality mental health services delivered to seriously mentally ill Medi-Cal-eligible adults, and collect information helpful in reducing California's stark mental health care disparities. Stakeholders have expressed dissatisfaction with the ability of the current dashboard to communicate information important to them in a timely and meaningful way. The California Pan-Ethnic Health Network is the sponsor of this bill, and it has no opposition.
2. Medi-Cal Mental Health Services. Two separate systems are charged with providing mental health services in Medi-Cal: managed care plans and county mental health plans. Medi-Cal managed care plans are responsible for lower-level mental health screening and treatment, generally for “mild to moderate” diagnoses. County mental health plans deliver specialty mental health services for more severe diagnoses that meet specified medical necessity criteria. Adults must have a significant level of impairment to qualify for county-run specialty mental health services. Pursuant to a specialty mental health services federal waiver, these services are carved out of managed care and delivered by counties under contract with the state. Pursuant to 2011 realignment, such specialty mental health services are locally funded.
3. Dashboard Systems Already Exist. SB 1009 (Committee on Budget and Fiscal Review), Chapter 34, Statutes of 2012, expressed the intent of the Legislature to develop a performance outcomes system for children's mental health services delivered by county mental health plans. Subsequently, DHCS created a plan and requested implementation resources in the 2014-15 Budget Act. DHCS has produced statewide and county-specific reports, which are publicly available.

Pursuant to the Special Terms and Conditions (STCs) of the federal government's approval of the waiver that authorizes county mental health plans, DHCS also must produce a dashboard based on performance data of each county mental health plan, including quality, access, timeliness, and translation/interpretation capabilities for both children's and adults' services. The STCs requires the performance dashboard to be published annually. This bill builds on existing requirements with more types of information and more frequent reporting.

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

Date of Hearing: April 4, 2017

ASSEMBLY COMMITTEE ON HEALTH

Jim Wood, Chair

ABPCA Bill Id:AB 470

Author:(Arambula) – As Amended Ver:March 28, 2017

SUBJECT: Medi-Cal: specialty mental health services: performance outcome dashboard.

SUMMARY: Requires the Department of Health Care Services (DHCS), in collaboration with the California Health and Human Service Agency (HHS), to create a plan for a performance outcome system for specialty mental health services (SMHS) provided to eligible Medi-Cal beneficiaries. Specifically, this bill:

1. Requires DHCS, commencing on January 15, 2018, to convene a stakeholder advisory committee every quarter comprised of representatives of consumer advocates, consumers, family members, counties and the Legislature to inform the creation of a plan for a performance outcome system for SMHS. Provides that the consultation will inform the creation of the performance outcome dashboard for SMHS.
2. Requires DHCS, in developing a plan for a performance outcome system to consider the following objectives:
   1. High-quality and accessible SMHS for eligible adults, consistent with federal law;
   2. Information that improves practice at the individual, program, and system levels;
   3. Minimization of costs by building upon existing resources to the fullest extent possible;
   4. Reliable data that are collected and analyzed in a timely fashion; and,
   5. Elimination or reduction of mental health disparities and strategies for addressing the social determinants of mental health.
3. Requires the performance outcome dashboard for SMHS to consider evidence-based models for performance outcome systems, federal requirements, as specified, a review by the External Quality Review Organization (EQRO), and the Medicaid Managed Care Quality Rating System, and timelines for implementation at the provider, county, and state levels.
4. Requires the performance outcome dashboard for SMHS to include both statewide and plan-specific data in the following areas:
   1. Mental health disparities;
   2. Measurement of timely access to services, including waiting time to assessment and waiting time to first appointment;
   3. Language capacity and access;
   4. Quality indicators, including beneficiary experience and clinical outcomes; and,
   5. Utilization and penetration rates.
5. Requires data collected under 5) above to be disaggregated by age, sex, gender identity, race, ethnicity, primary language, sexual orientation, ZIP Code, and any other factors for which there is peer-reviewed evidence of mental health disparities.
6. Prohibits DHCS from reporting any demographic data under 5) above that would permit identification of individuals.
7. Requires DHCS to provide the performance outcome dashboard to specified committees of the Legislature no later than December 31, 2018.
8. Requires DHCS, commencing no later than January 1, 2019, to provide quarterly updates to the performance outcome dashboard and post the updated report on its Internet Website.
9. Requires DHCS, commencing on January 1, 2019, to consult with the stakeholder advisory committee to do both of the following:
   1. Incorporate additional components into the dashboard including but not limited to: components concerning the reduction of mental health disparities, timely access to services, language access, and quality and utilization measures relating to mental health services obtained through Medi-Cal managed care (MCMC) plans; and,
   2. Make recommendations for statewide quality improvement and efforts to reduce mental health disparities based on information reported in the performance outcome dashboard.

EXISTING LAW:

1. Establishes the Medi-Cal Program, through which eligible low-income individuals receive health care services.
2. Establishes the federal Early and Periodic Screening, Diagnostic, and Treatment (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.
   

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

COMMENTS:

1. PURPOSE OF THIS BILL. According to the author, providing consistency in the mental health services throughout the state is necessary to ensure equity and access to everyone. Current mental health plans (MHPs) show major disparities in language access and timely access for underserved communities who are in need of quality SMHS.
2. BACKGROUND. Mental health services under Medi-Cal are delivered through a unique system that involves MCMC plans, county MHPs, and fee for service (FFS) Medi-Cal.
   1. Mental Health Services under Medi-Cal. When the state adopted the Patient Protection and Affordable Care Act in 2014, California was required to provide behavioral health services, including mental health services to the Medicaid expansion population and the same scope of behavioral services are currently provided to all Medi-Cal beneficiaries. Currently, MCMC plans are required to provide mental health benefits covered in the state plan, except those benefits provided by county MHPs under the Specialty Mental Health Services Waiver (discussed below). MCMC plans cover the following mental health services: individual and group mental health evaluation and treatment (psychotherapy), psychological testing (when clinically indicated) outpatient services for the purposes of monitoring drug therapy, outpatient laboratory, drugs, supplies and supplements, and psychiatric consultation. MCMC plans are also obligated to cover outpatient mental health services to beneficiaries with mild to moderate impairment of mental, emotional or behavioral functioning, and for this reason, the scope of services provided by MCMC plans is often referred to as “mild to moderate.”
      
      Under Section 1915 (b) of the Specialty Mental Health Services Waiver, California continues to provide SMHS to Medi-Cal beneficiaries through the MHPs. SMHS are those mental health services which are provided to Medi-Cal beneficiaries who meet medical necessity criteria (a person must have a listed diagnosis, and meet specified impairment and intervention criteria). SMHS include rehabilitative mental health services, medication support, day treatment intervention, crisis stabilization, adult residential treatment, crisis residential treatment, psychiatric health facility services, psychologist services, and psychiatric nursing facility services.
      
      Effective January 1, 2014, the following mental health services are also available through the FFS/Medi-Cal provider system: individual and group mental health evaluation and treatment (psychotherapy); psychological testing when clinically indicated and medically necessary to evaluate a mental health condition; outpatient services for the purposes of monitoring drug therapy; outpatient laboratory, drugs, supplies and supplements, and psychiatric consultation.

Additionally, children and adolescents from birth through age 21 are eligible for EPSDT programs that provide diagnostic and treatment services needed to "correct or ameliorate defects, physical and mental illnesses, and conditions discovered by screening services, whether or not such services were covered under the Medicaid State Plan." Under this program, states are required to inform Medicaid-eligible beneficiaries from birth through age 21 of the services available to them. EPSDT services include:

• • 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; and,
    10. Therapeutic behavioral services.
  1. Monitoring and Compliance Requirements. DHCS must ensure that local public mental health programs and their contract providers comply with tate and federal laws and regulations for the Medi-Cal program. As part of this monitoring, DHCS conducts triennial outpatient reviews of MHP consolidated specialty mental health services system and chart reviews.
     
     Additionally, under the Special Terms and Conditions (STCs) of the 1915 (b) Waiver for SMHS, the state also monitors MHP activities. Specifically, the STCs direct the state on an annual basis, to make readily available to beneficiaries, providers, and other interested stakeholders, a MHP dashboard that is based on performance data of each county MHP included in the annual external quality review (EQR) technical report and/or other appropriate resources. Each MHP dashboard must be posted on the state’s and the MHP's Website. Each dashboard will present an easily understandable summary of quality, access, timeliness, and translation/interpretation capabilities regarding the performance of each participating MHP. The dashboards must include the performance of subcontracted providers. The first dashboard was due on September 1, 2016. Additionally, the STCs require the state to commit to having a system in place for tracking and measuring timeliness of care, including wait times to assessments and wait times to providers. On DHCS's Internet Website, a dashboard has been published that includes statewide information on race, gender, age, and utilization. The sponsor of this bill points out that DHCS has not complied with all the requirements of the dashboard, specifically as easily understandable summary of plan specific data, and information regarding timeliness, translation, and interpretation capabilities, and quality.
     
     Lastly, federal regulations require states to conduct an EQR of its contracted managed care organizations and prepaid inpatient health plans, including county MHPs. The EQRO conducts reviews of MHPs to analyze and evaluate information related to quality, timeliness, and access to SMHS provided by California's 56 MHPs and/or their subcontractors for Medi-Cal beneficiaries. The California EQRO for the Medi-Cal SMHS Program is Behavioral Health Concepts, Inc. EQRO reviews consist of site visits, consumer (beneficiary) and family member focus groups, MHP and provider staff focus groups, data analysis and reporting, information system reviews, and the evaluation of MHP Performance Improvement Projects. Each EQRO review is summarized in an individualized MHP report. Information included in individualized MHP reports is also included in an annual statewide summary report.
  2. EPSDT Performance Outcome System. SB 1009 (Committee on Budget and Fiscal Review), Chapter 34, Statutes of 2012, expressed the intent of the Legislature to develop a performance outcome system for EPSDT that will improve outcomes at the individual and systems levels and will inform fiscal decision making related to the purchase of services. DHCS, in collaboration with HHS, and in consultation with the Mental Health Services Oversight and Accountability Commission, created a plan for a performance outcome system for EPSDT. A stakeholder advisory committee was convened for the purpose of developing this plan. The Performance Outcomes System will be used to evaluate access, engagement, service appropriateness to need, service effectiveness, linkages, cost effectiveness, and satisfaction. The reports are available on DHCS’s Internet Website and include statewide aggregate data; regional data; and, county specific data. Regional data are organized by county size: small-rural, small, medium, and large counties, and Los Angeles.

1. SUPPORT. The California Pan-Ethnic Health Network (the sponsor of this bill), the Asian Law Alliance, Southeast Asia Resource Action Center and the California Immigrant Policy Center state that approximately one in five Californians live with a mental health condition, and one in 20 lives with a mental health condition that impacts daily functioning. While mental health challenges impact all communities, communities of color, immigrant and refugee communities, the LGBT community, and limited English proficient communities have experienced decades of trauma that also impact mental health and well-being. These communities have lower rates of accessing necessary mental health services. Including specific measures of mental health disparities, timely access to services, quality, and utilization will assist in addressing the causes of mental health disparities and barriers to access for historically underserved communities.

REGISTERED SUPPORT / OPPOSITION:

Support

California Pan-Ethnic Health Network (sponsor)

Asian Law Alliance

California Access Coalition

California Immigrant Policy Center

California LGTB Health & Human Services Network

California Rural Legal Assistance Foundation

California School-Based Health Alliance

Consumers Union

Disability Rights California

Fathers and Families of San Joaquin

Gender Health Center

Having Our Say

Health Access California

LGBT Community Center of the Desert

Los Angeles LGBT Center

Mental Health America of Northern California

NAMI California

Southeast Asia Resource Action Center

Street Level Health Project

Western Center on Law and Poverty

Opposition

None on file.

Analysis Prepared by: Rosielyn Pulmano / HEALTH / (916) 319-2097