GOVERNOR'S VETO

GV Bill Id:AB 512

Author:(Ting)

As Enrolled Ver:September 10, 2019

2/3 vote

SUMMARY:

Codifies a requirement that county mental health plans (MHPs) prepare a cultural competence plan, expands the required elements to be included in the plan, including mental health disparities and at least eight statewide performance targets for disparities reduction, and requires the plan to address county mental health plans progress towards meeting the reduction targets or making year-over-year improvements. Requires the external quality review organization (EQRO) review of county MHPs to include a report on progress related to statewide mental health disparities reduction targets, commencing January 1, 2024. Requires the EQRO to ensure that the required annual technical report that it performs of each MHP includes a report on statewide disparities reduction targets in its annual detailed technical report.

The Senate Amendments:

Define "mental health disparities," modify and rename the requirements of the cultural competence plan, delay the requirement for adoption of the statewide disparities reduction targets, delay and modify the EQRO reporting requirements, and delete the requirement that DHCS adopt regulations.

Governor's Veto Message:

This bill would require each county mental health plan to meet health disparities reduction targets developed by DHCS and imposes additional reporting requirements and processes on county MHPs.

Although I support the intent and efforts of this bill to reduce mental health disparities, the new requirements imposed by this bill would result in significant General Fund.

COMMENTS:

CULTURAL COMPETENCE PLAN. Existing regulations for county MHPs require each MHP to comply with cultural competence and linguistic requirements, the terms of the contract between the MHP and DHCS, and the MHP's Cultural Competence Plan. Under the regulation, each MHP is required to develop and implement a Cultural Competence Plan that includes specified components.

EQRO. Federal Medicaid regulations require each State that contracts with Medicaid managed care plans to ensure that a qualified EQRO performs an annual external quality review (EQR) for each such contracting plan. EQROs must perform mandatory EQR-related activities, which include validation of performance improvement projects that were underway during the preceding 12 months, validation of plan performance measures, and validation of plan network adequacy during the preceding 12 months. Federal regulations require states to ensure that the EQR results in an annual detailed technical report that summarizes findings on access and quality of care. States are required to finalize the annual technical report by April 30th of each year, and post the most recent copy of the annual EQR technical report on the website.

According to the Author:

The federal Patient Protection and Affordable Care Act (ACA) required nearly all health plans to provide mental health care for their members. Public mental health coverage is provided through state implementation of the ACA, which expanded the scope of Medi-Cal mental health coverage, and through California's county safety net programs. Despite tremendous gains in access to care, communities of color often experience suboptimal outcomes from mental health treatment. This results in great inequity as communities of color and other vulnerable populations who desperately need these services are often met with the greatest barriers to access them. In order to continue to strive for a more accessible system, there has to be an exact understanding of the disparities, data which currently is not reported. This bill is needed to start pinpointing the exact solutions and implementing them to strive for an accessible mental health care system.

Arguments in Support:

This bill is jointly sponsored the California Pan-Ethnic Health Network, the Steinberg Institute, #Out4MentalHealth, the Southeast Asia Resource Action Center, and the Latino Coalition for a Healthy California to require counties to set forward-looking goals in their mental health cultural competence plans and to require DHCS to annually review and monitor their progress. The sponsors argue cultural competence plans are an important tool to address mental health disparities, particularly among historically underserved populations. However, under existing law, these plans lack goals to improve access and utilization of mental health services. Despite tremendous gains in mental health coverage, communities of color and LGBTQ+ communities continue to experience disparities in quality and access to mental health treatment. The sponsors conclude this bill would ensure that counties have the guidance, expertise, and assistance they need to realize the intended purpose of cultural competence plan requirements—to actively respond to and reduce disparities in mental health outcomes.

Arguments in Opposition:

The Department of Finance is opposed to this bill because it results in significant and unknown General Fund costs.

FISCAL COMMENTS:

According to the Senate Appropriations Committee, staff estimates:

1. DHCS. At least $185,000 in Fiscal Year (FY) 2019-20 and $310,000 in FY 2020-21, and ongoing, for 1.0 Research Scientist III and 1.0 Health Program Specialist II at DHCS to conduct research, identify and develop statewide mental health disparities reduction targets, expand the specialty mental health services Performance Dashboard for the new non-duplicative data requirements.
2. Department of Public Health (DPH). Unknown, possibly 1.0 Health Program Specialist I at the Office of Health Equity to analyze the Cultural Competence Plan Requirements to prepare the review. No costs for data-sharing, as DPH and DHCS have an existing interagency agreement.
3. Other. Unknown, potentially minor Proposition 30 impacts to account for a county MHP increased workload and updating electronic health record systems. Unknown cost pressures to the extent that the cultural competence plans call for increased use of county Medi-Cal specialty mental health services, which the state would be obligated under Proposition 30 to reimburse.

VOTES:

ASM HEALTH: 15-0-0

YES: Wood, Mayes, Aguiar-Curry, Bigelow, Bonta, Burke, Carrillo, Flora, Limón, McCarty, Nazarian, Ramos, Rodriguez, Santiago, Waldron

ASM APPROPRIATIONS: 13-0-5

YES: Gonzalez, Bloom, Bonta, Calderon, Carrillo, Chau, Eggman, Gabriel, Eduardo Garcia, Maienschein, Petrie-Norris, Quirk, Robert Rivas

ABS, ABST OR NV: Bigelow, Brough, Diep, Fong, Obernolte

ASSEMBLY FLOOR: 68-2-10

YES: Aguiar-Curry, Arambula, Bauer-Kahan, Berman, Bigelow, Bloom, Boerner Horvath, Bonta, Brough, Burke, Calderon, Carrillo, Cervantes, Chau, Chen, Chiu, Chu, Cooper, Cunningham, Daly, Diep, Eggman, Flora, Fong, Frazier, Friedman, Gabriel, Cristina Garcia, Gipson, Gloria, Gonzalez, Gray, Grayson, Holden, Irwin, Jones-Sawyer, Kalra, Kamlager-Dove, Lackey, Levine, Limón, Low, Maienschein, Mayes, McCarty, Medina, Mullin, Muratsuchi, Nazarian, O'Donnell, Petrie-Norris, Quirk, Quirk-Silva, Ramos, Reyes, Luz Rivas, Robert Rivas, Rodriguez, Blanca Rubio, Salas, Santiago, Smith, Mark Stone, Ting, Waldron, Wicks, Wood, Rendon

NO: Melendez, Obernolte

ABS, ABST OR NV: Choi, Cooley, Dahle, Gallagher, Eduardo Garcia, Kiley, Mathis, Patterson, Voepel, Weber

SENATE FLOOR: 31-8-1

YES: Allen, Archuleta, Atkins, Beall, Bradford, Caballero, Chang, Dodd, Durazo, Galgiani, Glazer, Lena Gonzalez, Hertzberg, Hill, Hueso, Hurtado, Jackson, Leyva, McGuire, Mitchell, Monning, Pan, Portantino, Roth, Rubio, Skinner, Stern, Umberg, Wieckowski, Wiener, Wilk

NO: Bates, Dahle, Grove, Jones, Moorlach, Morrell, Nielsen, Stone

ABS, ABST OR NV: Borgeas

ASSEMBLY FLOOR: 72-4-3

YES: Aguiar-Curry, Arambula, Bauer-Kahan, Berman, Bigelow, Bloom, Boerner Horvath, Bonta, Brough, Burke, Calderon, Carrillo, Cervantes, Chau, Chen, Chiu, Chu, Cooley, Cooper, Cunningham, Daly, Diep, Eggman, Flora, Fong, Frazier, Friedman, Gabriel, Gallagher, Cristina Garcia, Eduardo Garcia, Gipson, Gloria, Gonzalez, Gray, Grayson, Holden, Irwin, Jones-Sawyer, Kalra, Kamlager-Dove, Lackey, Levine, Limón, Low, Maienschein, Mayes, McCarty, Medina, Mullin, Muratsuchi, Nazarian, O'Donnell, Petrie-Norris, Quirk, Quirk-Silva, Ramos, Reyes, Luz Rivas, Robert Rivas, Rodriguez, Blanca Rubio, Salas, Santiago, Smith, Mark Stone, Ting, Waldron, Weber, Wicks, Wood, Rendon

NO: Mathis, Melendez, Obernolte, Patterson

ABS, ABST OR NV: Choi, Kiley, Voepel

UPDATED:

VERSION: September 10, 2019

CONSULTANT: Scott Bain / HEALTH / (916) 319-2097 FN: 0002589

CONCURRENCE IN SENATE AMENDMENTS

CSA1 Bill Id:AB 512

Author:(Ting)

As Amended Ver:August 30, 2019

Majority vote

SUMMARY:

Codifies a requirement that county mental health plans (MHPs) prepare a cultural competence plan, expands the required elements to be included in the plan, including mental health disparities and at least eight statewide performance targets for disparities reduction, and requires the plan to address county mental health plans progress towards meeting meeting the reduction targets or making year-over-year improvements. Requires the external quality review organization (EQRO) review of county MHPs to include a report on progress related to statewide mental health disparities reduction targets, commencing January 1, 2024. Requires the EQRO to ensure that the required annual technical report that it performs of each MHP includes a report on statewide disparities reduction targets in its annual detailed technical report.

The Senate Amendments:

Define "mental health disparities," modify and rename the requirements of the cultural competence plan, delay the requirement for adoption of the statewide disparities reduction targets, delay and modify the EQRO reporting requirements, and delete the requirement that DHCS adopt regulations.

COMMENTS:

CULTURAL COMPETENCE PLAN. Existing regulations for county MHPs require each MHP to comply with cultural competence and linguistic requirements, the terms of the contract between the MHP and DHCS, and the MHP's Cultural Competence Plan. Under the regulation, each MHP is required to develop and implement a Cultural Competence Plan that includes specified components.

EQRO. Federal Medicaid regulations require each State that contracts with Medicaid managed care plans to ensure that a qualified EQRO performs an annual external quality review (EQR) for each such contracting plan. EQROs must perform mandatory EQR-related activities, which include validation of performance improvement projects that were underway during the preceding 12 months, validation of plan performance measures, and validation of plan network adequacy during the preceding 12 months. Federal regulations require states to ensure that the EQR results in an annual detailed technical report that summarizes findings on access and quality of care. States are required to finalize the annual technical report by April 30th of each year, and post the most recent copy of the annual EQR technical report on the website.

According to the Author:

The federal Patient Protection and Affordable Care Act (ACA) required nearly all health plans to provide mental health care for their members. Public mental health coverage is provided through state implementation of the ACA, which expanded the scope of Medi-Cal mental health coverage, and through California's county safety net programs. Despite tremendous gains in access to care, communities of color often experience suboptimal outcomes from mental health treatment. This results in great inequity as communities of color and other vulnerable populations who desperately need these services are often met with the greatest barriers to access them. In order to continue to strive for a more accessible system, there has to be an exact understanding of the disparities, data which currently is not reported. This bill is needed to start pinpointing the exact solutions and implementing them to strive for an accessible mental health care system.

Arguments in Support:

This bill is jointly sponsored the California Pan-Ethnic Health Network, the Steinberg Institute, #Out4MentalHealth, the Southeast Asia Resource Action Center, and the Latino Coalition for a Healthy California to require counties to set forward-looking goals in their mental health cultural competence plans and to require DHCS to annually review and monitor their progress. The sponsors argue cultural competence plans are an important tool to address mental health disparities, particularly among historically underserved populations. However, under existing law, these plans lack goals to improve access and utilization of mental health services. Despite tremendous gains in mental health coverage, communities of color and LGBTQ+ communities continue to experience disparities in quality and access to mental health treatment. The sponsors conclude this bill would ensure that counties have the guidance, expertise, and assistance they need to realize the intended purpose of cultural competence plan requirements—to actively respond to and reduce disparities in mental health outcomes.

Arguments in Opposition:

The Department of Finance is opposed to this bill because it results in significant and unknown General Fund costs.

FISCAL COMMENTS:

According to the Senate Appropriations Committee, staff estimates:

1. DHCS. At least $185,000 in Fiscal Year (FY) 2019-20 and $310,000 in FY 2020-21, and ongoing, for 1.0 Research Scientist III and 1.0 Health Program Specialist II at DHCS to conduct research, identify and develop statewide mental health disparities reduction targets, expand the specialty mental health services Performance Dashboard for the new non-duplicative data requirements.
2. DPH. Unknown, possibly 1.0 Health Program Specialist I at the Office of Health Equity to analyze the Cultural Competence Plan Requirements to prepare the review. No costs for data-sharing, as DPH and DHCS have an existing interagency agreement.
3. Other. Unknown, potentially minor Proposition 30 impacts to account for a county MHP increased workload and updating electronic health record systems. Unknown cost pressures to the extent that the cultural competence plans call for increased use of county Medi-Cal specialty mental health services, which the state would be obligated under Proposition 30 to reimburse.

VOTES:

ASM HEALTH: 15-0-0

YES: Wood, Mayes, Aguiar-Curry, Bigelow, Bonta, Burke, Carrillo, Flora, Limón, McCarty, Nazarian, Ramos, Rodriguez, Santiago, Waldron

ASM APPROPRIATIONS: 13-0-5

YES: Gonzalez, Bloom, Bonta, Calderon, Carrillo, Chau, Eggman, Gabriel, Eduardo Garcia, Maienschein, Petrie-Norris, Quirk, Robert Rivas

ABS, ABST OR NV: Bigelow, Brough, Diep, Fong, Obernolte

ASSEMBLY FLOOR: 68-2-10

YES: Aguiar-Curry, Arambula, Bauer-Kahan, Berman, Bigelow, Bloom, Boerner Horvath, Bonta, Brough, Burke, Calderon, Carrillo, Cervantes, Chau, Chen, Chiu, Chu, Cooper, Cunningham, Daly, Diep, Eggman, Flora, Fong, Frazier, Friedman, Gabriel, Cristina Garcia, Gipson, Gloria, Gonzalez, Gray, Grayson, Holden, Irwin, Jones-Sawyer, Kalra, Kamlager-Dove, Lackey, Levine, Limón, Low, Maienschein, Mayes, McCarty, Medina, Mullin, Muratsuchi, Nazarian, O'Donnell, Petrie-Norris, Quirk, Quirk-Silva, Ramos, Reyes, Luz Rivas, Robert Rivas, Rodriguez, Blanca Rubio, Salas, Santiago, Smith, Mark Stone, Ting, Waldron, Wicks, Wood, Rendon

NO: Melendez, Obernolte

ABS, ABST OR NV: Choi, Cooley, Dahle, Gallagher, Eduardo Garcia, Kiley, Mathis, Patterson, Voepel, Weber

SENATE FLOOR: 31-8-1

YES: Allen, Archuleta, Atkins, Beall, Bradford, Caballero, Chang, Dodd, Durazo, Galgiani, Glazer, Lena Gonzalez, Hertzberg, Hill, Hueso, Hurtado, Jackson, Leyva, McGuire, Mitchell, Monning, Pan, Portantino, Roth, Rubio, Skinner, Stern, Umberg, Wieckowski, Wiener, Wilk

NO: Bates, Dahle, Grove, Jones, Moorlach, Morrell, Nielsen, Stone

ABS, ABST OR NV: Borgeas

UPDATED:

VERSION: August 30, 2019

CONSULTANT: Scott Bain / HEALTH / (916) 319-2097 FN: 0001947

 THIRD READING  

Bill No: AB 512

Author: Ting (D), et al.

Amended: 8/30/19 in Senate

Vote: 21

SENATE HEALTH COMMITTEE: 7-1, 7/10/19

AYES: Pan, Lena Gonzalez, Hurtado, Leyva, Mitchell, Monning, Rubio

NOES: Stone

NO VOTE RECORDED: Grove

SENATE APPROPRIATIONS COMMITTEE: 5-1, 8/30/19

AYES: Portantino, Bradford, Durazo, Hill, Wieckowski

NOES: Jones

NO VOTE RECORDED: Bates

ASSEMBLY FLOOR: 68-2, 5/23/19 - See last page for vote

SUBJECT: Medi-Cal: specialty mental health services

SOURCE: California Pan-Ethnic Health Network

DIGEST: This bill codifies the requirement that county mental health plans prepare a cultural competence plan (CCP), expands the required elements to be included in the CCP, and requires counties to convene a committee to review and approve the CCP. Places requirements on the Department of Health Care Services (DHCS) and the external quality review organization to develop a protocol for monitoring performance on established disparities reduction targets and to include a report on statewide disparities reduction targets, as specified.

ANALYSIS:

Existing law:

1. Establishes the Bronzan-McCorquodale Act to organize and finance community mental health (MH) services for those with MH disorders in every county through locally administered and controlled programs. [WIC §5600, et seq.]
2. Establishes the Medi-Cal program, administered by DHCS, under which qualified low-income individuals receive health care services. [WIC §14001.1]
3. Requires the development of county mental health plans (CMHP) for the provision of managed Medi-Cal specialty mental health services (SMHS) at the local level to eligible Medi-Cal beneficiaries. [WIC §14680, 14684]
4. Requires a CMHP to provide for culturally competent and age-appropriate services, to the extent feasible. Requires a CMHP to assess the cultural competency needs of the program. Requires performance outcome measures to include a reliable method of measuring and reporting the extent to which services are culturally competent and age appropriate. [WIC §14684]
5. Requires a CMHP to develop and implement a CCP, as specified. [9 CCR §1810.410]
6. Requires a CMHP review to be conducted annually by an external quality review organization (EQRO), as specified, to include specific data for Medi-Cal eligible minor and nonminor dependents in foster care, as specified. [WIC §14717.5]
7. States legislative intent to build upon performance outcomes system reports DHCS has developed and per the Special Terms and Conditions of the Medi-Cal SHMS Waiver in order to provide data to inform strategies to reduce MH disparities. Requires DHCS to consult with stakeholders to inform the updates to the performance outcomes reports for SMHS, as specified. [WIC §14707.7]

This bill:

1. Codifies the requirement for a CMHP to prepare a CCP. Requires the CCP to address, but not be limited to, all of the following:
   1. MH disparities in access, utilization, and outcomes by race, ethnicity, primary language, sexual orientation, gender identity, age, disability status, income level, and immigration status, to the extent data is available;
   2. Progress toward meeting mental health disparity reduction targets, as specified, for reducing MH disparities in access, utilization, and outcomes, as well as additional MH disparity reduction targets, as appropriate;
   3. Designated strategies for reaching performance targets, including the CMHP’s rationale for each strategy;
   4. The CMHP’s performance on prior mental health disparity reduction targets;
   5. The CMHP’s strategies for addressing trauma and developing trauma-informing services; and,
   6. The process for community input, including a list of community entities participating.
2. Requires a CMHP to utilize available data and permits the solicitation of information from Medi-Cal beneficiaries who receive SMHS from the CMHP and recipients of other county MH services for purposes of developing the CCP.
3. Requires data to be collected, maintained, and kept confidential in a manner consistent with state and federal medical privacy laws.
4. Requires a CMHP to convene a committee of relevant stakeholders, as specified, for the purpose of reviewing and approving the CCP. Requires the committee to convene monthly either in person or through electronic means. Requires the meetings to be open and accessible to the public.
5. Requires a CMHP to update annually its CCP, in coordination with the committee, to reflect population changes, and to include in the annual update a report on its progress toward achieving MH disparity reduction targets. Requires a CMHP to submit this material to DHCS for approval. Requires a CMHP to post this information on its Web site and submit the web address to DHCS.
6. Requires a CMHP to submit the CCP to DHCS every three years for technical assistance and implementation feedback. Requires DHCS, within 90 days of receipt of material, to approve or deny the CCP. Required the CMHP to post the approved CCP to its Web site and submit the Web address to DHCS.
7. Requires DHCS to consult with the Department of Public Health’s (DPH) Office of Health Equity (OHE), and permits consultation with the Office of the State Surgeon General, for purposes of reviewing statewide performance on MH disparities reduction. Requires the review to include a summary about the extent to which CMHPs’ strategies utilize both evidence-based and community-defined best practices, and to address documented MH disparities, including progress in meeting MH disparity reduction targets.
8. Requires DHCS to direct an EQRO to develop and implement a protocol for monitoring performance on established MH disparities reduction targets for each CMHP.
9. Requires DHCS, by July 1, 2022, to develop at least eight statewide MH disparities reduction targets, and require each CMHP to meet these targets or make year-over-year improvements toward meeting the targets that include access, utilization, and outcomes targets with metrics addressing MH disparities, as specified.
10. Requires DHCS to consult with CMHPs, and permits DHCS to consult with additional stakeholders, for the development of statewide MH disparity reduction targets.
11. Requires the EQRO, commencing January 1, 2024, to ensure that the annual review it performs of each CMHP includes a report on the progress related to the statewide MH disparities reduction targets established by this bill. Requires the EQRO to publish information related to statewide progress on statewide MH disparities reduction targets and recommendations for statewide strategies to reduce MH disparities in the annual detailed technical report, as specified.
12. Permits DHCS to implement, interpret, or make specific provisions of this bill through specified means without taking regulatory action.
13. Makes other conforming, nonsubstantive changes, and findings and declarations about MH disparities, the effects of disparities on vulnerable communities, and the need for addressing those disparities by improving outreach strategies.

Comments

1. Author’s statement. According to the author, the federal Patient Protection and Affordable Care Act (ACA) required nearly all health plans to provide MH care for their members. Public MH coverage is provided through state implementation of the ACA, which expanded the scope of Medi-Cal MH coverage and through California’s county safety net programs. Despite tremendous gains in access to care, communities of color often experience suboptimal outcomes from MH treatment. This results in great inequity as communities of color and other vulnerable populations who desperately need these services are often met with the greatest barriers to access them. In order to continue to strive for a more accessible system, there has to be an exact understanding of the disparities, which requires detailed data. This bill is needed to start pinpointing the exact solutions and implementing them to strive for an accessible MH system.
2. CCP. Existing regulations require each CMHP to develop and implement a CCP that includes the following components:
   
   1. Objectives and strategies for improving the CMHP’s cultural competence based on a required assessment and the CMHP’s performance on the standards, as specified;
   2. A population assessment and an organizational and service provider assessment focusing on issues of cultural competence and linguistic capability;
   3. A listing of SMHS and other CMHP services available for beneficiaries in their primary language by location of the services, as specified; and,
   4. A plan for cultural competency training for the administrative and management staff of the CMHP, the persons providing SMHS employed by or contracting with the CMHP or with contractors of the CMHP, and the persons employed by or contracting with the CMHP or with contractors of the CMHP to provide interpreter or other support services to Medi-Cal beneficiaries.

The regulation also requires DHCS to establish timelines for the submission and review of the CCP, either as a component of the implementation plan process or as a term of the contract between the CMHP and DHCS. The CMHP is required to submit the CCP to DHCS for review and approval in accordance with these timelines, and the CMHP is required to update the CCP and submit these updates to DHCS for review and approval annually.

According to information provided by the author’s office, many vulnerable communities consistently receive inequitable MH care, which leads these communities to be less likely to seek out care when needed. A contributing factor to this inequity is that CMHPs are lacking in cultural competency and language abilities. The author’s office states that current CCPs developed by CMHPs lack vital information to accurately reflect the diversity of California’s communities. This bill seeks to remedy this deficiency by expanding data gathering requirements for CMHPs and creating specific performance targets for executing these CCPs.

(NOTE: For a more extensive analysis, see the Senate Health Committee analysis from July 8, 2019.)

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

According to the Senate Appropriations Committee, staff estimates:

• DHCS. At least $185,000 in FY 2019-20 and $310,000 in FY 2020-21, and ongoing, for 1.0 Research Scientist III and 1.0 Health Program Specialist II at DHCS to conduct research, identify and develop statewide mental health disparities reduction targets, expand the specialty mental health services Performance Dashboard for the new non-duplicative data requirements.
• DPH. Unknown, possibly 1.0 Health Program Specialist I at the Office of Health Equity to analyze the Cultural Competence Plan Requirements to prepare the review. No costs for data-sharing, as DPH and DHCS have an existing interagency agreement.
• Other. Unknown, potentially minor Proposition 30 impacts to account for a CMHP increased workload and updating electronic health record systems. Unknown cost pressures to the extent that the CCPs call for increased use of county Medi-Cal specialty mental health services, which the state would be obligated under Proposition 30 to reimburse.

SUPPORT: (Verified 8/28/19)

California Pan-Ethnic Health Network (source)

#Out4MentalHealth

ACCESS Women’s Health Justice

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

API Equality-LA

API Forward Movement

Asian Americans Advancing Justice-California

Asian Health Services

Asian Pacific Policy and Planning Council

California Academy of Family Physicians

California Association of Marriage and Family Therapists

California Black Health Network

California Council of Community Behavioral Health Agencies

California Family Resource Association

California Immigrant Policy Center

California Latinas for Reproductive Justice

California School Employees Association

California School-Based Health Alliance

CaliforniaHealth+ Advocates

CalPACE

Center for Empowering Refugees and Immigrants

Community Clinic Association of Los Angeles County

Disability Rights California

Educated Men with Meaningful Messages

Empowering Pacific Islander Communities

Equality California

Fathers & Families of San Joaquin

Filipino Advocates for Justice

Fresno Interdenominational Refugee Ministries

Hmong Cultural Center of Butte County

Hmong Innovating Politics

Khmer Girls in Action

Latino Coalition for a Healthy California

Little Manila Rising

Maternal Mental Health NOW

Mental Health Services Oversight and Accountability Commission

Mid-City Community Advocacy Network

National Alliance on Mental Illness-California

National Association of Social Workers, California Chapter

Pomona Students Union

Professional Fiduciary Association of California

Racial and Ethnic Mental Health Disparities Coalition

Southeast Asia Resource Action Center

Steinberg Institute

Stone Soup Fresno

The Cambodian Family Community Center

The Child Abuse Prevention Center

The Fresno Center

UPAC Positive Solutions Program

Vietnamese American Roundtable

Vietnamese Youth Development Center

Western Center on Law & Poverty

OPPOSITION: (Verified 8/28/19)

None received

ARGUMENTS IN SUPPORT: The California Pan-Ethnic Health Network, sponsor of this bill, and other supporters representing various underrepresented communities state that disparities data is currently being made available by DHCS, yet counties are not required to utilize this data to build their cultural competence strategies. Specifically, DHCS must currently publish annual updates to the performance outcomes system that identify MH disparities in the areas of access, language access, quality, and utilization. This bill requires that each county utilizes the annual disparities data to identify disparities in access, utilization, and outcomes by race, ethnicity, language, sexual orientation, disability, age, gender identify, and immigration status, to the extent the information is available. Supporters also state that the EQRO is currently contracted with DHCS to conduct in-depth review of each CMHP and their compliance with certain standards, including CCPs. This bill directs the EQRO to develop a statewide plan for monitoring disparities reduction in each county. Supporters further argue that services are greatly underutilized by communities of color and historically disenfranchised communities. Supporters cite various studies that found that 12% of African-Americans in California missed four or more days of work per year because of MH issues, outpacing every other group surveyed; a majority of Latinos who reached out for MH services found providers did not adequately consider language or cultural needs; and, 30% of transgender individuals did not seek or postponed seeking MH services because they felt discriminated against. By making services more culturally accessible, early detection and intervention of more serious MH conditions can be identified and treated. Supporters state that we know early childhood trauma can have lasting negative health impacts if left unaddressed. To reduce incidences of a more serious health crisis later in life, warranting prolonged hospitalization or emergency room visits, it is imperative to invest in MH services sooner rather than later. This bill ensures that counties have the guidance, expertise, and assistance they need to realize the intended purpose of CCP requirements—to actively respond to and reduce disparities in MH outcomes.

ASSEMBLY FLOOR: 68-2, 5/23/19

AYES: Aguiar-Curry, Arambula, Bauer-Kahan, Berman, Bigelow, Bloom, Boerner Horvath, Bonta, Brough, Burke, Calderon, Carrillo, Cervantes, Chau, Chen, Chiu, Chu, Cooper, Cunningham, Daly, Diep, Eggman, Flora, Fong, Frazier, Friedman, Gabriel, Cristina Garcia, Gipson, Gloria, Gonzalez, Gray, Grayson, Holden, Irwin, Jones-Sawyer, Kalra, Kamlager-Dove, Lackey, Levine, Limón, Low, Maienschein, Mayes, McCarty, Medina, Mullin, Muratsuchi, Nazarian, O'Donnell, Petrie-Norris, Quirk, Quirk-Silva, Ramos, Reyes, Luz Rivas, Robert Rivas, Rodriguez, Blanca Rubio, Salas, Santiago, Smith, Mark Stone, Ting, Waldron, Wicks, Wood, Rendon

NOES: Melendez, Obernolte

NO VOTE RECORDED: Choi, Cooley, Dahle, Gallagher, Eduardo Garcia, Kiley, Mathis, Patterson, Voepel, Weber

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

9/3/19 11:22:02

**** END ****

SENATE COMMITTEE ON APPROPRIATIONS

Senator Anthony Portantino, Chair

2019 - 2020 Regular Session

AB 512 (Ting) - Medi-Cal: specialty mental health services

Bill Summary:

AB 512 would codify the requirement that a county health plan must prepare a cultural competency plan, and would specify additional requirements for the Department of Health Care Services (DHCS) and county mental health plans related mental health disparity reduction targets.

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

The following information is revised to reflect amendments

adopted by the committee on August 30, 2019

Fiscal Impact:

Staff estimates:

• DHCS. At least $185,000 in FY 2019-20 and $310,000 in FY 2020-21, and ongoing, for 1.0 Research Scientist III and 1.0 Health Program Specialist II at the Department of Health Care Services (DHCS) to conduct research, identify and develop statewide mental health disparities reduction targets, expand the specialty mental health services Performance Dashboard for the new non-duplicative data requirements.
• Department of Public Health (CDPH). Unknown, possibly 1.0 Health Program Specialist I at the Office of Health Equity to analyze the Cultural Competence Plan Requirements to prepare the review. No costs for data-sharing, as CDPH and DHCS have an existing interagency agreement.
• Other. Unknown, potentially minor Proposition 30 impacts to account for a county mental health plan increased workload and updating electronic health record systems. Unknown cost pressures to the extent that the cultural competency plans call for increased use of county Medi-Cal specialty mental health services, which the state would be obligated under Proposition 30 to reimburse.

Author Amendments:

The author’s amendments would include the following:

• Delays to July 1, 2022, for the DHCS to establish the eight statewide mental health disparities reduction targets, as specified;
• Requires, commencing January 1, 2024, the external quality review organization to ensure the annual review includes a progress report on the stateside mental health disparities reduction targets, and to publish specified information;
• Increases, from 30 days to 90 days, the amount of time the department must approve or deny the cultural competence plan;
• Requires the mental health plan to post the approved cultural competence plan to its website and submit the web address to the department.
• Authorizes the department to implement the bill’s provisions through all plan letters, provider bulletins, or other instructions without taking regulatory action;
• Clarifies the cultural competence plan must address progress towards meeting mental health disparity reduction targets, as specified; and,
• Makes other minor, conforming changes.

-- END --

SENATE COMMITTEE ON APPROPRIATIONS

Senator Anthony Portantino, Chair

2019 - 2020 Regular Session

AB 512 (Ting) - Medi-Cal: specialty mental health services

Bill Summary:

AB 512 would codify the requirement that a county health plan must prepare a cultural competency plan, and would specify additional requirements for the Department of Health Care Services (DHCS) and county mental health plans related mental health disparity reduction targets.

Fiscal Impact:

• DHCS. Beginning January 1, 2020, $185,000 in FY 2019-20 and $310,000 in FY 2020-21, and ongoing, for 1.0 Research Scientist III and 1.0 Health Program Specialist II at the Department of Health Care Services (DHCS) to conduct research, identify and develop statewide mental health disparities reduction targets, expand the specialty mental health services Performance Dashboard for the new data requirements that are non-duplicative with existing Performance Outcomes System (POS) or Special Terms and Conditions reporting.
• Department of Public Health (CDPH). Up to $137,783 General Fund in FY 2019-20, and $142,823 in FY 2020-21, and ongoing, for 1.0 Health Program Specialist I at the Office of Health Equity to analyze the Cultural Competence Plan Requirements (CCPR) to prepare the review. No costs for data-sharing, as CDPH and DHCS have an existing interagency agreement.
• Other. Unknown, potentially minor Proposition 30 impacts to account for a county mental health plan increased workload and updating electronic health record systems. In addition, unknown cost pressures to the extent that the cultural competency plans call for increased use of county Medi-Cal specialty mental health services, which the state would be obligated under Proposition 30 to reimburse those costs. However, given that the bill largely codifies existing practice, these may not be a significant cost.

Background:

Medi-Cal mental health benefits are delivered through two separate systems: specialty mental health services (SMHS) to individuals with more severe mental illnesses, while Medi-Cal managed care plans plans provide non-specialty mental health services. Specialty mental health services are delivered through 56 county mental health plans (two of which are dual-county combined).

In November of 2004, California voters passed Proposition 63, the Mental Health Services Act (MHSA), which levied an additional one percent tax on any resident making more than $1 million dollars. The MHSA requires each county mental health program to prepare and submit a three-year plan, updated at least annually and submitted for review to the DHCS and the Mental Health Oversight and Accountability Commission (OAC). The intent of the MHSA Three Year Plan and Annual Updates is to provide a public plan of action on the following MHSA funding components: (1) Community Services and Supports; (2) Prevention and Early Intervention; (3) Innovation; (4) Capital Facilities/Technological Needs; and (5) Workforce and Education Training. Under California’s realigned community mental health system, counties provide community mental health services, to the extent resources are available.

Existing regulations require each county mental health plan to develop and implement a CCP that include specified components, such as a population assessment, a listing of specialty mental health services, a plan for cultural competency, and other strategies to improve cultural competence. The cultural competency plan is either a component of the implementation plan or a term of the contract between the DHCS and the county mental health plan.

Proposed Law:

AB 512 would include the following provisions, among others:

• Codifies the requirement for county mental health plans to prepare a cultural competency assessment plan and specifies the required elements to be included in the plan;
• Requires a county mental health plan to annually update its plan, provide a progress report on performance targets, and submit the plan the DHCS every three years for technical assistance and implementation feedback.
• Requires DHCS to:
  • Review, in consultation with the CDPH’s Office of Health Equity and the office of the state Surgeon General, county assessments and county statewide performance on mental health disparities reduction;
  • Develop, in consultation with the aforementioned specified entities, at least eight statewide mental health disparities reduction targets and require each mental health plan to meet the specified mental health disparities reduction targets or make year-over-year improvements toward meeting the targets;
  • Direct an external quality review organization (EQRO) to develop and implement a protocol for monitoring performance on established mental health disparities reduction targets.
  • Adopt, by January 1, 2021, regulations to implement the bill.
• Requires the EQRO, beginning January 1, 2020, to include, as part of its annual review, a report related to progress in addressing statewide mental health disparities reduction targets and publish specified information.

-- END --

SENATE COMMITTEE ON HEALTH

Senator Dr. Richard Pan, Chair

BILL NO: AB 512

SUBJECT: Medi-Cal: specialty mental health services

SUMMARY:

Codifies the requirement that county mental health plans prepare a cultural competency assessment plan (CCP), expands the required elements to be included in the CCP, and requires counties to convene a committee to review and approve the CCP. Places requirements on the Department of Health Care Services and the external quality review organization to develop a protocol for monitoring performance on established disparities reduction targets and to include a report on statewide disparities reduction targets, as specified.

Existing law:

1. Establishes the Bronzan-McCorquodale Act to organize and finance community mental health (MH) services for those with MH disorders in every county through locally administered and controlled programs. [WIC §5600, et seq.]
2. Establishes the Medi-Cal program, administered by the Department of Health Care Services (DHCS), under which qualified low-income individuals receive health care services. [WIC §14001.1]
3. Requires the development of county mental health plans (CMHP) for the provision of managed Medi-Cal specialty mental health services (SMHS) at the local level to eligible Medi-Cal beneficiaries. [WIC §14680, 14684]
4. Requires a CMHP to provide for culturally competent and age-appropriate services, to the extent feasible. Requires a CMHP to assess the cultural competency needs of the program. Requires performance outcome measures to include a reliable method of measuring and reporting the extent to which services are culturally competent and age appropriate. [WIC §14684]
5. Requires a CMHP to develop and implement a CCP, as specified. [9 CCR §1810.410]
6. Requires a CMHP review to be conducted annually by an external quality review organization (EQRO), as specified, to include specific data for Medi-Cal eligible minor and nonminor dependents in foster care, as specified. [WIC §14717.5]
7. States legislative intent to build upon performance outcomes system reports DHCS has developed and per the Special Terms and Conditions of the Medi-Cal SHMS Waiver in order to provide data to inform strategies to reduce MH disparities. Requires DHCS to consult with stakeholders to inform the updates to the performance outcomes reports for SMHS, as specified. [WIC §14707.7]

This bill:

1. Codifies the requirement for a CMHP to prepare a CCP. Requires the CCP to address, but not be limited to, all of the following:
   1. MH disparities in access, utilization, and outcomes by race, ethnicity, primary language, sexual orientation, gender identity, age, disability status, income level, and immigration status, to the extent data is available;
   2. Annual statewide performance targets for reducing MH disparities in access, utilization, and outcomes, as determined by DHCS, as specified. Permits a CMHP to include additional performance targets, as appropriate;
   3. Designated strategies for reaching performance targets, including the CMHP’s rationale for each strategy;
   4. The CMHP’s performance on prior performance targets;
   5. The CMHP’s strategies for addressing trauma and developing trauma-informing services; and,
   6. The process for community input, including a list of community entities participating.
2. Requires a CMHP to utilize available data and permits the solicitation of information from Medi-Cal beneficiaries who receive SMHS from the CMHP and recipients of other county MH services for purposes of developing the CCP.
3. Requires data to be collected, maintained, and kept confidential in a manner consistent with state and federal medical privacy laws.
4. Requires a CMHP to convene a committee of relevant stakeholders, as specified, for the purpose of reviewing and approving the CCP. Requires the committee to convene monthly either in person or through electronic means. Requires the meetings to be open and accessible to the public.
5. Requires a CMHP to update annually its CCP, in coordination with the committee, to reflect population changes, and to include in the annual update a report on its progress toward achieving performance targets. Requires a CMHP to post this information on its website.
6. Requires a CMHP to submit the CCP to DHCS every three years for technical assistance and implementation feedback. Requires DHCS, within 30 days of receipt of material, to post the CCP submitted by each CMHP on its website.
7. Requires DHCS to consult with the Department of Public Health’s (DPH) Office of Health Equity (OHE) and the office of the state Surgeon General for purposes of reviewing county assessments and statewide performance in MH disparities reduction. Requires these reviews to include an assessment about the extent to which strategies utilize both evidence-based and community-defined best practices, and to address documented MH disparities, including progress in meeting performance targets.
8. Requires DHCS to direct an EQRO to develop and implement a protocol for monitoring performance on established MH disparities reduction targets for each CMHP. Requires DHCS to consult with specified entities in developing and implementing this protocol.
9. Requires DHCS to develop, in consultation with CMHPs, stakeholders and the OHE, at least eight statewide MH disparities reduction targets, and require each CMHP to meet these targets or make year-over-year improvements toward meeting the targets. Requires the targets to include access and outcomes targets and to consider, at a minimum, metrics addressing MH disparities, as specified.
10. Requires DHCS, by January 1, 2021, to adopt regulations to implement the provisions in this bill.
11. Requires the external quality review organization (EQRO), commencing January 1, 2020, to ensure that the annual review it performs of each CMHP includes a report on the progress related to the statewide MH disparities reduction targets established by this bill. Requires the EQRO to publish information related to statewide progress on statewide MH disparities reduction targets and recommendations for statewide strategies to reduce MH disparities in the annual detailed technical report, as specified.
12. Makes other conforming, nonsubstantive changes, and findings and declarations about MH disparities, the effects of disparities on vulnerable communities, and the need for addressing those disparities by improving outreach strategies.

FISCAL EFFECT:

According to the Assembly Appropriations Committee:

1. One-time contract costs of $150,000 to DHCS for stakeholder facilitation and development of statewide disparities reduction targets (General Fund (GF)/federal).
2. If EQRO contract costs increase 5% to account for additional analysis required by this bill, annual costs of $300,000 (GF/federal).
3. Unknown annual costs, likely about $200,000 to DHCS, for ongoing review of plans and compliance (GF/federal).
4. Costs of $140,000 annually to the OHE within DPH for one position to support the required consultation and review and to provide technical assistance (GF/federal).
5. Costs to the state Office of the Surgeon General are expected to be minor and absorbable.

PRIOR VOTES:

COMMENTS:

1. Author’s statement. According to the author, the federal Patient Protection and Affordable Care Act (ACA) required nearly all health plans to provide MH care for their members. Public MH coverage is provided through state implementation of the ACA, which expanded the scope of Medi-Cal MH coverage and through California’s county safety net programs. Despite tremendous gains in access to care, communities of color often experience suboptimal outcomes from MH treatment. This results in great inequity as communities of color and other vulnerable populations who desperately need these services are often met with the greatest barriers to access them. In order to continue to strive for a more accessible system, there has to be an exact understanding of the disparities, which requires detailed data. This bill is needed to start pinpointing the exact solutions and implementing them to strive for an accessible MH system.
2. CCP. Existing regulations require each CMHP to develop and implement a CCP that includes the following components:
   
   1. Objectives and strategies for improving the CMHP’s cultural competence based on a required assessment and the CMHP’s performance on the standards, as specified;
   2. A population assessment and an organizational and service provider assessment focusing on issues of cultural competence and linguistic capability;
   3. A listing of SMHS and other CMHP services available for beneficiaries in their primary language by location of the services, as specified; and,
   4. A plan for cultural competency training for the administrative and management staff of the CMHP, the persons providing SMHS employed by or contracting with the CMHP or with contractors of the CMHP, and the persons employed by or contracting with the CMHP or with contractors of the CMHP to provide interpreter or other support services to Medi-Cal beneficiaries.

The regulation also requires DHCS to establish timelines for the submission and review of the CCP, either as a component of the implementation plan process or as a term of the contract between the CMHP and DHCS. The CMHP is required to submit the CCP to DHCS for review and approval in accordance with these timelines, and the CMHP is required to update the CCP and submit these updates to DHCS for review and approval annually.

According to information provided by the author’s office, many vulnerable communities consistently receive inequitable MH care, which leads these communities to be less likely to seek out care when needed. A contributing factor to this inequity is that CMHPs are lacking in cultural competency and language abilities. The author’s office states that current CCPs developed by CMHPs lack vital information to accurately reflect the diversity of California’s communities. This bill seeks to remedy this deficiency by expanding data gathering requirements for CMHPs and creating specific performance targets for executing these CCPs.

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 CMHPs 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 CMHP;
2. An assessment of each CMHP’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 CMHP;
4. Comparative information about all CMHPs, as DHCS determines methodologically appropriate; and,
5. An assessment of the degree to which each CMHP has addressed effectively the recommendations for quality improvement made by the EQRO during the previous year’s review.
6. Related legislation. AB 1175 (Wood) places various requirements on the DHCS, the EQRO, CMHPs, and Medi-Cal managed care health plans related to MH services provided to Medi-Cal enrollees, information sharing between plans, continuity of care, and other responsibilities to improve Medi-Cal MH service delivery, and to provide additional information for service delivery improvements. AB 1175 was heard in this Committee on July 3, 2019, and passed out by a vote of 8-0.
7. Prior legislation. AB 470 (Arambula, Chapter 550, Statutes of 2018) requires DHCS to create a performance outcome report for SMHS, as specified, and to make it available to specified entities. Requires DHCS to consult with stakeholders, as specified, for purposes of creating the report, and to update the report, as specified.

SB 1009 (Committee on Budget and Fiscal Review, Chapter 34, Statutes of 2012), among other provisions, requires DHCS, in collaboration and in consultation with specified entities, to create a plan for a performance outcome system for Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) MH services provided to eligible Medi-Cal beneficiaries under the age of 21. Requires DHCS to convene a stakeholder advisory committee and to consider specified objectives when developing a plan for a performance outcomes system for EPSDT MH services.

1. Support. The California Pan-Ethnic Health Network, sponsor of this bill, and other supporters representing various underrepresented communities state that disparities data is currently being made available by DHCS, yet counties are not required to utilize this data to build their cultural competence strategies. Specifically, DHCS must currently publish annual updates to the performance outcomes system that identify MH disparities in the areas of access, language access, quality, and utilization. This bill requires that each county utilizes the annual disparities data to identify disparities in access, utilization, and outcomes by race, ethnicity, language, sexual orientation, disability, age, gender identify, and immigration status, to the extent the information is available. Supporters also state that the EQRO is currently contracted with DHCS to conduct in-depth review of each CMHP and their compliance with certain standards, including CCPs. This bill directs the EQRO to develop a statewide plan for monitoring disparities reduction in each county. Supporters further argue that services are greatly underutilized by communities of color and historically disenfranchised communities. Supporters cite various studies that found that 12% of African-Americans in California missed four or more days of work per year because of MH issues, outpacing every other group surveyed; a majority of Latinos who reached out for MH services found providers did not adequately consider language or cultural needs; and, 30% of transgender individuals did not seek or postponed seeking MH services because they felt discriminated against. By making services more culturally accessible, early detection and intervention of more serious MH conditions can be identified and treated. Supporters state that we know early childhood trauma can have lasting negative health impacts if left unaddressed. To reduce incidences of a more serious health crisis later in life, warranting prolonged hospitalization or emergency room visits, it is imperative to invest in MH services sooner rather than later. This bill would ensure that counties have the guidance, expertise, and assistance they need to realize the intended purpose of CCP requirements—to actively respond to and reduce disparities in MH outcomes.

SUPPORT AND OPPOSITION:

Support: California Pan-Ethnic Health Network (sponsor)

ACCESS Women’s Health Justice

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

API Equality-LA

API Forward Movement

Asian Americans Advancing Justice-California

Asian Health Services

Asian Pacific Policy and Planning Council

California Academy of Family Physicians

California Association of Marriage and Family Therapists

California Black Health Network

California Council of Community Behavioral Health Agencies

California Family Resource Association

California Immigrant Policy Center

California Latinas for Reproductive Justice

California School Employees Association

California School-Based Health Alliance

CaliforniaHealth+ Advocates

CalPACE

Center for Empowering Refugees and Immigrants

Community Clinic Association of Los Angeles County

Disability Rights California

Educated Men with Meaningful Messages

Empowering Pacific Islander Communities

Equality California

Fathers & Families of San Joaquin

Filipino Advocates for Justice

Fresno Interdenominational Refugee Ministries

Hmong Cultural Center of Butte County

Hmong Innovating Politics

Khmer Girls in Action

Latino Coalition for a Healthy California

Little Manila Rising

Maternal Mental Health NOW

Mental Health Services Oversight and Accountability Commission

Mid-City Community Advocacy Network

National Alliance on Mental Illness-California

National Association of Social Workers, California Chapter

Pomona Students Union

Professional Fiduciary Association of California

Racial and Ethnic Mental Health Disparities Coalition

Southeast Asia Resource Action Center

Steinberg Institute

Stone Soup Fresno

The Cambodian Family Community Center

The Child Abuse Prevention Center

The Fresno Center

UPAC Positive Solutions Program

Vietnamese American Roundtable

Vietnamese Youth Development Center

Western Center on Law & Poverty

#Out4MentalHealth

Oppose: None received

-- END --

ASSEMBLY THIRD READING

ATR Bill Id:AB 512

Author:(Ting)

As Amended Ver:May 16, 2019

Majority vote

SUMMARY:

Codifies a requirement that county mental health plans (MHPs) prepare a cultural competency assessment plan, expands the required elements to be included in the plan including statewide performance targets for disparities reduction, and requires counties to convene a committee to review and approve the plan. Requires the Department of Health Care Services (DHCS) to direct an external quality review organization (EQRO) to develop a protocol for monitoring performance on established disparities reduction targets for each MHP. Requires the EQRO to ensure that the annual review that it performs of each MHP includes a report on statewide disparities reduction targets in its annual detailed technical report.

Major Provisions

COMMENTS:

CULTURAL COMPETENCE PLAN. Existing regulations for county MHPs require each MHP to comply with cultural competence and linguistic requirements, the terms of the contract between the MHP and DHCS, and the MHP's Cultural Competence Plan. Under the regulation, each MHP is required to develop and implement a Cultural Competence Plan that includes specified components.

EQRO. Federal Medicaid regulations require each State that contracts with Medicaid managed care plans to ensure that a qualified EQRO performs an annual external quality review (EQR) for each such contracting plan. EQROs must perform mandatory EQR-related activities, which include validation of performance improvement projects that were underway during the preceding 12 months, validation of plan performance measures, and validation of plan network adequacy during the preceding 12 months. Federal regulations require states to ensure that the EQR results in an annual detailed technical report that summarizes findings on access and quality of care. States are required to finalize the annual technical report by April 30th of each year, and post the most recent copy of the annual EQR technical report on the Website.

According to the Author:

The federal Patient Protection and Affordable Care Act (ACA) required nearly all health plans to provide mental health care for their members. Public mental health coverage is provided through state implementation of the ACA, which expanded the scope of Medi-Cal mental health coverage, and through California’s county safety net programs. Despite tremendous gains in access to care, communities of color often experience suboptimal outcomes from mental health treatment. This results in great inequity as communities of color and other vulnerable populations who desperately need these services are often met with the greatest barriers to access them. In order to continue to strive for a more accessible system, there has to be an exact understanding of the disparities, data which currently is not reported. This bill is needed to start pinpointing the exact solutions and implementing them to strive for an accessible mental health care system.

Arguments in Support:

This bill is jointly sponsored the California Pan-Ethnic Health Network, the Steinberg Institute, #Out4MentalHealth, the Southeast Asia Resource Action Center, and the Latino Coalition for a Healthy California to require counties to set forward-looking goals in their mental health cultural competence plans and to require DHCS to annually review and monitor their progress. The sponsors argue cultural competence plans are an important tool to address mental health disparities, particularly among historically underserved populations. However, under existing law, these plans lack goals to improve access and utilization of mental health services. Despite tremendous gains in mental health coverage, communities of color and LGBTQ+ communities continue to experience disparities in quality and access to mental health treatment. The sponsors conclude this bill would ensure that counties have the guidance, expertise, and assistance they need to realize the intended purpose of cultural competence plan requirements—to actively respond to and reduce disparities in mental health outcomes.

Arguments in Opposition:

There is no known opposition.

FISCAL COMMENTS:

According to the Assembly Appropriations Committee:

1. One-time contract costs of $150,000 to DHCS for stakeholder facilitation and development of statewide disparities reduction targets (General Fund (GF)/federal).
2. If EQRO contract costs increase 5% to account for additional analysis required by this bill, annual costs of $300,000 (GF/federal).
3. Unknown annual costs, likely about $200,000 to DHCS for ongoing review of plans and compliance (GF/federal).
4. Costs of $140,000 annually to the Office of Health Equity within the California Department of Public Health for one position to support the required consultation and review and to provide technical assistance (GF/federal).
5. Costs to the Office of the Surgeon General are expected to be minor and absorbable.

VOTES:

ASM HEALTH: 15-0-0

YES: Wood, Mayes, Aguiar-Curry, Bigelow, Bonta, Burke, Carrillo, Flora, Limón, McCarty, Nazarian, Ramos, Rodriguez, Santiago, Waldron

ASM APPROPRIATIONS: 13-0-5

YES: Gonzalez, Bloom, Bonta, Calderon, Carrillo, Chau, Eggman, Gabriel, Eduardo Garcia, Maienschein, Petrie-Norris, Quirk, Robert Rivas

ABS, ABST OR NV: Bigelow, Brough, Diep, Fong, Obernolte

UPDATED:

VERSION: May 16, 2019

CONSULTANT: Scott Bain / HEALTH / (916) 319-2097 FN: 0000823

Date of Hearing: May 16, 2019

ASSEMBLY COMMITTEE ON APPROPRIATIONS

Lorena Gonzalez, Chair

ABPCA Bill Id:AB 512

Author:(Ting) – As Amended Ver:April 2, 2019

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

SUMMARY:

This bill imposes additional requirements related to county Medi-Cal mental health plans’ efforts on cultural competency and disparity reduction. Specifically, this bill:

1. Codifies the requirement for each MHP to have a cultural competency assessment plan and specifies the required contents of the plan, requires each MHP to convene a committee that meets publicly to review and approve the plan, and requires annual updates to the plan.
2. Requires each plan to be submitted to the Department of Health Care Services (DHCS) every three years and requires DHCS to post plans publicly, to consult with the Office of Health Equity and the office of the state Surgeon General on review of plans and performance on disparities reduction, and to direct an external quality review organization (EQRO) to develop and implement a protocol for monitoring performance on established disparities reduction targets for each MHP.
3. Requires DHCS to develop, with stakeholder consultation, at least eight statewide disparities reduction targets and requires each mental health plan to meet the specified disparities reduction targets every three years.
4. Requires the EQRO assigned to review plans to report annually on progress related to statewide disparities reduction targets on both the plan level and statewide.

FISCAL EFFECT:

1. One-time contract costs of $150,000 to DHCS for stakeholder facilitation and development of statewide disparities reduction targets (GF/federal).
2. If EQRO contract costs increase 5% to account for additional analysis required by this bill, annual costs of $300,000 (GF/federal).
3. Unknown annual costs, likely about $200,000 to DHCS for ongoing review of plans and compliance (GF/federal).
4. Costs of $140,000 annually to the Office of Health Equity within the California Department of Public Health for one position to support the required consultation and review and to provide technical assistance (GF/federal).
5. Costs to the Office of the Surgeon General are expected to be minor and absorbable.
6. Unknown, potentially significant costs to county MHPs to comply with this bill and implement strategies needed to reduce disparities. It is unclear whether costs to comply with disparities reduction targets would be state-reimbursable pursuant to Proposition 30.

COMMENTS:

1. Purpose. This bill is jointly sponsored the California Pan-Ethnic Health Network, the Steinberg Institute, #Out4MentalHealth, the Southeast Asia Resource Action Center and the Latino Coalition for a Healthy California to require counties to set forward-looking goals in their mental health cultural competence plans and to require DHCS to annually review and monitor their progress. The sponsors contend, despite progress in improving coverage and despite the existence of cultural competence plans, communities of color and LGBTQ+ communities continue to experience disparities in quality and access to mental health treatment.
2. Background. Medi-Cal mental health benefits are delivered through two separate systems. County MHPs provide a broad range of specialty mental health services to individuals with more severe mental illnesses. Medi-Cal managed care plans provide mental health care for so-called “mild to moderate” conditions.

Existing regulations for county MHPs require each MHP to comply with cultural competence and linguistic requirements, the terms of the contract between the MHP and DHCS, and the MHP's cultural competence plan. DHCS indicates the plan establishes standards and criteria for the entire county mental health system, including Medi-Cal services, Mental Health Services Act and realignment.

Federal Medicaid regulations require each state that contracts with Medicaid managed care plans to ensure a qualified EQRO performs an annual external quality review (EQR) for each such contracting plan.

1. Prior Legislation. AB 470 (Arambula), Chapter 550, Statutes of 2018, requires DHCS to create a performance outcome report for specialty mental health services.

SB 1009 (Committee on Budget and Fiscal Review), Chapter 34, Statutes of 2012, among other provisions, requires DHCS, in collaboration with the California Health and Human Services Agency, and in consultation with the Mental Health Services Oversight and Accountability Commission, to create a plan for a performance outcome system for mental health services provided to eligible Medi-Cal beneficiaries under the age of 21.

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

Date of Hearing: March 26, 2019

ASSEMBLY COMMITTEE ON HEALTH

Jim Wood, Chair

ABPCA Bill Id:AB 512

Author:(Ting) – As Amended Ver:March 14, 2019

SUBJECT: Medi-Cal: specialty mental health services.

SUMMARY: Codifies a requirement that county mental health plans (MHPs) prepare a cultural competency assessment plan, expands the required elements to be included in the plan, and requires counties to convene a committee to review and approve the plan. Requires the Department of Health Care Services (DHCS) to direct an external quality review organization (EQRO) to develop a protocol for monitoring performance on established disparities reduction targets for each MHP. Requires the EQRO to ensure that the annual review that it performs of each MHP includes a report on statewide disparities reduction targets, progress related to disparities reduction, and outcomes. Specifically, this bill:

1. Requires a MHP to prepare a cultural competency assessment plan, which addresses, but is not limited to, all of the following:
2. Disparities in access, utilization, and outcomes by race, ethnicity, language, sexual orientation, gender identity, and immigration status, to the extent data is available;
3. Annual performance targets for reducing disparities in access, utilization, and outcomes;
4. Designated strategies for reaching performance targets, including the MHP’s rationale for each strategy;
5. The MHP’s performance on prior performance targets;
6. The MHP’s strategies for addressing trauma and developing trauma-informing services; and,
7. The process for community input, including a list of community entities participating.
   
8. Requires a MHP, for purposes of developing the cultural competency assessment plan, to utilize available data and may solicit information from Medi-Cal beneficiaries who receive specialty mental health services (SMHS) from the MHP.
   
9. Requires a MHP to comply with federal Medicaid program law and regulations and applicable state and federal privacy laws that govern medical information, including the state Confidentiality of Medical Information Act, and the federal Health Insurance Portability and Accountability Act of 1996.
   
10. Requires a MHP to convene a committee, through open invitation to relevant stakeholders, including, but not limited to, agency and department representatives, consumer advocates, consumers, disparities reduction experts, and providers, for the purpose of reviewing and approving the cultural competency assessment plan.
    
11. Requires the committee to convene monthly either in person or through electronic means, and requires meetings to be open and accessible to the public.
    
12. Requires a MHP to annually update its cultural competency assessment plan, in coordination with the committee, to reflect population changes, and to include in the annual update a report on its progress toward achieving performance targets. Requires a MHP to post this material on its Internet Website.
13. Requires a MHP to submit the cultural competency assessment plan to DHCS every three years for technical assistance and implementation feedback.
    
14. Requires DHCS, within 30 days of its receipt, to post the cultural competency assessment plan submitted by each plan to its Internet Website.
    
15. Requires DHCS to consult with the Office of Health Equity and the California Surgeon General for purposes of reviewing county assessments and statewide performance on disparities reduction. Requires the review to include an assessment about the extent to which strategies utilize both evidence-based and community-defined best practices, and to address documented disparities, including progress about performance targets.
    
16. Requires DHCS to direct an EQRO to develop and implement a protocol for monitoring performance on established disparities reduction targets for each MHP. Requires DHCS, in creating and implementing this protocol, to consult with consumer advocates, consumers, experts in disparities reduction, and providers.
    
17. Requires DHCS to require each MHP to meet specified disparities reduction targets every three years.
    
18. Requires, commencing January 1, 2020, the EQRO review required under state law, to ensure that the annual review that it performs of each mental health plan, includes a report on statewide disparities reduction targets, progress related to disparities reduction, and outcomes.
    
19. Makes legislative findings and declarations related to this bill, including that disparities in access to mental health services vary across demographic groups, including race, age, gender, income level, and immigration status, that disparities in mental health services can be reduced or eliminated by addressing barriers to the mental health care system and improving outreach strategies.

EXISTING LAW:

1. Designates DHCS as the state agency responsible for the development and implementation of, MHPs for Medi-Cal beneficiaries.
   
2. Requires DHCS to implement managed mental health care for Medi-Cal beneficiaries through contracts with MHPs. Permits MHPs to include individual counties, counties acting jointly, or an organization or nongovernmental entity determined by DHCS to meet MHP standards. Permits a contract to be exclusive and may be awarded on a geographic basis.
   
3. Requires, to the extent permitted by federal law, MHPs, whether administered by public or private entities, to be governed by specified guidelines, including the following:
   1. To provide SMHS to eligible Medi-Cal beneficiaries, including both adults and children. SMHS include EPSDT to eligible Medi-Cal beneficiaries under the age of 21;
   2. To provide for culturally competent and age-appropriate services, to the extent feasible;
   3. To assess the cultural competency needs of the program;
   4. To include, as part of the quality assurance program, a process to accommodate the significant needs with reasonable timeliness, and requires DHCS to provide demographic data and technical assistance; and,
   5. Requires performance outcome measures to include a reliable method of measuring and reporting the extent to which services are culturally competent and age-appropriate.
4. Requires MHPs, pursuant to regulation, to develop and implement a Cultural Competence Plan that includes specified components.
   
5. Requires, pursuant to federal Medicaid regulation, that each state that contracts with plans, to ensure (with exceptions) that a qualified EQRO performs an annual external quality review (EQR) for each such contracting plan.
   
6. Requires, under state law, a MHP review to be conducted annually by an EQRO pursuant to federal Medicaid regulations.
   
7. Requires, commencing July 1, 2018, the review to include specific data for Medi-Cal eligible minor and nonminor dependents in foster care.
   
8. Requires, through an amendment to the State Constitution enacted by Proposition 30 of 2012, legislation enacted after September 30, 2012, that has an overall effect of increasing the costs already borne by a local agency (including MHPs) for programs or levels of service mandated by the 2011 Realignment Legislation (which includes Drug Medi-Cal (DMC) and Medi-Cal specialty mental health) to:
   
   1. Apply to local agencies only to the extent that the State provides annual funding for the cost increase; and,
   2. Prohibits local agencies from being obligated to provide programs or levels of service required by legislation above the level for which funding has been provided.

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

COMMENTS:

1. PURPOSE OF THIS BILL. According to the author, the federal Patient Protection and Affordable Care Act (ACA) required nearly all health plans to provide mental health care for their members. Public mental health coverage is provided through state implementation of the ACA, which expanded the scope of Medi-Cal mental health coverage, and through California’s county safety net programs. Despite tremendous gains in access to care, communities of color often experience suboptimal outcomes from mental health treatment. This results in great inequity as communities of color and other vulnerable populations who desperately need these services are often met with the greatest barriers to access them. In order to continue to strive for a more accessible system, there has to be an exact understanding of the disparities, data which currently is not reported. This bill is needed to start pinpointing the exact solutions and implementing them to strive for an accessible mental health care system.
2. BACKGROUND. Medi-Cal mental health benefits are delivered through two separate systems. MHPs provide a broad range of SMHS to individuals with more severe mental illnesses, while Medi-Cal managed care (MCMC) plans provide non-SMHS. The delivery of SMHS through MHPs is commonly referred to as a “carve out,” as is the coverage of anti-psychotic prescription medication through fee-for-service (FFS) Medi-Cal (described further below). A “carve out” is when services covered by the Medi-Cal program are delivered outside of a MCMC plan. Services for physical and behavioral health (which includes mental health and substance use disorders) historically have been financed and delivered under separate systems (the Drug Medi-Cal benefit is also delivered outside of MCMC plans).

MHPs are responsible for providing SMHS to Medi-Cal beneficiaries who meet SMHS medical necessity criteria. SMHS are delivered through 56 county mental health plans (Placer and Sierra Counties and Yuba and Sutter Counties operate two separate dual-county combined MHPs). Medi-Cal beneficiaries that meet medical necessity criteria for SMHS are entitled to receive medically necessary SMHS from their county MHP, regardless of whether or not they are enrolled in a MCMC plan.

MCMC plans are responsible for providing non-SMHS, and are responsible for prescription drug coverage for mental health conditions, except for approximately 40 anti-psychotic medications. These medications are contractually carved out of nearly all MCMC plan contracts and instead reimbursed through Medi-Cal FFS.

1. CULTURAL COMPETENCE PLAN. Existing regulations for county MHPs require each MHP to comply with cultural competence and linguistic requirements, the terms of the contract between the MHP and DHCS, and the MHP's Cultural Competence Plan. Under the regulation, each MHP is required to develop and implement a Cultural Competence Plan that includes the following components:
   
   1. A population assessment and an organizational and service provider assessment focusing on issues of cultural competence and linguistic capability;
   2. Objectives and strategies for improving the MHP's cultural competence based on the assessment, and the MHP's performance on the standards required by this bill;
   3. A listing of SMHS and other MHP services available for beneficiaries in their primary language by location of the services;
   4. A plan for cultural competency training for the administrative and management staff of the MHP, the persons providing SMHS employed by or contracting with the MHP or with contractors of the MHP, and the persons employed by or contracting with the MHP or with contractors of the MHP to provide interpreter or other support services to beneficiaries.

The regulation requires DHCS to establish timelines for the submission and review of the Cultural Competence Plan, either as a component of the Implementation Plan process or as a term of the contract between the MHP and DHCS. The MHP is required to submit the Cultural Competence Plan to DHCS for review and approval in accordance with these timelines, and the MHP is required to update the Cultural Competence Plan and submit these updates to DHCS for review and approval annually.

DHCS indicates the Cultural Competence Plan Requirements establish standards and criteria for the entire County Mental Health System, including Medi-Cal services, Mental Health Services Act, and Realignment as part of working toward achieving cultural and linguistic competence.

1. EQRO. Federal Medicaid regulations require each State that contracts with Medicaid managed care plans to ensure that a qualified EQRO performs an annual external quality review (EQR) for each such contracting plan. EQROs must perform mandatory EQR-related activities, which include validation of performance improvement projects that were underway during the preceding 12 months, validation of plan performance measures, and validation of plan network adequacy during the preceding 12 months. EQRO optional activities include validation of encounter data reported by plans, administration or validation of consumer or provider surveys of quality of care, calculation of performance measures in addition to those reported by a plan, conduct of performance improvement projects in addition to those conducted by the plan, conduct of studies on quality that focus on a particular aspect of clinical or nonclinical services at a point in time, and assisting with the quality rating of plans. Federal regulations require states to ensure that the EQR results in an annual detailed technical report that summarizes findings on access and quality of care. This includes an assessment of each plan’s strengths and weaknesses for the quality, timeliness, and access to health care services furnished to Medicaid beneficiaries, and recommendations for improving the quality of health care services furnished by each plan, including how the State can target goals and objectives in its quality strategy to better support improvement in the quality, timeliness, and access to health care services furnished to Medicaid beneficiaries. States are required to finalize the annual technical report by April 30th of each year, and post the most recent copy of the annual EQR technical report on the Website. Federal financial participation of 75% is available in expenditures for EQR (including the production of EQR results) and the EQR-related activities performed by plans that are conducted by EQROs and their subcontractors.
   
2. DISPARITIES IN HEALTH CARE. According to an August 2018 publication by the Kaiser Family Foundation, health and health care disparities refer to the differences in health and health care between populations. Disparities in “health” and “health care” are related, but not synonymous, concepts. A “health disparity” refers to a higher burden of illness, injury, disability, or mortality experienced by one group relative to another. A “health care disparity” typically refers to differences between groups in health insurance coverage, access to and use of care, and quality of care. Health and health care disparities often refer to differences that cannot be explained by variations in health needs, patient preferences, or treatment recommendations. Health inequality and inequity are also used to refer to disparities. There are multiple examples of health disparities and health care disparities in the broader mental health delivery system (including suicide rates are more than double in the Northern and Sierra regions) and the Medi-Cal mental health delivery system. For example, mental health utilization varies by race and region, and language. Lower service penetration rates for SMHS for Asian and Latino populations has been cited over many years, there are differences by race in receipt of services following an inpatient hospital stay for mental health (for example, blacks have the longest time frame from an outpatient visit following an in-patient hospitalization for mental illness.
   
3. PREVIOUS LEGISLATION. AB 470 (Arambula), Chapter 550, Statutes of 2018, requires DHCS to create a performance outcome report for SMHS, 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.

SB 1009 (Committee on Budget and Fiscal Review), Chapter 34, Statutes of 2012, among other provisions, requires DHCS, in collaboration with the California Health and Human Services Agency, and in consultation with the Mental Health Services Oversight and Accountability Commission, to create a plan for a performance outcome system for EPSDT mental health services provided to eligible Medi-Cal beneficiaries under the age of 21. SB 1009 required DHCS to convene a stakeholder advisory committee, and in developing a plan for a performance outcomes system for EPSDT mental health services, to consider specified objectives, including: a) high quality and accessible EPSDT mental health services for eligible children and youth, consistent with federal law; b) information that improves practice at the individual, program, and system levels; c) reliable data that are collected and analyzed in a timely fashion; d) federal requirements; and, e) timelines for implementation at the provider, county, and state levels.

DHCS was required to provide the performance outcomes system plan, including milestones and timelines, for EPSDT mental health services to all fiscal committees and appropriate policy committees of the Legislature no later than October 1, 2013. Finally, SB 1009 required DHCS to propose how to implement the performance outcomes system plan for EPSDT mental health services described no later than January 10, 2014.

1. SUPPORT. This bill is jointly sponsored the California Pan-Ethnic Health Network, the Steinberg Institute, #Out4MentalHealth, the Southeast Asia Resource Action Center, and the Latino Coalition for a Healthy California to require counties to set forward-looking goals in their mental health cultural competence plans and to require DHCS to annually review and monitor their progress. The sponsors argue cultural competence plans are an important tool to address mental health disparities, particularly among historically underserved populations. However, under existing law, these plans lack goals to improve access and utilization of mental health services. Despite tremendous gains in mental health coverage, communities of color and LGBTQ+ communities continue to experience disparities in quality and access to mental health treatment. The sponsors conclude this bill would ensure that counties have the guidance, expertise, and assistance they need to realize the intended purpose of cultural competence plan requirements—to actively respond to and reduce disparities in mental health outcomes.
   
2. PROPOSED AMENDMENTS. Following discussions between supporters and staff, this bill will be amended to: a) require the cultural competency plan to also include age and disability status; b) to require DHCS to determine the performance targets in consultation with stakeholders and the Office of Health Equity; c) to require at least eight statewide disparities reduction targets that include access and outcome targets and include metrics addressing disparities on the basis of race, ethnicity, language, sexual orientation, gender identity, age, disability status, and immigration; d) to clarify that the cultural competency assessment plan solicits information from recipients of county mental health services; e) to require existing confidential protections for data reported under existing law to apply to data reported under this bill and to specifically reference federal and state privacy laws; f) to require DHCS to also consult with the Office of the Surgeon General for purposes of reviewing county assessments and statewide performance on disparities reductions; and, g) to clarify the EQRO annual review includes progress related to statewide disparities reduction targets established by this bill, and to clarify this information is published in the annual EQRO technical report required under existing federal regulation.
   

REGISTERED SUPPORT / OPPOSITION:

Support

California Pan-Ethnic Health Network (cosponsor)
Steinberg Institute (cosponsor)
#Out4MentalHealth (cosponsor)

Latino Coalition for a Healthy California (cosponsor
Southeast Asia Resource Action Center (cosponsor)

Access Women's Health Justice
American Federation of State, County And Municipal Employees, AFL-CIO
API Equality-LA
Asian Americans Advancing Justice - California
Asian Health Services
Asian Pacific Islander Forward Movement
California Immigrant Policy Center
California Latinas for Reproductive Justice
California LGBTQ Health and Human Services Network
California School Employees Association
California School-Based Health Alliance
CaliforniaHealth+ Advocates
Center For Empowering Refugees And Immigrants
Community Clinic Association of Los Angeles County
Disability Rights California
Equality California.
Fathers And Families of San Joaquin
Fresno Interdenominational Refugees Ministries
Khmer Girls in Action
Latino Coalition For a Healthy California
Little Manila Rising
Maternal Mental Health Now
Mid-City Community Advocacy Network
Racial and Ethnic Mental Health Disparities Coalition
Southeast Asia Resource Action Center
Stone Soup Fresno
The Cambodian Family
Union of Pan Asian Communities
Vietnamese Youth Development Center
Western Center on Law & Poverty

Opposition

None on file.

Analysis Prepared by: Scott Bain / HEALTH / (916) 319-2097