SENATE THIRD READING

STR Bill Id:SB 803

Author:(Beall)

As Amended Ver:August 30, 2020

Majority vote

SUMMARY:

Requires the Department of Health Care Services (DHCS) to seek any federal waivers it deems necessary to establish a Medi-Cal demonstration or pilot project for the provision of peer support services in counties that agree to participate and provide the nonfederal share of funding for a demonstration or pilot that include a certified peer support specialist as a Medi-Cal provider type. Authorizes, subject to DHCS approval, a county or an agency representing the county, to develop a peer supper specialist certification program in accordance with this bill. Establishes requirements for applicants for certification as a peer support specialist.

Major Provisions

1. Requires DHCS to seek any federal waivers it deems necessary to establish a demonstration or pilot project for the provision of peer support services in counties that agree to participate and provide the necessary nonfederal share of funding.
2. Requires the demonstration or pilot project to:
   1. Include a peer support specialist certified pursuant to this bill as a Medi-Cal provider type for purposes of the demonstration or pilot project;
   2. Include peer support specialist services as a distinct service type in counties that opt in to the demonstration or pilot project; and,
   3. Develop and implement one or more billing codes, reimbursement rates, and claiming requirement for peer support specialist services.
3. Defines, a "peer support specialist" to mean an individual who is 18 years of age or older who has self-identified as having lived experience with the process of recovery from mental illness, substance use disorder (SUD), or both, either as a consumer of these services or as the parent or family member of the consumer, and who has been granted certification under a county peer support specialist certification program.
4. Implements the peer support demonstration or pilot project only to the extent DHCS obtains any necessary federal approvals and federal financial participation is available and is not otherwise jeopardized. Requires a county that opts to participate in a demonstration or pilot project to fund the nonfederal share of any applicable expenditures through certified public expenditures or intergovernmental transfers to qualify for federal financial participation under Medicaid.
5. Requires DHCS, by July 1, 2022, to do all of the following:
   1. Establish statewide requirements for counties, or an agency representing counties, to use in developing certification programs for the certification of peer support specialists;
   2. Define the range of responsibilities, practice guidelines, and supervision standards for peer support specialists.
   3. Determine curriculum and core competencies required for certification of an individual as a peer support specialist, including curriculum that may be offered in areas of specialization, including, but not limited to, transition-age youth, veterans, gender identity, sexual orientation, and any other areas of specialization identified by the DHCS. Requires core-competencies-based curriculum to include, at a minimum, training related to specified elements;
   4. Specify peer support specialist employment training requirements, including core-competencies-based training and specialized training necessary to become certified under this bill, and require training to include people with lived experience as consumers and family members;
   5. Establish a code of ethics;
   6. Determine continuing education requirements for biennial certification renewal, and determine the process for biennial certification renewal;
   7. Determine a process for investigation of complaints and corrective action, including suspension and revocation of certification;
   8. Determine a process for an individual employed as a peer support specialist on January 1, 2022, to obtain certification under this bill;
   9. Determine requirements for peer support specialist certification reciprocity between counties, and for peer support specialists from out of state; and,
   10. Seek any federal approvals related to the statewide certification standards that it deems necessary to implement this bill.
6. Authorizes, subject to DHCS approval, a county or an agency representing the county, to develop a peer support specialist certification program in accordance with this bill and any standards established by DHCS, requires a county to oversee and enforce the certification requirements, requires a county to take specified steps to request DHCS approval, and requires, subject to an appropriation by the Legislature, the state to fund the startup costs to implement these requirements.
7. Requires, to receive certification under this bill, an applicant to meet all of the following requirements:
   1. Be at least 18 years of age;
   2. Possess a high school diploma or equivalent degree;
   3. Be self-identified as having experience with the process of recovery from mental illness or SUD treatment either as a consumer of these services or as the parent or family member of the consumer;
   4. Be willing to share their experience;
   5. Have a strong dedication to recovery;
   6. Agree, in writing, to adhere to a code of ethics;
   7. Successfully complete the curriculum and training requirements for a peer support specialist; and,
   8. Pass a certification examination approved by DHCS for a peer support specialist.
8. Requires a peer support specialist, to maintain certification under this bill, to meet both of the following requirements:
   1. Adhere to the code of ethics and biennially sign an affirmation; and,
   2. Complete any required continuing education, training, and recertification requirements.
9. Permits a participating county or an agency representing a participating county, to establish a certification fee schedule for the purpose of supporting the activities associated with the ongoing administration of the peer support specialist certification program. Requires DHCS to review and either approve or disapprove the fee schedule before it may be implemented.
10. Permits DHCS, for the purpose of implementing this bill, to enter into exclusive or nonexclusive contracts on a bid or negotiated basis, including contracts, and exempts these contracts from specified state requirements.
11. Permits DHS to implement, interpret, or make specific the requirements of this bill by means of informal notices, plan letters, plan or provider bulletins, or similar instructions, without taking regulatory action, until the time regulations are adopted.

COMMENTS:

BACKGROUND. In 2007 and 2013, Center for Medicare and Medicaid Services (CMS) provided guidance to states interested in peer support services under the Medicaid program. CMS stated Medicaid will reimburse for peer support services delivered directly to Medicaid beneficiaries with mental health and/or SUDs. CMS indicated that, in order to be considered for federal reimbursement, states must identify the Medicaid authority to be used for coverage and payment, describe the service, the provider of the service, and their qualifications in full detail. CMS established the minimum requirements that should be addressed for supervision, care coordination, and training when electing to provide peer support services, including that peer support providers must complete training and certification as defined by the State that provide peer support providers with a basic set of competencies necessary to perform the peer support function.

According to the Author:

The COVID-19 pandemic and subsequent economic downturn pose a serious threat to the mental health of Californians. Calls to the SAMHSA's disaster distress hotline increased nearly 10 fold from March 2019 to March 2020. The need for mental health response will continue to grow even as the state of emergency subsides. The sharp rise in mental health disorders triggered by COVID-19 is likely to linger long after the end of the pandemic itself, thus highlighting the need for an effective, comprehensive, and economically viable mental health care response. Peer support, recognized as an evidence-based model of care by CMS since 2007, is a cost-effective practice that is proven to reduce hospitalization and homelessness, increase participation in treatment, and service experience. Peer support specialists are self-identified consumers who use their lived experience along with skills learned in formal training to assist others in their own recovery from mental illness. Forty-eight states recognize their value and have a certification process in place or in development for mental health peer support specialists. Despite increase demand for peer services, there remains no statewide scope of practice, training standards, supervision standards, or certification in California. Statewide certification would ensure quality, standardization, and effectiveness of peer support services across California's 58 counties.

Arguments in Support:

This bill is jointly sponsored by the Los Angeles County Board of Supervisors, CHBDA, the California Association of Mental Health Peer Run Organizations, and the Steinberg Institute, which argue that peer providers who use their life experience with mental illness and recovery, coupled with skills learned through formal training, have proven to be a valuable addition to service delivery in mental health settings. The sponsors and supporters argue peer providers use their lived experience with mental illness, addiction, and recovery, coupled with skills learned through formal training to provide invaluable behavioral health services. The sponsors also point out that research demonstrates that peer support specialists reduce hospitalizations and hospital days, improve client functioning, increase client satisfaction, reduce family concerns, alleviate clinical symptoms, and increase client self-advocacy. Across California, peer providers are already utilized in many settings. However, there are no statewide standards of practice, consistent curriculum, training or supervision standards, or certification protocol. They claim that, without the standardization of this profession, California is unable to secure federal approval or Medicaid federal financial support for peer support services. Creating and fortifying California's peer support specialist workforce through ensuring federal Medicaid assistance is more critical than ever because of the current public health emergency, which is increasing anxiety and trauma experienced by Californians statewide. The number of unexpected deaths, the fear of getting ill, social isolation and economic uncertainty are creating and exacerbating a behavioral health crisis. They conclude that counties need a workforce with experience in successfully navigating their own behavioral health crises to help and support them. Supporters conclude that the ability of peers to connect with those in need and exemplifying the path to recovery and wellness will be vital in the aftermath of the pandemic.

Arguments in Opposition:

The California Right to Life Committee (CRLC) writes in opposition that it continue to oppose bills that appeal to the emotion of the citizen but expand the work and reach of the state government. CRLC considers this bill to be one such bill, stating that it is an Orwellian model of the use of science, technology, and human compassion as a means to control all activities of the human person. CRLC argues this bill utilizes the serious COVID-19 condition to further the necessity for mental health counseling without any specific reference to age of the potential needy person. CRLC states this bill is another attempt to broaden the workforce with non-professional persons who would become government employees.

FISCAL COMMENTS:

The most recently amended version of this bill has not been analyzed by a fiscal committee.

VOTES:

SENATE FLOOR: 39-0-1

YES: Allen, Archuleta, Atkins, Bates, Beall, Borgeas, Bradford, Caballero, Chang, Dahle, Dodd, Durazo, Galgiani, Glazer, Lena Gonzalez, Grove, Hertzberg, Hill, Hueso, Hurtado, Jackson, Jones, Leyva, McGuire, Melendez, Mitchell, Monning, Moorlach, Morrell, Nielsen, Pan, Portantino, Roth, Rubio, Skinner, Umberg, Wieckowski, Wiener, Wilk

ABS, ABST OR NV: Stern

ASM HEALTH: 15-0-0

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

ASM APPROPRIATIONS: 18-0-0

YES: Gonzalez, Bigelow, Bauer-Kahan, Bloom, Bonta, Calderon, Carrillo, Chau, Megan Dahle, Diep, Eggman, Fong, Gabriel, Eduardo Garcia, Petrie-Norris, Quirk, Robert Rivas, Voepel

UPDATED:

VERSION: August 30, 2020

CONSULTANT: Scott Bain / HEALTH / (916) 319-2097 FN: 0003439

 UNFINISHED BUSINESS  

Bill No: SB 803

Author: Beall (D), et al.

Amended: 8/30/20

Vote: 21

SENATE HEALTH COMMITTEE: 9-0, 5/13/20

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

SENATE APPROPRIATIONS COMMITTEE: 7-0, 6/18/20

AYES: Portantino, Bates, Bradford, Hill, Jones, Leyva, Wieckowski

SENATE FLOOR: 39-0, 6/24/20

AYES: Allen, Archuleta, Atkins, Bates, Beall, Borgeas, Bradford, Caballero, Chang, Dahle, Dodd, Durazo, Galgiani, Glazer, Lena Gonzalez, Grove, Hertzberg, Hill, Hueso, Hurtado, Jackson, Jones, Leyva, McGuire, Melendez, Mitchell, Monning, Moorlach, Morrell, Nielsen, Pan, Portantino, Roth, Rubio, Skinner, Umberg, Wieckowski, Wiener, Wilk

NO VOTE RECORDED: Stern

ASSEMBLY FLOOR: Not available

SUBJECT: Mental health services: peer support specialist certification

SOURCE: California Association of Mental Health Peer Run Organizations

County Behavioral Health Directors Association of California

County of Los Angeles

Steinberg Institute

DIGEST:

This bill (1) requires the Department of Health Care Services (DHCS) to establish statewide requirements for a program for certifying peer support specialists; (2) requires DHCS to seek any federal waivers to implement the certification program; and (3) permits DHCS to implement, interpret, and make specific the certification program through available means, as specified.

Assembly Amendments make the peer support specialist (PSS) certification program a county opt-in program, and require DHCS to establish statewide requirements for counties, or an agency representing a county, to use in developing a PSS certification program.

ANALYSIS:

Existing law:

1. Establishes the Medi-Cal program, administered by DHCS, under which qualified low-income individuals receive health care services. [WIC §14001.1]
2. Grants DHCS the sole authority in state government to determine the qualifications, including the appropriate skills, education, training, and experience of personnel working within substance use disorder (SUD) recovery and treatment programs licensed and/or certified by DHCS. [HSC §11833]
3. Authorizes DHCS to require an individual providing counseling services in SUD programs licensed and/or certified by DHCS to be registered with or certified by a certifying organization (CO) approved by DHCS to register and certify counselors. [HSC §11833]
4. Grants DHCS the authority to conduct periodic reviews of COs to determine compliance with all applicable laws and regulations and to take actions for non-compliance, including revocation of DHCS’s approval. [HSC §11833]
5. Requires, through regulations, the certification of SUD counselors to be based on specific counseling competencies, training, and education, including understanding addiction and knowledge of treatment methods. [CCR, Title 9, Division 4, Chapter 8]

This bill:

1. Requires DHCS, by July 1, 2022, to do all of the following:
   1. Establish statewide requirements for counties, or an agency representing a county, to use in developing a certification program for certifying a PSS if those entities opt to provide PSS services;
   2. Defines qualifications, the range of responsibilities, practice guidelines, and supervision standards for PSS, as specified;
   3. Determine curriculum and core competencies, including areas of specialization for PSS, such as transition-age youth, veterans, gender identity, and sexual orientation, and core competencies that include trauma-informed care, co-occurring mental health and SUDs, preparation for employment opportunities, and navigation of, and referral to, other services;
   4. Specify PSS employment training requirements, and requiring training to include individuals with lived experience as consumers and family members;
   5. Establish a code of ethics and processes for investigations and corrective action, as specified;
   6. Determine continuing education for initial certification and renewal;
   7. Determine a process for allowing existing personnel employed in the peer support field to obtain certification, as specified;
   8. Determine a process for PSS certification reciprocity between counties and for PSS from out of state; and,
   9. Seek any federal approvals, as specified.
2. Permits a county, or an agency representing a county, subject to DHCS approval, to develop a PSS certification program in accordance with requirements in this bill and any standards established by DHCS. Requires a county, or an agency representing a county, to oversee and enforce the certification requirements, as specified, and to meet other requirements, such as submitting a PSS certification plan and annual reports to DHCS, and submitting to periodic reviews conducted by DHCS to ensure adherence to all federal and state requirements.
3. Permits a county, or an agency representing a county, to develop a certification fee schedule to support the activities associated with the ongoing administration of the PSS certification program, as specified.
4. Requires DHCS to solicit stakeholder input from entities such as the Office of Statewide Health Planning and Development, peer support and family organizations, mental health and SUD treatment providers and organizations, the County Behavioral Health Directors Association of California, the California Behavioral Health Planning Council, in implementing the PSS certification program, as specified.
5. Requires DHCS to seek federal waivers it deems necessary to include PSS as a provider type and develop billing codes for PSS services in counties that opt to provide PSS services pursuant to the requirements in this bill.
6. Permits DHCS to implement, interpret, or make specific the requirements of the PSS certification program through plan letters, plan or provider bulletins, or similar instructions without further regulatory action.
7. Requires a PSS applicant to, among other requirements, be at least 18 years of age, possess a high school diploma or equivalent degree, be self-identified as having experience with recovery from mental illness or an SUD, adhere to the code of ethics, and successfully complete the curriculum and training and pass the certification examination.
8. Defines “peers support specialist services” as culturally competent services that promote engagement, socialization, recovery, self-sufficiency, and self-advocacy, development of natural supports, and identification of strengths, including prevention services, support, coaching, facilitation, or education that is individualized and is conducted by a certified PSS.
9. Prohibits the PSS certification program to be construed as permitting a PSS to diagnose an illness, prescribe medication, or provide clinical services.

Comments

1. Author’s statement. According to the author, peer support, recognized as an evidence-based model of care by the Centers for Medicare and Medicaid Services (CMS) since 2007, is a cost-effective practice that is proven to reduce hospitalization and homelessness and increase participation in treatment and service experience. Further, it encourages hope, empowerment, and personal advocacy for clients receiving behavioral health services. PSS are self-identified consumers who use their lived experience along with skills learned in formal training to assist others in their own recovery from mental illness. The U.S. Department of Veterans Affairs and 48 states have a certification process in place or in development for mental health PSS. Demand for peer services is growing, but there is no statewide scope of practice, training standards, supervision standards, or certification in California. Statewide certification would ensure quality, standardization, and effectiveness of PSS across California’s 58 counties. Studies demonstrate that use of PSS in a comprehensive mental health or SUD treatment program helps reduce client hospitalizations, improve client functioning, increase client satisfaction, alleviate depression and other symptoms, and diversify the behavioral health workforce. Data shows a clear return on investment when peers are part of the behavioral health system.
2. PSS. According to the federal Substance Abuse and Mental Health Service Administration, a PSS is a person who uses lived experience of recovery from mental illness and/or an SUD, plus skills learned in formal training, to deliver services in behavioral health settings to promote recovery and resiliency. According to DHCS, a substantial number of studies demonstrate that PSS improves patient functioning, increases patient satisfaction, reduces family burden, alleviates depression and other symptoms, reduces hospitalizations and hospital days, increases patient activation, and enhances patient self-advocacy. PSS are used in more than 40 states and throughout the Veterans Health Administration. PSS participating in SUD treatment activities are currently a recognized Medicaid service provider in California for SUD services; however, these providers are often limited in the services they are able to provide in traditional health care settings. DHCS states that expanded use of PSS in mental health and SUD as part of a care team can improve care coordination between behavioral health and physical health care needs of patients. DHCS included PSS as a component in the 2015 Section 1115 Waiver renewal, known as Medi-Cal 2020 and expires in 2020, by providing financial incentives to managed care plans to support non-physician community providers, promoting both physical and behavioral health care integration, and team-based care. DHCS states that peer support services defined in this bill appear to align with allowable service activities under the existing Specialty Mental Health Services (SMHS) waiver. DHCS also states that it is in the process of developing its waiver renewals but does not plan on making changes to the definition of “other qualified providers.”
3. PSS certification. CMS released guidance in 2007 and further clarification in 2013 for establishing a PSS certification program to enable FFP in an effort to more fully incorporate and expand the use of peers. CMS requires peer support providers to complete training and certification as defined by each state, and specified that services can be offered for mental illness and/or SUDs. Substantive work has been conducted in California by the Working Well Together Statewide Technical Assistance Center, a collaborative of peer and client-oriented organizations, which culminated in a final report of recommendations to proceed with peer certification. This effort identified key issues for laying the foundation of certification, including training recommendations and core components for a statewide certification program; establishing a standard of practice and core competencies; defining the level of care and services; integrating services across physical health, mental health, and SUD services; and allowing for portability from one county to another.
4. DHCS current certification duties. DHCS ensures that registered and certified SUD counselors provide quality treatment to clients by enforcing counselor certification regulations. DHCS approves COs that register and certify SUD counselors who provide counseling services in an SUD program licensed or certified by DHCS. There are approximately 28,000 SUD counselors, of which roughly half are certified and half are registered while working towards certification. DHCS’s oversight authority of COs includes periodic reviews of the COs to monitor adherence to state requirements.

Related/Prior Legislation

SB 10 (Beall, 2019), SB 906 (Beall, 2018), and SB 614 (Leno, 2015) were identical to this bill. SB 10 was vetoed by Governor Newsom who stated that counties may currently opt to use PSS for the delivery of Medicaid SMHS and as the state works to transform the behavioral health care delivery system, we have an opportunity to more comprehensively include PSS in these transformation plans. SB 906 was vetoed by Governor Brown who stated PSS are currently used as providers in Medi-Cal without a state certificate, and SB 906 would have imposed a costly new program, which would have permitted some individuals to continue providing services but shut others out. Governor Brown urged stakeholders and DHCS to improve upon the existing framework while allowing all PSS to continue to work. SB 614 was amended on August 18, 2016, on the Assembly Floor to a new purpose.

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

According to the Assembly Appropriations Committee:

1. Minor and absorbable costs to the Office of Statewide Health Planning and Development for its consultative role (Health Data and Planning Fund).
2. Costs to DHCS below, assuming the state administers the certification program (MHSA state administrative dollars, fee revenue or GF /federal).
   1. One-time administrative costs of $1 million to $2 million to DHCS to certify peer support specialists (MHSA state administrative dollars or GF /federal).
   2. $1 million to $3 million in administrative costs annually to DHCS for investigation and oversight.
   3. Contract costs to DHCS for administration of the certification program of $3 million annually.

If DHCS instead delegates this role to counties, state costs would be lower, limited to the costs to create statewide standards, designate certifying entities and oversee county-based certification programs (MHSA state administrative dollars or GF /federal).

1. Unknown, potentially significant county and federal costs to provide peer support specialist services.

SUPPORT: (Verified 8/30/20)

California Association of Mental Health Peer Run Organizations (co-source)

County Behavioral Health Directors Association of California (co-source)

County of Los Angeles (co-source)

Steinberg Institute (co-source)

2020 Mom

Alameda County District Attorney

Alum Rock Counseling Center

American Foundation for Suicide Prevention

Arc and United Cerebral Palsy California Collaboration

Association of California Healthcare Districts

Association of Community Human Service Agencies

Bay Area Community Services

Cal Voices

California Academy of Child and Adolescent Psychiatry

California Access Coalition

California Alliance of Child and Family Services

California Association of Alcohol and Drug Program Executives, Inc.

California Association of Local Behavioral Health Boards & Commissions

California Association of Public Hospitals & Health Systems

California Association of Social Rehabilitation Agencies

California Association of Veteran Service Agencies

California Behavioral Health Planning Council

California Board of Behavioral Sciences

California Chapter of the American College of Emergency Physicians

California Commission on Aging

California Consortium of Addiction Programs and Professionals

California Council of Community Behavioral Health Agencies

California Institute for Behavioral Health Solutions

California Judges Association

California Mental Health Advocates for Children and Youth

California Pan-Ethnic Health Network

California Psychiatric Association

California Psychological Association

California School Nurses Organizations

California State Association of Counties

California Youth Empowerment Network

CaliforniaHealth+ Advocates

Children Now

Children’s Defense Fund-California

Community Research Foundation

County of Orange

County of Riverside

County of Santa Clara

County of Ventura

Crestwood Behavioral Health

Depression and Bipolar Support Alliance California

Disability Community Resource Center

Disability Rights California

First 5 Alameda County

Gateways CONREP

Hope Cooperative

Housing for All Alliance

Juvenile Court Judges of California

Kelechi Ubozoh Consulting

Law Foundation of Silicon Valley

Local Health Plans of California

Mental Health America of California

Mental Health America of Los Angeles

Mental Health Association of San Francisco

Mental Health Services Oversight and Accountability Commission

Mentor and Peer Support

Napa MomSquad

National Alliance on Mental Illness California

National Alliance on Mental Illness California Fresno

National Alliance on Mental Illness California Santa Clara County

National Alliance on Mental Illness California Solano County

National Alliance on Mental Illness California Yolo County

National Association of Social Workers, California

Occupational Therapy Association of California

Peers Envisioning and Engaging in Recovery Services

Project Return Peer Support Network

Psychiatric Occupational Therapy Action Coalition

Racial and Ethnic Mental Health Disparities Coalition

Santa Clara Family Health Plan

SEIU California

Self Help and Recovery Exchange

Seneca Family of Agencies

Solano County Mental Health Advisory Board

The Children's Partnership

Transitions-Mental Health Association

United Parents

Vinaj Telosity

Western Center on Law & Poverty

Winter Faith Collaborative

Women's Wisdom Art

One individual

OPPOSITION: (Verified 8/30/20)

California Right to Life Committee

ARGUMENTS IN SUPPORT: The co-sponsors of this bill and other supporters, largely behavioral health providers and advocates, state that peer providers use their lived experience with mental illness, addiction, and recovery, coupled with skills learned through formal training to provide invaluable behavioral health services. Research demonstrates that PSS reduce hospitalizations and hospital days, improve client functioning, increase client satisfaction, reduce family concerns, alleviate clinical symptoms, and increase client self-advocacy. The County Behavioral Health Directors Association of California states that, for example, in Texas one long-term study focusing on SUD peer specialists, also called recovery coaches, found health care utilization dropped after 12 months of recovery coaching: outpatient visits dropped to 815 visits from 4,118 at enrollment; inpatient care days dropped to 1,117 days from 9,082 at enrollment; and, emergency room visits dropped to 146 from 426 at enrollment. In total, recovery coaching saved $3,422,632 in health care costs, representing a 72% reduction in costs over 12 months. Supporters argue that creating and fortifying California’s PSS workforce through ensuring federal Medicaid assistance is more critical than ever because of the current public health emergency, which is increasing anxiety and trauma experienced statewide. The number of unexpected deaths, the fear of getting ill, social isolation, and economic uncertainty are creating and exacerbating a behavioral health crisis, and Californians need a workforce with experience in successfully navigating their own behavioral health crises to help and support them.

ARGUMENTS IN OPPOSITION: The California Right to Life Committee, Inc. (CRLC) states it opposes this bill because it appeals to the emotion of the citizen but expands the work and reach of the state government. CRLC states this bill uses the present and serious COVID condition to further the necessity for mental health counseling without any specific reference to age of the potential needy person and is another attempt to broaden the workforce with non-professional persons who would become government employees.

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

8/31/20 21:54:27

**** END ****

SENATE THIRD READING

STR Bill Id:SB 803

Author:(Beall)

As Amended Ver:August 24, 2020

Majority vote

SUMMARY:

Requires the Department of Health Care Services (DHCS) to seek any federal waivers to include a certified peer support specialist as a Medi-Cal provider type, and to include peer support specialist services as a distinct service type in the Medi-Cal program, which may be provided to eligible Medi-Cal beneficiaries who receive specialty mental health services or Drug Medi-Cal (DMC) services in any county, including any county that has implemented a DMC organized delivery system (DMC-ODS), or both, if that county elects to both opt-in to provide peer support specialist services, and to fund the nonfederal share of those services. Requires DHCS to establish a certifying body and to establish curriculum and core competencies required for certification, including a process for an individual employed as a peer support specialist on January 1, 2021, to obtain certification under this bill, unless DHCS delegates this responsibility to a single county entity that enters into an agreement with DHCS. Establishes requirements for applicants for certification as a peer support specialist, and for continued certification.

Major Provisions

1. Requires DHCS to seek any federal waivers, as necessary, to do all of the following:
   1. Include a peer support specialist certified pursuant to this bill as a provider type for purposes of the Medi-Cal program; b) Include peer support specialist services as a distinct service type for purposes of the Medi-Cal program, which may be provided to eligible Medi-Cal beneficiaries who receive specialty mental health services or DMC services in any county, including any county that has implemented a DMC-ODS, or both, if that county elects to do both of the following: i) Opt in to provide peer support specialist services; and, ii) Fund the nonfederal share of those services; c) Develop and implement one or more billing codes, reimbursement rates, and claiming requirements for peer support specialist services; and, d) Delegate responsibility for the peer support certification process.
2. Defines, a "peer support specialist" to mean a person who is 18 years of age or older and who is a person who has self-identified as having lived experience with the process of recovery from mental illness, substance use disorder (SUD), or both, either as a consumer of these services or as the parent or family member of the consumer.
3. Requires DHCS, by July 1, 2021, to do all of the following:
   1. Establish a certifying body, either through contract or through an interagency agreement, to provide for the certification activities described in this bill, unless the federal Centers for Medicare and Medicaid Services (CMS) allows the state to delegate the peer support certification selection process to a single county entity that continues to allow the federal Medicaid match for peer support specialist services;
   2. Retain responsibility for the peer certification program if the federal CMS does not allow DHCS to delegate the peer support certification process to a county entity;
   3. Provide for a statewide certification for peer support specialists, as contained in federal guidance;
   4. Define the range of responsibilities, practice guidelines, and supervision standards for peer support specialists by utilizing best practice materials published by the federal Substance Abuse and Mental Health Services Administration (SAMHSA), the federal Department of Veterans Affairs, and related notable experts in the field as a basis for development;
   5. Determine curriculum and core competencies required for certification of an individual as a peer support specialist, including curriculum that may be offered in areas of specialization, including, but not limited to, transition-age youth, veterans, gender identity, sexual orientation, and any other areas of specialization identified by the DHCS. Requires core-competencies-based curriculum to include, at a minimum, training related to specified elements;
   6. Specify training requirements, including core-competencies-based training and specialized training necessary to become certified under this bill, allowing for multiple qualified training entities, and requiring training to include people with lived experience as consumers and family members;
   7. Establish a code of ethics;
   8. Determine continuing education requirements for biennial certification renewal;
   9. Determine the process for biennial certification renewal;
   10. Determine a process for investigation of complaints and corrective action, including suspension and revocation of certification; and,
   11. Determine a process for an individual employed as a peer support specialist on January 1, 2021, to obtain certification under this bill.
4. Requires an applicant for certification under this bill to meet all of the following requirements:
   1. Be at least 18 years of age;
   2. Possess a high school diploma or equivalent degree;
   3. Be self-identified as having experience with the process of recovery from mental illness or SUD treatment either as a consumer of these services or as the parent or family member of the consumer;
   4. Be willing to share their experience;
   5. Demonstrate leadership and advocacy skills;
   6. Have a strong dedication to recovery;
   7. Agree, in writing, to adhere to a code of ethics;
   8. Successfully complete the curriculum and training requirements for a peer support specialist; and,
   9. Pass a certification examination approved by DHCS for a peer support specialist.
5. Requires a peer support specialist, to maintain certification under this bill, to meet both of the following requirements:
   1. Adhere to the code of ethics and biennially sign an affirmation; and,
   2. Complete any required continuing education, training, and recertification requirements.
6. Permits DHCS to establish a certification fee schedule and to require remittance as contained in the certification fee schedule for the purpose of supporting the activities associated with the ongoing administration of the peer support specialist certification program. Requires fees to be deposited in the continuously appropriated Peer Support Specialist Certification Fee Fund established by this bill.
7. Requires certification fees charged by DHCS reasonably reflect the expenditures directly applicable to the ongoing administration of the peer support specialist certification program.
8. Requires Medi-Cal reimbursement for peer support specialist services to be implemented only if, and to the extent that, federal financial participation (FFP) under federal Medicaid law is available and all necessary federal approvals have been obtained.
9. Permits DHCS, for the purpose of implementing this bill, to enter into exclusive or nonexclusive contracts on a bid or negotiated basis, including contracts for the purpose of obtaining subject matter expertise or other technical assistance.
10. Permits DHS to implement, interpret, or make specific the various requirements of this bill by means of informal notices, plan letters, plan or provider bulletins, or similar instructions, without taking regulatory action, until the time regulations are adopted. Requires DHCS to adopt regulations by January 1, 2022, in accordance with the requirements of the Administrative Procedures Act.
11. Permits DHCS, to the extent authorized by a specified provision of the Mental Health Services Act (MHSA) and if authorized under the annual Budget Act, in fiscal year (FY) 2020-21, to fund state administrative costs, including but not limited to, the costs of delegated activities, related to developing and administering the peer support specialist certification program. Permits DHCS, subject to an express appropriation in the Budget Act of 2021 for FY 2021-22, and to the extent authorized by specified provision of the MHSA, to fund state administrative costs related to developing and administering the peer support specialist certification program. Requires, to the extent permissible, those funds to be available for purposes of claiming FFP under federal Medicaid law.

COMMENTS:

BACKGROUND. In 2007 and 2013, CMS provided guidance to states interested in peer support services under the Medicaid program. CMS stated Medicaid will reimburse for peer support services delivered directly to Medicaid beneficiaries with mental health and/or SUDs. CMS indicated that, in order to be considered for federal reimbursement, states must identify the Medicaid authority to be used for coverage and payment, describe the service, the provider of the service, and their qualifications in full detail. CMS established the minimum requirements that should be addressed for supervision, care coordination, and training when electing to provide peer support services, including that peer support providers must complete training and certification as defined by the State that provide peer support providers with a basic set of competencies necessary to perform the peer support function.

According to the Author:

The COVID-19 pandemic and subsequent economic downturn pose a serious threat to the mental health of Californians. Calls to the SAMHSA's disaster distress hotline increased nearly 10 fold from March 2019 to March 2020. The need for mental health response will continue to grow even as the state of emergency subsides. The sharp rise in mental health disorders triggered by COVID-19 is likely to linger long after the end of the pandemic itself, thus highlighting the need for an effective, comprehensive, and economically viable mental health care response. Peer support, recognized as an evidence-based model of care by CMS since 2007, is a cost-effective practice that is proven to reduce hospitalization and homelessness, increase participation in treatment, and service experience. Peer support specialists are self-identified consumers who use their lived experience along with skills learned in formal training to assist others in their own recovery from mental illness. Forty-eight states recognize their value and have a certification process in place or in development for mental health peer support specialists. Despite increase demand for peer services, there remains no statewide scope of practice, training standards, supervision standards, or certification in California. Statewide certification would ensure quality, standardization, and effectiveness of peer support services across California's 58 counties.

Arguments in Support:

This bill is jointly sponsored by the Los Angeles County Board of Supervisors, CHBDA, the California Association of Mental Health Peer Run Organizations, and the Steinberg Institute, which argue that peer providers who use their life experience with mental illness and recovery, coupled with skills learned through formal training, have proven to be a valuable addition to service delivery in mental health settings. The sponsors and supporters argue peer providers use their lived experience with mental illness, addiction, and recovery, coupled with skills learned through formal training to provide invaluable behavioral health services. The sponsors also point out that research demonstrates that peer support specialists reduce hospitalizations and hospital days, improve client functioning, increase client satisfaction, reduce family concerns, alleviate clinical symptoms, and increase client self-advocacy. Across California, peer providers are already utilized in many settings. However, there are no statewide standards of practice, consistent curriculum, training or supervision standards, or certification protocol. They claim that, without the standardization of this profession, California is unable to secure federal approval or Medicaid federal financial support for peer support services. Creating and fortifying California's peer support specialist workforce through ensuring federal Medicaid assistance is more critical than ever because of the current public health emergency, which is increasing anxiety and trauma experienced by Californians statewide. The number of unexpected deaths, the fear of getting ill, social isolation and economic uncertainty are creating and exacerbating a behavioral health crisis. They conclude that counties need a workforce with experience in successfully navigating their own behavioral health crises to help and support them. Supporters conclude that the ability of peers to connect with those in need and exemplifying the path to recovery and wellness will be vital in the aftermath of the pandemic.

Arguments in Opposition:

The California Right to Life Committee (CRLC) writes in opposition that it continue to oppose bills that appeal to the emotion of the citizen but expand the work and reach of the state government. CRLC considers this bill to be one such bill, stating that it is an Orwellian model of the use of science, technology, and human compassion as a means to control all activities of the human person. CRLC argues this bill utilizes the serious COVID-19 condition to further the necessity for mental health counseling without any specific reference to age of the potential needy person. CRLC states this bill is another attempt to broaden the workforce with non-professional persons who would become government employees.

FISCAL COMMENTS:

According to the Assembly Appropriations Committee:

1. Minor and absorbable costs to the Office of Statewide Health Planning and Development for its consultative role (Health Data and Planning Fund).
2. Costs to DHCS below, assuming the state administers the certification program (MHSA state administrative dollars, fee revenue or GF /federal).
   1. One-time administrative costs of $1 million to $2 million to DHCS to certify peer support specialists (MHSA state administrative dollars or GF /federal).
   2. $1 million to $3 million in administrative costs annually to DHCS for investigation and oversight.
   3. Contract costs to DHCS for administration of the certification program of $3 million annually.

If DHCS instead delegates this role to counties, state costs would be lower, limited to the costs to create statewide standards, designate certifying entities and oversee county-based certification programs (MHSA state administrative dollars or GF /federal).

1. Unknown, potentially significant county and federal costs to provide peer support specialist services.

VOTES:

SENATE FLOOR: 39-0-1

YES: Allen, Archuleta, Atkins, Bates, Beall, Borgeas, Bradford, Caballero, Chang, Dahle, Dodd, Durazo, Galgiani, Glazer, Lena Gonzalez, Grove, Hertzberg, Hill, Hueso, Hurtado, Jackson, Jones, Leyva, McGuire, Melendez, Mitchell, Monning, Moorlach, Morrell, Nielsen, Pan, Portantino, Roth, Rubio, Skinner, Umberg, Wieckowski, Wiener, Wilk

ABS, ABST OR NV: Stern

ASM HEALTH: 15-0-0

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

ASM APPROPRIATIONS: 18-0-0

YES: Gonzalez, Bigelow, Bauer-Kahan, Bloom, Bonta, Calderon, Carrillo, Chau, Megan Dahle, Diep, Eggman, Fong, Gabriel, Eduardo Garcia, Petrie-Norris, Quirk, Robert Rivas, Voepel

UPDATED:

VERSION: August 24, 2020

CONSULTANT: Scott Bain / HEALTH / (916) 319-2097 FN: 0003237

Date of Hearing: August 11, 2020

ASSEMBLY COMMITTEE ON APPROPRIATIONS

Lorena Gonzalez, Chair

SBPCA Bill Id:SB 803

Author:(Beall) – As Amended Ver:July 27, 2020

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

SUMMARY:

This bill requires the Department of Health Care Services to establish standards and a certification process for peer support specialists and requires DHCS to seek federal approvals to allow counties to provide peer support specialist services as a distinct Medi-Cal service type, provided the county funds the nonfederal share of Medi-Cal costs for the services. Specifically, this bill:

1. Requires DHCS to
   1. Establish a certifying body, either through contract or through an interagency agreement, for mental health and substance use disorder peer support specialists.
   2. Provide for a statewide certification for peer support specialists.
   3. Define the range of responsibilities, education and training, core competencies, practice guidelines and supervision standards for peer support specialists, as specified.
   4. Consult with specified stakeholders in the development of the program.
2. Sets forth minimum standards an applicant for peer support specialist certification must meet.
3. Allows the department to establish a certification fee schedule to support program administration that reasonably reflects the expenditures directly applicable to the administration of the peer support specialist certification program.
4. Requires the department to seek any federal waivers or other state plan amendments, as necessary, to implement inclusion of peer support specialist services as a Medi-Cal provider type, billing, reimbursement and provision of peer support services by counties that opt in to provide and fund peer support specialist services.
5. Makes Medi-Cal reimbursement for peer support specialist services contingent on federal financial participation (FFP, or the federal share of program funding) and federal approval.
6. Allows DHCS to enter into contracts on a no-bid or negotiated basis for administration of a certification program, and requires DHCS to promulgate regulations by January 1, 2022.

FISCAL EFFECT:

1. Minor and absorbable costs to the Office of Statewide Health Planning and Development for its consultative role (Health Data and Planning Fund).
2. One-time administrative costs of $1 million to $2 million to DHCS to establish a process and contract or formulate an interagency agreement to certify peer support specialists (MHSA state administrative dollars or GF /federal).
3. $1 million to $3 million in administrative costs annually to DHCS for investigation, discipline and contract oversight (MHSA state administrative dollars or GF /federal).
4. Contract costs to DHCS for administration of the certification program of $3 million annually (fee revenue/federal).
5. Assuming federal approval and availability of federal financial participation (FFP), unknown, potentially significant county and federal costs to provide peer support specialist services. Since the bill specifies a county must opt in to provide the services, no state costs are expected for the provision of services. Staff assumes this approval would be possible through a waiver of the federal requirement for standardized statewide benefits.

According to Proposition 30, legislation enacted after September 30, 2012:

That has an overall effect of increasing the costs already borne by a local agency for programs or levels of service mandated by the 2011 Realignment Legislation shall apply to local agencies only to the extent that the State provides annual funding for the cost increase.

State mandates requiring new substance use disorder and mental health services often trigger concern about state costs pursuant to Proposition 30, since these services were among those referenced above that were realigned to counties.

Staff does not, however, expect state costs pursuant to Proposition 30 because the July 27, 2020, version of the bill specifies these services will be provided only to the extent a county opts in to provide the services and funds the nonfederal share of the services. Even if legislation mandated the service be provided, pursuant to Proposition 30, if no state funding is provided for peer support services the mandate would not apply to counties and a county could simply choose not to provide the services.

COMMENTS:

1. Purpose. The purpose of this bill is to create a state-level certification program for peer support specialists and facilitate provision of these services through Medi-Cal. The author notes a substantial body of research shows peer support services improve outcomes and quality of life for clients of the mental health and substance use disorder (behavioral health) system and their families and save money by reducing acute incidents such as hospitalization. Based on years of discussion and research, stakeholders in the behavioral health community strongly recommend creating a state certification program to standardize training and core competencies as well as to allow counties that deliver behavioral health services to leverage federal financial participation (FFP) in Medi-Cal.
2. Peer specialists and certification. Peer support specialists are persons who have lived experience from mental illness or substance use disorder, plus formal training, to deliver services in a behavioral health setting to promote recovery. The federal Substance Abuse and Mental Health Services Administration (SAMHSA) notes peer services are varied and can include: (a) peer mentoring or coaching, (b) connecting to recovery resources, (c) facilitating and leading recovery groups, and (d) building community. A 2007 Center for Medicare and Medicaid Services (CMS) letter to state health officials clarifies states can seek federal approval to receive Medicaid (Medi-Cal in California) reimbursement for peer support services, but notes state-defined training and certification is required in order to receive reimbursement. The U.S. Department of Veterans Affairs and most other states have established programs for certification of peers.

Notably, state law allows for Medi-Cal reimbursement for peer support services under certain conditions. Specifically, most California counties have opted to participate in an effort called the Drug Medi-Cal Organized Delivery System waiver, which allows counties to provide and claim Medi-Cal reimbursement for a robust continuum of substance use services. The waiver allows coverage of peer-to-peer substance use disorder services as a component of recovery services. In order to claim FFP for these services, counties must develop a substance use disorder peer support training plan and provide a county designation for staff serving as peers. Counties have implemented the DMC-ODS waiver in phases that started July 1, 2017. This bill would centralize personnel certification standards and verification at the state level for providers of both substance use disorder and mental health peer services.

1. DHCS Existing Certification Programs. DHCS currently licenses or certifies drug and alcohol rehabilitation facilities, programs and counselors. With respect to certified counselors, DHCS oversees counselors indirectly via oversight of designated certifying entities.
2. Prior Legislation. A number of prior bills have addressed this issue in recent years. Notably, prior bills generally required the statewide provision of peer support specialist service, whereas SB 803 makes this a county option.

SB 614 (Leno), of the 2015-16 Legislative Session, was similar to this bill. After passing this committee, it was amended to a different subject matter with a different author and signed.

SB 906 (Beall), of the 2017-18 Legislative Session, was similar to this bill and was vetoed by Governor Brown, who stated peer support specialists are currently used as providers in Medi-Cal without a state certificate, and that SB 906 imposed a costly new program, which will permit some of these individuals to continue providing services but shut others out. Governor Brown urged the stakeholders and DHCS to improve upon the existing framework while allowing all peer support specialists to continue to work.

SB 10 (Beall), of the current legislative session, was similar to this bill and was vetoed by Governor Newsom, who noted significant costs that should be considered in the budget process as well as the opportunity to collaborate with the Legislature to more comprehensively include peer support services in ongoing system transformation efforts.

1. Staff Comment. The author has proposed technical amendments that will create a special fund in which to deposit fee revenues and allow DHCS to use fee revenues to support the program.

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

Date of Hearing: August 4, 2020

ASSEMBLY COMMITTEE ON HEALTH

Jim Wood, Chair

SBPCA Bill Id:SB 803

Author:(Beall) – As Amended Ver:July 27, 2020

SENATE VOTE: 39-0

SUBJECT: Mental health services: peer support specialist certification.

SUMMARY Requires the Department of Health Care Services (DHCS) to seek any federal waivers or state plan amendments (SPAs) to include a certified peer support specialist as a Medi-Cal provider type, and to include peer support specialist services as a distinct service type in the Medi-Cal program, which may be provided to eligible Medi-Cal beneficiaries who receive specialty mental health services or Drug Medi-Cal (DMC) services in any county, including any county that has implemented a DMC organized delivery system (DMC-ODS), or both, if that county elects to both opt-in to provide peer support specialist services, and to fund the nonfederal share of those services. Requires DHCS to establish a certifying body and to establish curriculum and core competencies required for certification, including a process for an individual employed as a peer support specialist on January 1, 2021, to obtain certification under this bill. Establishes requirements for applicants for certification as a peer support specialist, and for continued certification. Specifically, this bill:

1. Requires DHCS to seek any federal waivers or other SPAs, as necessary, to do all of the following:
   1. Include a peer support specialist certified pursuant to this bill as a provider type for purposes of the Medi-Cal program;
   2. Include peer support specialist services as a distinct service type for purposes of the Medi-Cal program, which may be provided to eligible Medi-Cal beneficiaries who receive specialty mental health services or DMC services in any county, including any county that has implemented a DMC-ODS, or both, if that county elects to do both of the following:
      1. Opt in to provide peer support specialist services; and,
      2. Fund the nonfederal share of those services.
   3. Develop and implement one or more billing codes, reimbursement rates, and claiming requirements for peer support specialist services.
2. Defines, for purposes of this bill, the following:
   1. “Peer support specialist” to mean a person who is 18 years of age or older and who is a person who has self-identified as having lived experience with the process of recovery from mental illness, substance use disorder (SUD), or both, either as a consumer of these services or as the parent or family member of the consumer; and,
   2. “Peer support specialist services” to mean culturally competent services that promote engagement, socialization, recovery, self-sufficiency, self-advocacy, development of natural supports, identification of strengths, and maintenance of skills learned in other support services, which include, but are not limited to, support, coaching, facilitation, or education to Medi-Cal beneficiaries that is individualized to the beneficiary and is conducted by a certified peer support specialist.
      
3. Requires DHCS to develop one or more billing codes, reimbursement rates, and claiming requirements for peer support specialist services.
   
4. Requires DHCS, by July 1, 2021, to do all of the following:
   1. Establish a certifying body, either through contract or through an interagency agreement, to provide for the certification activities described in this bill;
   2. Provide for a statewide certification for peer support specialists, as contained in federal guidance in State Medicaid Director Letter No. 07-011, issued by the federal Centers for Medicare and Medicaid Services (CMS) on August 15, 2007;
   3. Define the range of responsibilities, practice guidelines, and supervision standards for peer support specialists by utilizing best practice materials published by the federal Substance Abuse and Mental Health Services Administration (SAMHSA), the federal Department of Veterans Affairs, and related notable experts in the field as a basis for development; and,
   4. Determine curriculum and core competencies required for certification of an individual as a peer support specialist, including curriculum that may be offered in areas of specialization, including, but not limited to, transition-age youth, veterans, gender identity, sexual orientation, and any other areas of specialization identified by the DHCS. Requires core-competencies-based curriculum to include, at a minimum, training related to all of the following elements:
      1. The concepts of hope, recovery, and wellness;
      2. The role of advocacy;
      3. The role of consumers and family members;
      4. Psychiatric rehabilitation skills and service delivery, and addiction recovery principles, including defined practices;
      5. Cultural competence training;
      6. Trauma-informed care;
      7. Group facilitation skills;
      8. Self-awareness and self-care;
      9. Co-occurring disorders of mental health and substance use;
      10. Conflict resolution;
      11. Professional boundaries and ethics;
      12. Preparation for employment opportunities, including study and test-taking skills, application and résumé preparation, interviewing, and other potential requirements for employment;
      13. Safety and crisis planning;
      14. Navigation of, and referral to, other services;
      15. Documentation skills and standards; and,
      16. Confidentiality.
   5. Specify training requirements, including core-competencies-based training and specialized training necessary to become certified under this bill, allowing for multiple qualified training entities, and requiring training to include people with lived experience as consumers and family members;
   6. Establish a code of ethics;
   7. Determine continuing education requirements for biennial certification renewal;
   8. Determine the process for biennial certification renewal;
   9. Determine a process for investigation of complaints and corrective action, including suspension and revocation of certification;
   10. Determine a process for an individual employed as a peer support specialist on January 1, 2021, to obtain certification under this bill.
       
5. Requires an applicant for certification under this bill to meet all of the following requirements:
   1. Be at least 18 years of age;
   2. Possess a high school diploma or equivalent degree;
   3. Be self-identified as having experience with the process of recovery from mental illness or SUD treatment either as a consumer of these services or as the parent or family member of the consumer;
   4. Be willing to share their experience;
   5. Demonstrate leadership and advocacy skills;
   6. Have a strong dedication to recovery;
   7. Agree, in writing, to adhere to a code of ethics;
   8. Successfully complete the curriculum and training requirements for a peer support specialist; and,
   9. Pass a certification examination approved by DHCS for a peer support specialist.
      
6. Requires a peer support specialist, to maintain certification under this bill, to meet both of the following requirements:
   1. Adhere to the code of ethics and biennially sign an affirmation; and,
   2. Complete any required continuing education, training, and recertification requirements.
      
7. Prohibits this bill from implying that an individual who is certified pursuant to this bill is qualified to, or authorized to, diagnose an illness, prescribe medication, or provide clinical services.
   
8. Prohibits this bill from altering the scope of practice for a health care professional or authorize the delivery of health care services in a setting or manner that is not authorized pursuant to the Business and Professions Code or the Health and Safety Code.
9. Requires DHCS to consult (at minimum, through quarterly stakeholder meetings) with the Office of Statewide Health Planning and Development, peer support and family organizations, mental health services and SUD treatment providers and organizations, the County Behavioral Health Directors Association of California (CBHDA), and the California Behavioral Health Planning Council in implementing this bill.
10. Permits DHCS to additionally conduct technical workgroups upon the request of stakeholders.
11. Permits community health workers, to facilitate early intervention for mental health services, to partner with peer support specialists to improve linkage to services for beneficiaries.
    
12. Permits DHCS to establish a certification fee schedule and to require remittance as contained in the certification fee schedule for the purpose of supporting the activities associated with the ongoing administration of the peer support specialist certification program.
    
13. Requires certification fees charged by DHCS reasonably reflect the expenditures directly applicable to the ongoing administration of the peer support specialist certification program.
14. Permits DHCS to seek any federal waivers or other state plan amendments as necessary to implement the certification program provided for under this bill.
    
15. Requires Medi-Cal reimbursement for peer support specialist services to be implemented only if, and to the extent that, federal financial participation (FFP) under federal Medicaid law is available and all necessary federal approvals have been obtained.
    
16. Permits DHCS, for the purpose of implementing this bill, to enter into exclusive or nonexclusive contracts on a bid or negotiated basis, including contracts for the purpose of obtaining subject matter expertise or other technical assistance.

.

1. Permits DHS to implement, interpret, or make specific the various requirements of this bill by means of informal notices, plan letters, plan or provider bulletins, or similar instructions, without taking regulatory action, until the time regulations are adopted. Requires DHCS to adopt regulations by January 1, 2022, in accordance with the requirements of the Administrative Procedures Act.
   
2. Permits DHCS, to the extent authorized by a specified provision of the Mental Health Services Act (MHSA) and if authorized under the annual Budget Act, in fiscal year (FY) 2020-21, to fund state administrative costs related to developing and administering the peer support specialist certification program. Permits DHCS, subject to an express appropriation in the Budget Act of 2021 for FY 2021-22, and to the extent authorized by specified provision of the MHSA, to fund state administrative costs related to developing and administering the peer support specialist certification program. Requires, to the extent permissible, those funds to be available for purposes of claiming FFP under federal Medicaid law.
   
3. States that this bill does not constitute a change in the MHSA, but is a clarification of a funding purpose under existing law that is consistent with the intent of the MHSA.

EXISTING LAW:

1. Establishes the Medi-Cal program, administered by DHCS, under which qualified low-income individuals receive health care services.
2. Establishes a schedule of benefits under the Medi-Cal program, which includes mental health and SUD services.
   
3. Permits, pursuant to state specialty mental health regulation, Mental Health Services, Day Rehabilitation Services, Day Treatment Intensive Services, Crisis Intervention Services, Targeted Case Management, and Adult Residential Treatment Services to be provided by “any person determined by the county mental health plan (MHP)” to be qualified to provide the service, consistent with state law.
   
4. Requires DHCS to have the sole authority in state government to determine the qualifications, including the appropriate skills, education, training, and experience of personnel working within alcoholism or drug abuse recovery and treatment programs licensed, certified, or funded by DHCS.
5. Requires DHCS, except for licensed professionals, as defined by DHCS, to require that an individual providing counseling services working within alcohol or drug abuse recovery and treatment programs licensed, certified or funded by DHCS to be registered with or certified by a certifying organization approved by the DHCS to register and certify counselors.

FISCAL EFFECT: The current version of this bill, as amended on July 27, 2020, has not been analyzed by a fiscal committee.

COMMENTS:

1. PURPOSE OF THIS BILL. According to the author, the COVID-19 pandemic and subsequent economic downturn pose a serious threat to the mental health of Californians. Calls to the SAMHSA’s disaster distress hotline increased nearly 10 fold from March 2019 to March 2020. The need for mental health response will continue to grow even as the state of emergency subsides. The sharp rise in mental health disorders triggered by COVID-19 is likely to linger long after the end of the pandemic itself, thus highlighting the need for an effective, comprehensive, and economically viable mental health care response. Peer support, recognized as an evidence-based model of care by CMS since 2007, is a cost-effective practice that is proven to reduce hospitalization and homelessness, increase participation in treatment, and service experience. Peer support specialists are self-identified consumers who use their lived experience along with skills learned in formal training to assist others in their own recovery from mental illness. Forty-eight states recognize their value and have a certification process in place or in development for mental health peer support specialists. Despite increase demand for peer services, there remains no statewide scope of practice, training standards, supervision standards, or certification in California. Statewide certification would ensure quality, standardization, and effectiveness of peer support services across California’s 58 counties.
2. BACKGROUND. In 2007 and 2013, CMS provided guidance to states interested in peer support services under the Medicaid program. CMS wrote that states are increasingly interested in covering peer support providers as a distinct provider type for the delivery of counseling and other support services to Medicaid eligible adults with mental illnesses and/or SUDs. CMS stated peer support services are an evidence-based mental health model of care which consists of a qualified peer support provider who assist individuals with their recovery from mental illness and SUD. CMS continued that it recognized that the experiences of peer support providers, as consumers of mental health and SUD services, can be an important component in a state’s delivery of effective treatment. CMS reaffirmed its commitment to state flexibility, increased innovation, consumer choice, self-direction, recovery, and consumer protection through approval of these services. CMS policy guidance includes requirements for supervision, care-coordination, and minimum training criteria for peer support providers.
   
   CMS indicated that, in order to be considered for federal reimbursement, states must identify the Medicaid authority to be used for coverage and payment, describe the service, the provider of the service, and their qualifications in full detail. States must describe utilization review and reimbursement methodologies. CMS stated Medicaid will reimburse for peer support services delivered directly to Medicaid beneficiaries with mental health and/or SUDs. Additionally, reimbursement must be based on an identified unit of service and be provided by one peer support provider, based on an approved plan of care. States must provide an assurance that there are mechanisms in place to prevent over-billing for services, such as prior authorization and other utilization management methods.

CMS established the minimum requirements that should be addressed for supervision, care coordination, and training when electing to provide peer support services, including:

• 1. Supervision: Supervision must be provided by a competent mental health professional (as defined by the State). CMS stated that the amount, duration, and scope of supervision will vary depending on State Practice Acts, the demonstrated competency and experience of the peer support provider, as well as the service mix, and may range from direct oversight to periodic care consultation;
  2. Care-coordination: Peer support services must be coordinated within the context of a comprehensive, individualized plan of care that includes specific individualized goals; and,
  3. Training and credentialing: Peer support providers must complete training and certification as defined by the State. Training must provide peer support providers with a basic set of competencies necessary to perform the peer support function. The peer must demonstrate the ability to support the recovery of others from mental illness and/or SUDs. Similar to other provider types, ongoing continuing educational requirements for peer support providers must be in place.

1. CURRENT USE OF PEERS FOR SUD AND MENTAL HEALTH SERVICES. Peers are used in drug treatment and mental health services in some instances. For example, the DMC-ODS Waiver Special Terms and Conditions (STCs) allows coverage of peer-to-peer substance abuse assistance services as a component of recovery services. DHCS guidance states that, as a component of recovery services, SUD peer support services cannot be reimbursed for any other service modality in the DMC-ODS. Counties utilizing SUD peer support services must comply with all federal Medicaid regulations and policy guidance. Counties are responsible for the development of a SUD Peer Support Training Plan and are to provide a county SUD designation for SUD peer support staff consistent with the requirements outlined in the STCs of the Waiver and in state guidance. Under DHCS guidance for DMC-ODS, peer support can only be billed under the substance abuse assistance component.
   

For Medi-Cal specialty mental health services provided by county MHPs, California’s Medicaid State Plan permits the provision of services by “Other Qualified Providers,” defined as, “an individual at least 18 years of age with a high school diploma or equivalent degree determined to be qualified to provide the service by the county mental health department.” Mental Health Services (excluding Therapy), Targeted Case Management, Day Rehabilitative Services, Day Treatment Intensive Services, Crisis Intervention, Crisis Stabilization, Adult Residential and Crisis Residential Treatment services may be provided by “any person” determined by the MHP to be qualified to provide the service, consistent with state law. State law requires these “Other Qualified Providers” to provide services “under the direction of” a licensed mental health professional within their respective scope of practice. The MHP may designate certain other qualified providers to contribute to the assessment, including gathering the beneficiary’s mental health and medical history, substance exposure and use, and identifying strengths, risks, and barriers to achieving goals. However, outside of the DMC-ODS recovery services, peer support specialist services provided by peer support specialists are not Medi-Cal billable.

1. RECENT AMENDMENTS. To address state mandated costs under Proposition 30 of 2012 and state General Fund (GF) costs for the new proposed benefit, the July 27, 2020 amendments limit the provisions of this bill to county specialty MHPs and to DMC (drug treatment) services in both counties that have implemented a DMC-ODS (37 counties with over 93% of the state’s population) and those that have not. For the peer support specialist services benefit to become in effect in a county under this bill, a county would have to opt into providing the benefit and provide the non-federal share (e.g., the funds used to drawn down federal Medicaid matching funds). Prior versions of this bill and bills introduced and vetoed in prior legislative sessions did not have this county opt in and requirement that counties provide the non-federal share. In addition, prior versions of this bill would have established the peer support specialist services as a benefit in Medi-Cal managed care plans (which have responsibility for what is known as the “mild to moderate” mental health benefit in Medi-Cal managed care plans). Because Proposition 30 requires the state to provide additional GF to cover increased costs for realigned programs, including specialty mental health and DMC services, adding a distinct Medi-Cal provider type and service therefore would have increased GF costs.
2. SUPPORT. This bill is jointly sponsored by the Los Angeles County Board of Supervisors, CHBDA, the California Association of Mental Health Peer Run Organizations, and the Steinberg Institute, which argue that peer providers who use their life experience with mental illness and recovery, coupled with skills learned through formal training, have proven to be a valuable addition to service delivery in mental health settings. The sponsors and supporters argue peer providers use their lived experience with mental illness, addiction, and recovery, coupled with skills learned through formal training to provide invaluable behavioral health services. The sponsors also point out that research demonstrates that peer support specialists reduce hospitalizations and hospital days, improve client functioning, increase client satisfaction, reduce family concerns, alleviate clinical symptoms, and increase client self-advocacy. Across California, peer providers are already utilized in many settings. However, there are no statewide standards of practice, consistent curriculum, training or supervision standards, or certification protocol. They claim that, without the standardization of this profession, California is unable to secure federal approval or Medicaid federal financial support for peer support services. Creating and fortifying California’s peer support specialist workforce through ensuring federal Medicaid assistance is more critical than ever because of the current public health emergency, which is increasing anxiety and trauma experienced by Californians statewide. The number of unexpected deaths, the fear of getting ill, social isolation and economic uncertainty are creating and exacerbating a behavioral health crisis. They conclude that counties need a workforce with experience in successfully navigating their own behavioral health crises to help and support them. Supporters conclude that the ability of peers to connect with those in need and exemplifying the path to recovery and wellness will be vital in the aftermath of the pandemic.
3. OPPOSITION. The California Right to Life Committee (CRLC) writes in opposition that it continue to oppose bills that appeal to the emotion of the citizen but expand the work and reach of the state government. CRLC considers this bill to be one such bill, stating that it is an Orwellian model of the use of science, technology, and human compassion as a means to control all activities of the human person. CRLC argues this bill utilizes the serious COVID-19 condition to further the necessity for mental health counseling without any specific reference to age of the potential needy person. CRLC states this bill is another attempt to broaden the workforce with non-professional persons who would become government employees.
4. PREVIOUS LEGISLATION.
   1. SB 614 (Leno) of 2015 would have required DHCS to establish a program for certifying peer and family support specialists and to collaborate with interested stakeholders and allows DHCS to seek any federal waivers or SPA to implement the certification program. SB 614 was amended into another unrelated subject.
      
   2. SB 906 (Beall) of 2018 was substantially similar to SB 614. SB 906 was vetoed by Governor Brown. In his veto message, Governor Brown wrote that peer support specialists are currently used as providers in Medi-Cal without a state certificate, and that SB 906 imposed a costly new program which will permit some of these individuals to continue providing services but shut others out. Governor Brown urged the stakeholders and DHCS to improve upon the existing framework while allowing all peer support specialists to continue to work.
   3. SB 10 (Beall) of 2019 was substantially similar to SB 906. SB 10 was vetoed by Governor Newsome. In his veto message, Governor Newsom wrote
      
      “Peer support services can play an important role in meeting individuals' behavioral health care needs by pairing those individuals with trained "peers" who offer assistance with navigating local community behavioral health systems and provide needed support. Currently, counties may opt to use peer support services for the delivery of Medicaid specialty mental health services. As the Administration, in partnership with the Legislature and counties, works to transform the state's behavioral health care delivery system, we have an opportunity to more comprehensively include peer support services in these transformation plans. I look forward to working with you on these transformations efforts in the budget process and future legislation, as improving the state of the state's behavioral health system is a critical priority for me.
      
      This proposal comes with significant costs that should be considered in the budget process.
   4. AB 704 (Patterson) of 2018-19 would have required a person, hired by an alcoholism or drug abuse recovery or treatment facility on or after January 1, 2020, who has frequent contact with clients of that alcoholism or drug abuse recovery or treatment facility to be subject to a criminal record review prior to that person’s involvement in the provision of services. A person hired by an alcoholism or drug abuse recovery or treatment facility before January 1, 2020, who has frequent contact with clients of that alcoholism or drug abuse recovery or treatment facility must complete a criminal record review on or before December 31, 2021. AB 704 was held on the Assembly Appropriations Committee suspense file.

Support

California Association of Mental Health Peer Run Organizations (cosponsor)

County Behavioral Health Directors Association of California (cosponsor)

Los Angeles County Board of Supervisors (cosponsor)

Steinberg Institute (cosponsor)

2020 Mom

Alameda County District Attorney’s Office

Association of California Health Care Districts

Bay Area Community Services

Cal Voices

California Access Coalition

California Alliance of Child and Family Services

California Association of Alcohol and Drug Program Executives, Inc.

California Association of Public Hospitals and Health Systems

California Association of Social Rehabilitation Agencies

California Behavioral Health Planning Council

California Chapter of the American College of Emergency Physicians

California Council of Community Behavioral Health Agencies

California Pan-Ethnic Health Network

California Psychiatric Association

California Psychological Association

California Schools Nurses Organization

California State Association of Counties

CaliforniaHealth+ Advocates

Children Now

Children’s Defense Fund – California

Community Research Foundation

County of Ventura

County of Santa Clara

Depression and Biopolar Support Alliance California

Disability Rights California

Juvenile Court Judges of California

Kelechi Ubozoh Consulting

Local Health Plans of California

National Alliance on Mental Illness, California

National Alliance on Mental Illness, Fresno

National Alliance on Mental Illness, Solano

National Association of Social Workers, California Chapter

Occupational Therapy Association of California

Orange County Board of Supervisors

Peers Envisioning and Engaging in Recovery Services

Racial and Ethnic Disparities Mental Health Coalition

Santa Clara Valley Health Plan

Seneca Family of Agencies

The Arc and United Cerebral Palsy California Collaboration

The Children’s Partnership

Transitions-Mental Health Association

Ventura County Board of Supervisors

Western Center on Law & Poverty

Opposition

California Right to Life Committee

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

 THIRD READING 

Bill No: SB 803

Author: Beall (D), et al.

Amended: 6/18/20

Vote: 21

SENATE HEALTH COMMITTEE: 9-0, 5/13/20

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

SENATE APPROPRIATIONS COMMITTEE: 7-0, 6/18/20

AYES: Portantino, Bates, Bradford, Hill, Jones, Leyva, Wieckowski

SUBJECT: Mental health services: peer support specialist certification

SOURCE: California Association of Mental Health Peer Run Organizations

County Behavioral Health Directors Association of California

Los Angeles County Board of Supervisors

Steinberg Institute

DIGEST:

This bill (1) requires the Department of Health Care Services (DHCS) to establish a program for certifying peer support specialists; (2) requires DHCS to amend its Medicaid state plan and to seek any federal waivers or state plan amendments to implement the certification program; and (3) permits DHCS to implement, interpret, and make specific the certification program through available means, as specified, until regulations are adopted.

ANALYSIS:

Existing law:

1. Establishes the Medi-Cal program, administered by DHCS, under which qualified low-income individuals receive health care services. [WIC §14001.1]
2. Grants DHCS the sole authority in state government to determine the qualifications, including the appropriate skills, education, training, and experience of personnel working within substance use disorder (SUD) recovery and treatment programs licensed and/or certified by DHCS. [HSC §11833]
3. Authorizes DHCS to require an individual providing counseling services in SUD programs licensed and/or certified by DHCS to be registered with or certified by a certifying organization (CO) approved by DHCS to register and certify counselors. [HSC §11833]
4. Grants DHCS the authority to conduct periodic reviews of COs to determine compliance with all applicable laws and regulations and to take actions for non-compliance, including revocation of DHCS’s approval. [HSC §11833]
5. Requires, through regulations, the certification of SUD counselors to be based on specific counseling competencies, training, and education, including understanding addiction and knowledge of treatment methods. [CCR, Title 9, Division 4, Chapter 8]

This bill:

1. Requires DHCS, by July 1, 2021, to do all of the following:
   1. Establish a certifying body to certify a peer support specialist (PSS);
   2. Provide for statewide certification of PSS;
   3. Define the range of responsibilities, practice guidelines, and supervision standards for PSS, as specified;
   4. Determine curriculum and core competencies, including areas of specialization for PSS, such as transition-age youth, veterans, gender identity, and sexual orientation, and core competencies that include trauma-informed care, co-occurring mental health and SUDs, preparation for employment opportunities, and navigation of, and referral to, other services;
   5. Specify training requirements, allowing for multiple qualified training entities, and requiring training to include individuals with lived experience as consumers and family members, as well as continuing education requirements for certification;
   6. Establish a code of ethics and processes for investigations and corrective action, as specified;
   7. Determine continuing education for certification renewal; and,
   8. Determine a process for allowing existing personnel employed in the peer support field to obtain certification, as specified.
2. Defines “peers support specialist services” as culturally competent services that promote engagement, socialization, recovery, self-sufficiency, and self-advocacy, and include, but are not limited to, support, coaching, facilitation, or education to Medi-Cal beneficiaries that is individualized to the beneficiary and is conducted by a PSS, as specified.
3. Requires a PSS applicant to, among other requirements, be at least 18 years of age, possess a high school diploma or equivalent degree, be self-identified as having experience with recovery from mental illness or an SUD, adhere to the code of ethics, and successfully complete the curriculum and training and pass the certification examination.
4. Prohibits the PSS certification program to be construed as permitting a PSS to diagnose an illness, prescribe medication, or provide clinical services. Prohibits the PSS certification program from altering the scope of practice for a health care professional, or authorize the delivery of health care services in a setting or manner that is not authorized by existing law.
5. Requires DHCS to consult with the Office of Statewide Health Planning and Development, peer support and family organizations, mental health and SUD treatment providers and organizations, the County Behavioral Health Directors Association of California, the California Behavioral Health Planning Council, and other interested parties in developing, implementing, and administering the PSS certification program, as specified.
6. Permits community health workers to partner with PSS for engagement, outreach, and education in order to facilitate early intervention for mental health services and improve linkage to services.
7. Permits DHCS to use Mental Health Services Act funds to develop and administer the PSS program, subject to an express appropriation in the annual Budget Act, and for the purposes of claiming federal financial participation (FFP), as specified.
8. Requires DHCS to amend its Medicaid state plan to include PSS as a provider type and peer support services as a distinct service type. Requires Medi-Cal reimbursement for PSS services to be implemented only to the extent that FFP is available and all necessary federal approvals have been obtained.
9. Permits DHCS to establish a certification fee schedule to support the activities associated with the ongoing administration of the PSS certification program. Requires any fees charged be reasonable and reflect the expenditures directly applicable to the ongoing administration of the PSS certification program.
10. Requires DHCS, by January 1, 2022, to adopt regulations for the PSS certification program. Permits DHCS to implement, interpret, or make specific the requirements of the PSS certification program through plan letters, plan or provider bulletins, or similar instructions until the time regulations are adopted.

Comments

1. Author’s statement. According to the author, peer support, recognized as an evidence-based model of care by the Centers for Medicare and Medicaid Services (CMS) since 2007, is a cost-effective practice that is proven to reduce hospitalization and homelessness and increase participation in treatment and service experience. Further, it encourages hope, empowerment, and personal advocacy for clients receiving behavioral health services. PSS are self-identified consumers who use their lived experience along with skills learned in formal training to assist others in their own recovery from mental illness. The U.S. Department of Veterans Affairs and 48 states have a certification process in place or in development for mental health PSS. Demand for peer services is growing, but there is no statewide scope of practice, training standards, supervision standards, or certification in California. Statewide certification would ensure quality, standardization, and effectiveness of PSS across California’s 58 counties. Studies demonstrate that use of PSS in a comprehensive mental health or SUD treatment program helps reduce client hospitalizations, improve client functioning, increase client satisfaction, alleviate depression and other symptoms, and diversify the behavioral health workforce. Data shows a clear return on investment when peers are part of the behavioral health system.
2. PSS. According to the federal Substance Abuse and Mental Health Service Administration, a PSS is a person who uses lived experience of recovery from mental illness and/or an SUD, plus skills learned in formal training, to deliver services in behavioral health settings to promote recovery and resiliency. According to DHCS, a substantial number of studies demonstrate that PSS improves patient functioning, increases patient satisfaction, reduces family burden, alleviates depression and other symptoms, reduces hospitalizations and hospital days, increases patient activation, and enhances patient self-advocacy. PSS are used in more than 40 states and throughout the Veterans Health Administration. PSS participating in SUD treatment activities are currently a recognized Medicaid service provider in California for SUD services; however, these providers are often limited in the services they are able to provide in traditional health care settings. DHCS states that expanded use of PSS in mental health and SUD as part of a care team can improve care coordination between behavioral health and physical health care needs of patients. DHCS included PSS as a component in the 2015 Section 1115 Waiver renewal, known as Medi-Cal 2020 and expires in 2020, by providing financial incentives to managed care plans to support non-physician community providers, promoting both physical and behavioral health care integration, and team-based care. DHCS states that peer support services defined in this bill appear to align with allowable service activities under the existing Specialty Mental Health Services (SMHS) waiver. DHCS also states that it is in the process of developing its waiver renewals but does not plan on making changes to the definition of “other qualified providers.”
3. PSS certification. CMS released guidance in 2007 and further clarification in 2013 for establishing a PSS certification program to enable FFP in an effort to more fully incorporate and expand the use of peers. CMS requires peer support providers to complete training and certification as defined by each state, and specified that services can be offered for mental illness and/or SUDs. Substantive work has been conducted in California by the Working Well Together Statewide Technical Assistance Center, a collaborative of peer and client-oriented organizations, which culminated in a final report of recommendations to proceed with peer certification. This effort identified key issues for laying the foundation of certification, including training recommendations and core components for a statewide certification program; establishing a standard of practice and core competencies; defining the level of care and services; integrating services across physical health, mental health, and SUD services; and allowing for portability from one county to another.
4. DHCS current certification duties. DHCS ensures that registered and certified SUD counselors provide quality treatment to clients by enforcing counselor certification regulations. DHCS approves COs that register and certify SUD counselors who provide counseling services in an SUD program licensed or certified by DHCS. There are approximately 28,000 SUD counselors, of which roughly half are certified and half are registered while working towards certification. DHCS’s oversight authority of COs includes periodic reviews of the COs to monitor adherence to state requirements.

Related/Prior Legislation

SB 10 (Beall, 2019), SB 906 (Beall, 2018), and SB 614 (Leno, 2015) were identical to this bill. SB 10 was vetoed by Governor Newsom who stated that counties may currently opt to use PSS for the delivery of Medicaid SMHS and as the state works to transform the behavioral health care delivery system, we have an opportunity to more comprehensively include PSS in these transformation plans. SB 906 was vetoed by Governor Brown who stated PSS are currently used as providers in Medi-Cal without a state certificate, and SB 906 would have imposed a costly new program, which would have permitted some individuals to continue providing services but shut others out. Governor Brown urged stakeholders and DHCS to improve upon the existing framework while allowing all PSS to continue to work. SB 614 was amended on August 18, 2016, on the Assembly Floor to a new purpose.

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

According to the Senate Appropriations Committee, ongoing costs (mid-/high hundreds of thousands to low millions per year) for DHCS to manage program certification (General Fund, federal funds, or Mental Health Services Act); to establish the certifying body, either through contract or interagency agreement; and to provide a peer support specialist as a specific provider type and service.

• One-time costs hundreds of thousands per year for one to three years) for DHCS to develop program standards and seek federal approvals (GF, FF, MHSA).
• Uncertain impact on county mental health plans that provide specialty mental health services in the Medi-Cal program (county funds, FF).
• Unknown but potentially significant cost-avoidance and long-term savings to state public health systems and public health to the extent that peer support services provide support and assistance to Medi-Cal beneficiaries with mental illness and reduce the need for more expensive downstream services, such as inpatient hospitalizations.

Staff notes the certification fee schedule would offset state operations and administrative costs, but may not capture all Medi-Cal costs to establish a peer support specialist as a specific provider type and service.

SUPPORT: (Verified 6/17/20)

California Association of Mental Health Peer Run Organizations (co-source)

County Behavioral Health Directors Association of California (co-source)

Los Angeles County Board of Supervisors (co-source)

Steinberg Institute (co-source)

ACCESS California

Alameda County District Attorney Nancy E. O’Malley

Alum Rock Counseling Center

American Foundation for Suicide Prevention

Association of California Healthcare Districts

Cal Voices

California Alliance of Child and Family Services

California Association of Local Behavioral Health Boards and Commissions

California Association of Public Hospitals and Health Systems

California Association of Veteran Service Agencies

California Behavioral Health Planning Council

California Consortium of Addiction Programs and Professionals

California Council of Community Behavioral Health Agencies

California Pan-Ethnic Health Network

California Psychiatric Association

California Psychological Association

California School Nurses Organization

California State Council of the Service Employees International Union

California Youth Empowerment Network

Children Now

County of Santa Clara

County of Ventura

Crestwood Behavioral Health Inc.

Depression and Bipolar Support Alliance

Disability Rights California

Mental Health America of Los Angeles

NAMI

Solano County Mental Health Advisory Board

Western Center on Law and Poverty

OPPOSITION: (Verified 6/17/20)

None received

ARGUMENTS IN SUPPORT: The co-sponsors of this bill and other supporters, largely behavioral health providers and advocates, state that peer providers use their lived experience with mental illness, addiction, and recovery, coupled with skills learned through formal training to provide invaluable behavioral health services. Research demonstrates that PSS reduce hospitalizations and hospital days, improve client functioning, increase client satisfaction, reduce family concerns, alleviate clinical symptoms, and increase client self-advocacy. The County Behavioral Health Directors Association of California states that, for example, in Texas one long-term study focusing on SUD peer specialists, also called recovery coaches, found health care utilization dropped after 12 months of recovery coaching: outpatient visits dropped to 815 visits from 4,118 at enrollment; inpatient care days dropped to 1,117 days from 9,082 at enrollment; and, emergency room visits dropped to 146 from 426 at enrollment. In total, recovery coaching saved $3,422,632 in health care costs, representing a 72% reduction in costs over 12 months. Supporters argue that creating and fortifying California’s PSS workforce through ensuring federal Medicaid assistance is more critical than ever because of the current public health emergency, which is increasing anxiety and trauma experienced statewide. The number of unexpected deaths, the fear of getting ill, social isolation, and economic uncertainty are creating and exacerbating a behavioral health crisis, and Californians need a workforce with experience in successfully navigating their own behavioral health crises to help and support them.

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

6/23/20 17:13:31

**** END ****

SENATE COMMITTEE ON APPROPRIATIONS

Senator Anthony Portantino, Chair

2019 - 2020 Regular Session

SB 803 (Beall) - Mental health services: peer support specialist certification

Bill Summary:

Senate Bill 803 would require the Department of Health Care Services (DHCS), no later than July 1, 2021, to establish a certifying body, either through contract or interagency agreement, to provide a statewide certification for peer support specialists, as specified, and develop practice guidelines for peer support specialists. Would require DHCS to amend its Medicaid state plan and to seek any federal waivers or state plan amendments to implement the certification program.

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

The following information is revised to reflect amendments

adopted by the committee on June 18, 2020

Fiscal Impact:

• Ongoing costs (mid-/high hundreds of thousands to low millions per year) for DHCS to manage program certification (General Fund, federal funds, or Mental Health Services Act); to establish the certifying body, either through contract or interagency agreement; and to provide a peer support specialist as a specific provider type and service.
• One-time costs hundreds of thousands per year for one to three years) for DHCS to develop program standards and seek federal approvals (GF, FF, MHSA).
• Uncertain impact on county mental health plans that provide specialty mental health services in the Medi-Cal program (county funds, FF).
• Unknown but potentially significant cost-avoidance and long-term savings to state public health systems and public health to the extent that peer support services provide support and assistance to Medi-Cal beneficiaries with mental illness and reduce the need for more expensive downstream services, such as inpatient hospitalizations.

Staff notes the certification fee schedule would offset state operations and administrative costs, but may not capture all Medi-Cal costs that would be incurred to establish a peer support specialist as a specific provider type and service.

Author Amendments:

The author’s amendments would authorize DHCS to establish a certification fee schedule to support administrative costs, and would require the fees charged by DHCS to reasonably reflect the administrative expenditures.

-- END --

SENATE COMMITTEE ON

Senator Anthony Portantino, Chair

2019 - 2020 Regular Session

SB 803 (Beall) - Mental health services: peer support specialist certification

Bill Summary:

Senate Bill 803 would require the Department of Health Care Services (DHCS), no later than July 1, 2021, to establish a certifying body, either through contract or interagency agreement, to provide a statewide certification for peer support specialists, as specified, and develop practice guidelines for peer support specialists. Would require DHCS to amend its Medicaid state plan and to seek any federal waivers or state plan amendments to implement the certification program.

Fiscal Impact:

The committee reviewed substantively similar bills in recent past, including SB 10 (2019) and SB 906 (2018). The Department of Finance provided fiscal analyses on similar versions of this bill, which are discussed in Staff Comments.

• Ongoing costs (range from mid-hundreds of thousands to low millions per year) for DHCS to manage the certification of the program (Mental Health Service Act funds, General Fund, federal funds, or special funds) and for costs to establish the certifying body.
• One-time costs, likely in the hundreds of thousands per year for one to three years, to develop program standards and seek federal approvals by DHCS (General Fund, Mental Health Services Act funds, and federal funds).
• Uncertain impact on county mental health plans that provide specialty mental health services in the Medi-Cal program (county funds and federal funds).
• Unknown but potentially significant cost-avoidance and long-term savings to state public health systems and public health to the extent that peer support services provide support and assistance to Medi-Cal beneficiaries with mental illness and reduce the need for more expensive downstream services, such as inpatient hospitalizations.

Staff notes unlike prior versions, this bill does not include the authorization for DHCS to establish a certification fee schedule to support administration and enforcement costs, which would assist in offsetting state operations costs.

Background:

The DHCS operates the Medi-Cal program, which provides health care coverage to income-eligible individuals, families, and children. Medi-Cal also provides coverage to childless adults and parents with household incomes up to 138 percent of the federal poverty level (FPL), and to children with household incomes up to 266 percent of the FPL. The federal government provides matching funds that vary from 50 percent to 90 percent of expenditures depending on the category of beneficiary. Medi-Cal managed care plans provide services to beneficiaries with mild mental illness; county mental health plans serve beneficiaries with moderate to severe mental illness.

Federal law allows states to include peer and family support specialists to provide services in state Medicaid programs, provided that PFSS are certified in that state. In California, PFSS are an eligible service provider for substance use disorder services, but not for mental health services.

DHCS ensures that registered and certified substance use disorder (SUD) counselors provide quality treatment to clients by enforcing counselor certification regulations. DHCS approves certifying organizations (CO) that register and certify SUD counselors who provide counseling services in an SUD program licensed or certified by DHCS. According to last year’s estimate, there were approximately 28,000 SUD counselors, of which roughly half are certified and half are registered while working towards certification.

Proposed Law:

SB 803 would require the DHCS, no later than, July 1, 2020, to establish a certifying body, either through contract or interagency agreement, and provide a statewide certification for peer support specialists, as specified. In addition, the bill would require DHCS to:

• • Define a range of responsibilities and practice guidelines for peer support specialists, determine curriculum and core competencies required for certification, and determine continuing education requirements for biennial certification renewal;
  • Determine a process for complaint investigation and corrective action, which may include suspension and certification revocation; and,
  • Determine a process for an individual employed as a peer support specialist on January 1, 2021, to obtain certification.

Minimum Qualifications. The bill establishes minimum requirements for an individual to be certified as a peer support specialist.

Medicaid State Plan. The bill requires DHCS to amend its state plan to include peer support specialist as a provider type, as specified; and, to include peer support specialist services as a distinct services, which may be provided to eligible Medi-Cal beneficiaries enrolled in a managed care plan or a mental health plan. The bill authorizes DHCS to seek any federal waivers or other state plan amendments to implement the certification program, as proposed by this bill.

Federal Financial Participation. The bill provides that Medi-Cal reimbursement for peer support specialist services must be implemented only if federal financial participation is available and all necessary federal approvals have been obtained.

Consultation with stakeholders. The bill requires DHCS to consult with the Office of Statewide Health Planning and Development (OSHPD) and other specified stakeholders in implementing the bill. Consultation must initially include, at a minimum, quarterly stakeholder meetings. DHCS may additionally conduct technical workgroups upon the request of stakeholders.

Other. The bill provides that the statute is not intended to be construed to imply that an individual who is certified is qualified to, or authorized to diagnose an illness, prescribe medication, or provide clinic services. The bill also provides that it does not alter scope of practice for a healthcare professional or delivery of healthcare services in a setting or unauthorized manner.

Related Legislation:

• SB 10 (Beall, 2019) and SB 906 (Beall, 2018) are nearly identical to this bill and were vetoed. The Governor’s veto message of SB 10 noted:

Peer support services can play an important role in meeting individuals’ behavioral health care needs… I look forward to working with you on these transformations efforts in the budget process and future legislation, as improving the state of the state's behavioral health system is a critical priority for me.

This proposal comes with significant costs that should be considered in the budget process.

Staff Comments:

The Legislature considered SB 10 (Beall, 2019) and SB 906 (Beall, 2018) last year. The Department of Finance’s August 8, 2019, analysis of SB 10 estimated costs to be $2.8 million ($1.4 million General Fund) in FY 2019-20 for 15 positions, and $6.4 million ($3.2 million General Fund) in FY 2020-21, and ongoing, to develop certification standards and seek necessary program approvals. In addition, the DOF analysis noted, “By establishing a distinct Medi-Cal provider type and service, the bill increases General Fund costs to the counties purposes to Proposition 30. To the extent counties are choosing to use the non-federal share of these services, the bill results in county savings.”

-- END --

SENATE COMMITTEE ON HEALTH

Senator Dr. Richard Pan, Chair

BILL NO: SB 803

SUBJECT: Mental health services: peer support specialist certification

SUMMARY:

Requires the Department of Health Care Services (DHCS) to establish a program for certifying peer support specialists; requires DHCS to amend its Medicaid state plan and to seek any federal waivers or state plan amendments to implement the certification program; and permits DHCS to implement, interpret, and make specific the certification program through available means, as specified, until regulations are adopted.

Existing law:

1. Establishes the Medi-Cal program, administered by DHCS, under which qualified low-income individuals receive health care services. [WIC §14001.1]
2. Grants DHCS the sole authority in state government to determine the qualifications, including the appropriate skills, education, training, and experience of personnel working within substance use disorder (SUD) recovery and treatment programs licensed and/or certified by DHCS. [HSC §11833]
3. Authorizes DHCS to require an individual providing counseling services in SUD programs licensed and/or certified by DHCS to be registered with or certified by a certifying organization (CO) approved by DHCS to register and certify counselors. [HSC §11833]
4. Grants DHCS the authority to conduct periodic reviews of COs to determine compliance with all applicable laws and regulations and to take actions for non-compliance, including revocation of DHCS’s approval. [HSC §11833]
5. Requires, through regulations, the certification of SUD counselors to be based on specific counseling competencies, training, and education, including understanding addiction and knowledge of treatment methods. [CCR, Title 9, Division 4, Chapter 8]

This bill:

1. Requires DHCS, by July 1, 2021, to do all of the following:
2. Establish a certifying body to certify a PSS;
3. Provide for statewide certification of PSS;
4. Define the range of responsibilities, practice guidelines, and supervision standards for PSS, as specified;
5. Determine curriculum and core competencies, including areas of specialization for PSS, such as transition-age youth, veterans, gender identity, and sexual orientation, and core competencies that include trauma-informed care, co-occurring mental health and SUDs, preparation for employment opportunities, and navigation of, and referral to, other services;
6. Specify training requirements, allowing for multiple qualified training entities, and requiring training to include individuals with lived experience as consumers and family members, as well as continuing education requirements for certification;
7. Establish a code of ethics and processes for investigations and corrective action, as specified;
8. Determine continuing education for certification renewal; and,
9. Determine a process for allowing existing personnel employed in the peer support field to obtain certification, as specified.
10. Defines “peers support specialist services” as culturally competent services that promote engagement, socialization, recovery, self-sufficiency, and self-advocacy, and include, but are not limited to, support, coaching, facilitation, or education to Medi-Cal beneficiaries that is individualized to the beneficiary and is conducted by a PSS, as specified.
11. Requires a PSS applicant to, among other requirements, be at least 18 years of age, possess a high school diploma or equivalent degree, be self-identified as having experience with recovery from mental illness or an SUD, adhere to the code of ethics, and successfully complete the curriculum and training and pass the certification examination.
12. Prohibits the PSS certification program to be construed as permitting a PSS to diagnose an illness, prescribe medication, or provide clinical services. Prohibits the PSS certification program from altering the scope of practice for a health care professional, or authorize the delivery of health care services in a setting or manner that is not authorized by existing law.
13. Requires DHCS to consult with the Office of Statewide Health Planning and Development (OSHPD), peer support and family organizations, mental health and SUD treatment providers and organizations, the County Behavioral Health Directors Association of California, the California Behavioral Health Planning Council, and other interested parties in developing, implementing, and administering the PSS certification program, as specified.
14. Requires DHCS to amend its Medicaid state plan to include PSS as a provider type and include PSS services as a distinct service type, as specified. Permits DHCS to seek any federal waivers or other state plan amendments as necessary to implement the PSS certification program.
15. Permits community health workers to partner with PSS for engagement, outreach, and education in order to facilitate early intervention for mental health services and improve linkage to services.
16. Permits DHCS to use Mental Health Services Act funds to develop and administer the PSS program, subject to an express appropriation in the annual Budget Act, and for the purposes of claiming Federal financial participation (FFP), as specified.
17. Requires DHCS to amend its Medicaid state plan to include PSS as a provider type and peer support services as a distinct service type. Requires Medi-Cal reimbursement for PSS services to be implemented only to the extent that FFP is available and all necessary federal approvals have been obtained.
18. Permits DHCS to establish a certification fee schedule to support the activities associated with the ongoing administration of the PSS certification program. Requires any fees charged be reasonable and reflect the expenditures directly applicable to the ongoing administration of the PSS certification program.
19. Requires DHCS, by January 1, 2022, to adopt regulations for the PSS certification program. Permits DHCS to implement, interpret, or make specific the requirements of the PSS certification program through plan letters, plan or provider bulletins, or similar instructions until the time regulations are adopted.

FISCAL EFFECT:

This bill has not been analyzed by a fiscal committee.

COMMENTS:

1. Author’s statement. According to the author, peer support, recognized as an evidence-based model of care by the Centers for Medicare and Medicaid Services (CMS) since 2007, is a cost-effective practice that is proven to reduce hospitalization and homelessness and increase participation in treatment and service experience. Further, it encourages hope, empowerment, and personal advocacy for clients receiving behavioral health services. PSS are self-identified consumers who use their lived experience along with skills learned in formal training to assist others in their own recovery from mental illness. The U.S. Department of Veterans Affairs and 48 states have a certification process in place or in development for mental health PSS. Demand for peer services is growing, but there is no statewide scope of practice, training standards, supervision standards, or certification in California. Statewide certification would ensure quality, standardization, and effectiveness of PSS across California’s 58 counties. Studies demonstrate that use of PSS in a comprehensive mental health or SUD treatment program helps reduce client hospitalizations, improve client functioning, increase client satisfaction, alleviate depression and other symptoms, and diversify the behavioral health workforce. Data shows a clear return on investment when peers are part of the behavioral health system.
2. PSS. According to the federal Substance Abuse and Mental Health Service Administration, a PSS is a person who uses lived experience of recovery from mental illness and/or an SUD, plus skills learned in formal training, to deliver services in behavioral health settings to promote recovery and resiliency. According to DHCS, a substantial number of studies demonstrate that PSS improves patient functioning, increases patient satisfaction, reduces family burden, alleviates depression and other symptoms, reduces hospitalizations and hospital days, increases patient activation, and enhances patient self-advocacy. PSS are used in more than 40 states and throughout the Veterans Health Administration. PSS participating in SUD treatment activities are currently a recognized Medicaid service provider in California for SUD services; however, these providers are often limited in the services they are able to provide in traditional health care settings. DHCS states that expanded use of PSS in mental health and SUD as part of a care team can improve care coordination between behavioral health and physical health care needs of patients. DHCS included PSS as a component in the 2015 Section 1115 Waiver renewal, known as Medi-Cal 2020 and expires in 2020, by providing financial incentives to managed care plans to support non-physician community providers, promoting both physical and behavioral health care integration, and team-based care. DHCS states that peer support services defined in this bill appear to align with allowable service activities under the existing Specialty Mental Health Services (SMHS) waiver. DHCS also states that it is in the process of developing its waiver renewals but does not plan on making changes to the definition of “other qualified providers.”
3. PSS certification. CMS released guidance in 2007 and further clarification in 2013 for establishing a PSS certification program to enable FFP in an effort to more fully incorporate and expand the use of peers. CMS requires peer support providers to complete training and certification as defined by each state, and specified that services can be offered for mental illness and/or SUDs. Substantive work has been conducted in California by the Working Well Together Statewide Technical Assistance Center, a collaborative of peer and client-oriented organizations, which culminated in a final report of recommendations to proceed with peer certification. This effort identified key issues for laying the foundation of certification, including training recommendations and core components for a statewide certification program; establishing a standard of practice and core competencies; defining the level of care and services; integrating services across physical health, mental health, and SUD services; and allowing for portability from one county to another.
4. DHCS current certification duties. DHCS ensures that registered and certified SUD counselors provide quality treatment to clients by enforcing counselor certification regulations. DHCS approves COs that register and certify SUD counselors who provide counseling services in an SUD program licensed or certified by DHCS. There are approximately 28,000 SUD counselors, of which roughly half are certified and half are registered while working towards certification. DHCS’s oversight authority of COs includes periodic reviews of the COs to monitor adherence to state requirements.
5. Prior legislation. SB 10 (Beall of 2019), SB 906 (Beall of 2018), and SB 614 (Leno of 2015) were identical to this bill. SB 10 was vetoed by Governor Newsom who stated that counties may currently opt to use PSS for the delivery of Medicaid SMHS and as the state works to transform the behavioral health care delivery system, we have an opportunity to more comprehensively include PSS in these transformation plans. SB 906 was vetoed by Governor Brown who stated PSS are currently used as providers in Medi-Cal without a state certificate, and SB 906 would have imposed a costly new program, which would have permitted some individuals to continue providing services but shut others out. Governor Brown urged stakeholders and DHCS to improve upon the existing framework while allowing all PSS to continue to work. SB 614 was amended on August 18, 2016, on the Assembly Floor to a new purpose.
6. Support. The co-sponsors of this bill and other supporters, largely behavioral health providers and advocates, state that peer providers use their lived experience with mental illness, addiction, and recovery, coupled with skills learned through formal training to provide invaluable behavioral health services. Research demonstrates that PSS reduce hospitalizations and hospital days, improve client functioning, increase client satisfaction, reduce family concerns, alleviate clinical symptoms, and increase client self-advocacy. The County Behavioral Health Directors Association states that, for example, in Texas one long-term study focusing on SUD peer specialists, also called recovery coaches, found health care utilization dropped after 12 months of recovery coaching: outpatient visits dropped to 815 visits from 4,118 at enrollment; inpatient care days dropped to 1,117 days from 9,082 at enrollment; and, emergency room visits dropped to 146 from 426 at enrollment. In total, recovery coaching saved $3,422,632 in health care costs, representing a 72% reduction in costs over 12 months. Supporters argue that creating and fortifying California’s PSS workforce through ensuring federal Medicaid assistance is more critical than ever because of the current public health emergency, which is increasing anxiety and trauma experienced statewide. The number of unexpected deaths, the fear of getting ill, social isolation, and economic uncertainty are creating and exacerbating a behavioral health crisis, and Californians need a workforce with experience in successfully navigating their own behavioral health crises to help and support them.
7. Support with amendments. The California Consortium of Addiction Program and Professionals (CCAPP) supports the concept of certifying PSS but is concerned that this bill may face issues with implementation during the pandemic and an uphill climb with regard to financing a new state regulatory entity that would issue individual professional credentials. CCAPP suggest some amendments to add PSS to the types of credentials that current DHCS-approved CO’s for SUD counselors may issue. CCAPP states that in doing so California could increase this vital resource, protect consumers, and provide career ladder opportunities for this workforce (regardless of the impact of the pandemic).

SUPPORT AND OPPOSITION:

Support: California Association of Mental Health Peer Run Organizations (co-sponsor)

County Behavioral Health Directors Association of California (co-sponsor)

Los Angeles County Board of Supervisors (co-sponsor)

Steinberg Institute (co-sponsor)

ACCESS California

Alum Rock Counseling Center

American Foundation for Suicide Prevention

Cal Voices

California Alliance of Child and Family Services

California Association of Local Behavioral Health Boards and Commissions

California Association of Public Hospitals and Health Systems

California Association of Veteran Service Agencies

California Behavioral Health Planning Council

California Council of Community Behavioral Health Agencies

California Pan-Ethnic Health Network

California Psychological Association

California School Nurses Organization

Children Now

County of Santa Clara

Crestwood Behavioral Health Inc.

Depression and Bipolar Support Alliance

Disability Rights California

District Attorney Nancy E. O’Malley, Alameda County

Mental Health America of Los Angeles

Solano County Mental Health Advisory Board

Western Center on Law and Poverty

Oppose: None received

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