Existing law, the Lanterman-Petris-Short Act, provides for the involuntary commitment and treatment of a person who is a danger to themselves or others or who is gravely disabled, as defined.

Existing law provides for the Medi-Cal program, which is administered by the State Department of Health Care Services, under which qualified low-income individuals receive health care services. The Medi-Cal program is, in part, governed and funded by federal Medicaid program provisions. Pursuant to a schedule of covered benefits, existing law requires Medi-Cal coverage for inpatient hospital services, subject to utilization controls, and with respect to fee-for service beneficiaries, coverage for emergency services and care necessary for the treatment of an emergency medical condition and medical care directly related to the emergency medical condition, as specified.

Existing law provides for the licensing and regulation of health facilities by the State Department of Public Health and makes a violation of those provisions a crime. Existing law defines psychiatric emergency medical condition, for purposes of providing treatment for emergency conditions, as a mental disorder that manifests itself by acute symptoms of sufficient severity that it renders the patient as being either an immediate danger to the patient or to others, or immediately unable to provide for, or utilize, food, shelter, or clothing, due to the mental disorder. Existing law includes various circumstances under which a patient is required to be treated by, or may be transferred to, specified health facilities for treatment that is solely necessary to relieve or eliminate a psychiatric emergency medical condition.

This bill would revise the definition of psychiatric emergency medical condition to make that definition applicable regardless of whether the patient is voluntary, or is involuntarily detained for assessment, evaluation, and crisis intervention, or placement for evaluation and treatment, under prescribed circumstances. The bill would make conforming and clarifying changes to provisions requiring facilities to provide that treatment. By expanding the definition of a crime with respect to those facilities, the bill would impose a state-mandated local program.

The bill would require the Medi-Cal program to cover emergency services and care necessary to treat an emergency medical condition, as defined, including poststabilization care services required under specified federal law, emergency room professional services, and facility charges for emergency room visits.

The bill would require coverage for emergency services necessary to relieve or eliminate a psychiatric emergency medical condition, regardless of whether the beneficiary is voluntary, or involuntarily detained for assessment, evaluation, and crisis intervention, or placement for evaluation and treatment, as specified. The bill would require a Medi-Cal managed care plan, as defined, to be responsible for covering, and reimbursing providers for furnishing, those emergency services and care. The bill would specify that those requirements do not limit or reduce the scope of covered emergency services and care for fee-for-service beneficiaries, as described in the bill.

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

This bill would provide that no reimbursement is required by this act for a specified reason.

Existing law, the Lanterman-Petris-Short Act, provides for the involuntary commitment and treatment of a person who is a danger to themselves or others or who is gravely disabled, as defined.

Existing law provides for the Medi-Cal program, which is administered by the State Department of Health Care Services, under which qualified low-income individuals receive health care services. The Medi-Cal program is, in part, governed and funded by federal Medicaid program provisions. Pursuant to a schedule of covered benefits, existing law requires Medi-Cal coverage for inpatient hospital services, subject to utilization controls, and with respect to fee-for service beneficiaries, coverage for emergency services and care necessary for the treatment of an emergency medical condition and medical care directly related to the emergency medical condition, as specified.

Existing law provides for the licensing and regulation of health facilities by the State Department of Public Health and makes a violation of those provisions a crime. Existing law defines psychiatric emergency medical condition, for purposes of providing treatment for emergency conditions, as a mental disorder that manifests itself by acute symptoms of sufficient severity that it renders the patient as being either an immediate danger to the patient or to others, or immediately unable to provide for, or utilize, food, shelter, or clothing, due to the mental disorder. Existing law includes various circumstances under which a patient is required to be treated by, or may be transferred to, specified health facilities for treatment that is solely necessary to relieve or eliminate a psychiatric emergency medical condition.

This bill would revise the definition of psychiatric emergency medical condition to make that definition applicable regardless of whether the patient is voluntary, or is involuntarily detained for assessment, evaluation, and crisis intervention, or placement for evaluation and treatment, under prescribed circumstances. The bill would make conforming and clarifying changes to provisions requiring facilities to provide that treatment. By expanding the definition of a crime with respect to those facilities, the bill would impose a state-mandated local program.

The bill would require the Medi-Cal program to cover emergency services and care necessary to treat an emergency medical condition, as defined, including poststabilization care services required under specified federal law, emergency room professional services, and facility charges for emergency room visits.

The bill would require coverage for emergency services necessary to relieve or eliminate a psychiatric emergency medical condition, regardless of whether the beneficiary is voluntary, or involuntarily detained for assessment, evaluation, and crisis intervention, or placement for evaluation and treatment, as specified. The bill would require a Medi-Cal managed care plan, as defined, to be responsible for covering, and reimbursing providers for furnishing, those emergency services and care. The bill would specify that those requirements do not limit or reduce the scope of covered emergency services and care for fee-for-service beneficiaries, as described in the bill.

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

This bill would provide that no reimbursement is required by this act for a specified reason.

Existing law, the Lanterman-Petris-Short Act, provides for the involuntary commitment and treatment of a person who is a danger to themselves or others or who is gravely disabled, as defined.

Existing law provides for the Medi-Cal program, which is administered by the State Department of Health Care Services, under which qualified low-income individuals receive health care services. The Medi-Cal program is, in part, governed and funded by federal Medicaid program provisions. Pursuant to a schedule of covered benefits, existing law requires Medi-Cal coverage for inpatient hospital services, subject to utilization controls, and with respect to fee-for service beneficiaries, coverage for emergency services and care necessary for the treatment of an emergency medical condition and medical care directly related to the emergency medical condition, as specified.

Existing law provides for the licensing and regulation of health facilities by the State Department of Public Health and makes a violation of those provisions a crime. Existing law defines psychiatric emergency medical condition, for purposes of providing treatment for emergency conditions, as a mental disorder that manifests itself by acute symptoms of sufficient severity that it renders the patient as being either an immediate danger to the patient or to others, or immediately unable to provide for, or utilize, food, shelter, or clothing, due to the mental disorder. Existing law includes various circumstances under which a patient is required to be treated by, or may be transferred to, specified health facilities for treatment that is solely necessary to relieve or eliminate a psychiatric emergency medical condition.

This bill would revise the definition of psychiatric emergency medical condition to make that definition applicable regardless of whether the patient is voluntary, or is involuntarily detained for assessment, evaluation, and crisis intervention, or placement for evaluation and treatment, under prescribed circumstances. The bill would make conforming and clarifying changes to provisions requiring facilities to provide that treatment. By expanding the definition of a crime with respect to those facilities, the bill would impose a state-mandated local program.

The bill would require the Medi-Cal program to cover emergency services and care necessary to treat an emergency medical condition, as defined, including all professional physical, mental, and substance use treatment services, including screening examinations necessary to determine the presence or absence of an emergency medical condition and, if an emergency medical condition exists, all services medically necessary to stabilize the beneficiary. poststabilization care services required under specified federal law, emergency room professional services, and facility charges for emergency room visits.

The bill would require coverage for emergency services necessary to relieve or eliminate a psychiatric emergency medical condition, regardless of duration, or whether the beneficiary is voluntary, or involuntarily detained for assessment, evaluation, and crisis intervention, or placement for evaluation and treatment, as specified. The bill would require a Medi-Cal managed care plan, as defined, to be responsible for covering, and reimbursing providers for furnishing, those emergency services and care, as specified. care. The bill would specify that those requirements do not limit or reduce the scope of covered emergency services and care for fee-for-service beneficiaries, as described in the bill.

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

This bill would provide that no reimbursement is required by this act for a specified reason.

Existing law, the Lanterman-Petris-Short Act, provides for the involuntary commitment and treatment of a person who is a danger to themselves or others or who is gravely disabled, as defined.

Existing law provides for the Medi-Cal program, which is administered by the State Department of Health Care Services, under which qualified low-income individuals receive health care services. The Medi-Cal program is, in part, governed and funded by federal Medicaid program provisions. Pursuant to a schedule of covered benefits, existing law requires Medi-Cal coverage for inpatient hospital services, subject to utilization controls, and with respect to fee-for service beneficiaries, coverage for emergency services and care necessary for the treatment of an emergency medical condition and medical care directly related to the emergency medical condition, as specified.

Existing law provides for the licensing and regulation of health facilities by the State Department of Public Health and makes a violation of those provisions a crime. Existing law defines psychiatric emergency medical condition, for purposes of providing treatment for emergency conditions, as a mental disorder that manifests itself by acute symptoms of sufficient severity that it renders the patient as being either an immediate danger to the patient or to others, or immediately unable to provide for, or utilize, food, shelter, or clothing, due to the mental disorder. Existing law includes various circumstances under which a patient is required to be treated by, or may be transferred to, specified health facilities for treatment that is solely necessary to relieve or eliminate a psychiatric emergency medical condition.

This bill would revise the definition of psychiatric emergency medical condition to make that definition applicable regardless of whether the patient is voluntary, or is involuntarily detained for evaluation and treatment, under prescribed circumstances. The bill would make conforming changes to provisions requiring facilities to provide that treatment. By expanding the definition of a crime with respect to those facilities, the bill would impose a state-mandated local program.

The bill would require the Medi-Cal program to cover emergency services and care necessary to treat an emergency medical condition, as defined, including all professional physical, mental, and substance use treatment services, including screening examinations necessary to determine the presence or absence of an emergency medical condition and, if an emergency medical condition exists, all services medically necessary to stabilize the beneficiary.

The bill would require coverage for emergency services necessary to relieve or eliminate a psychiatric emergency medical condition, regardless of duration, or whether the beneficiary is voluntary, or involuntarily detained for evaluation and treatment, as specified. The bill would require a Medi-Cal managed care plan, as defined, to be responsible for covering, and reimbursing providers for furnishing, those emergency services and care, as specified.

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

This bill would provide that no reimbursement is required by this act for a specified reason.

Existing law, the Lanterman-Petris-Short Act, provides for the involuntary commitment and treatment of a person who is a danger to themselves or others or who is gravely disabled, as defined.

Existing law provides for the Medi-Cal program, which is administered by the State Department of Health Care Services, under which qualified low-income individuals receive health care services. The Medi-Cal program is, in part, governed and funded by federal Medicaid program provisions. Pursuant to a schedule of covered benefits, existing law requires Medi-Cal coverage for inpatient hospital services, subject to utilization controls, and with respect to fee-for service beneficiaries, coverage for emergency services and care necessary for the treatment of an emergency medical condition and medical care directly related to the emergency medical condition, as specified.

Existing law provides for the licensing and regulation of health facilities by the State Department of Public Health and makes a violation of those provisions a crime. Existing law defines psychiatric emergency medical condition, for purposes of providing treatment for emergency conditions, as a mental disorder that manifests itself by acute symptoms of sufficient severity that it renders the patient as being either an immediate danger to the patient or to others, or immediately unable to provide for, or utilize, food, shelter, or clothing, due to the mental disorder. Existing law includes various circumstances under which a patient is required to be treated by, or may be transferred to, specified health facilities for treatment that is solely necessary to relieve or eliminate a psychiatric emergency medical condition.

This bill would revise the definition of psychiatric emergency medical condition to make that definition applicable regardless of whether the patient is voluntary, or is involuntarily detained for evaluation and treatment, under prescribed circumstances. The bill would make conforming changes to provisions requiring facilities to provide that treatment. By expanding the definition of a crime with respect to those facilities, the bill would impose a state-mandated local program.

The bill would require the Medi-Cal program to cover emergency services and care necessary to treat an emergency medical condition, as defined, including all professional physical, mental, and substance use treatment services, including screening examinations necessary to determine the presence or absence of an emergency medical condition and, if an emergency medical condition exists, all services medically necessary to stabilize the beneficiary.

The bill would require coverage, including by a Medi-Cal managed care plan, coverage for emergency services necessary to relieve or eliminate a psychiatric emergency medical condition, regardless of duration, or whether the beneficiary is voluntary, or involuntarily detained for evaluation and treatment, including emergency room professional services, as specified. The bill would require a Medi-Cal managed care plan, as defined, to be responsible for covering, and reimbursing providers for furnishing, those emergency services and care, as specified.

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

This bill would provide that no reimbursement is required by this act for a specified reason.

Existing law, the Lanterman-Petris-Short Act, provides for the involuntary commitment and treatment of a person who is a danger to themselves or others or who is gravely disabled, as defined.

Existing law provides for the Medi-Cal program, which is administered by the State Department of Health Care Services, under which qualified low-income individuals receive health care services. The Medi-Cal program is, in part, governed and funded by federal Medicaid program provisions. Pursuant to a schedule of covered benefits, existing law requires Medi-Cal coverage for inpatient hospital services, subject to utilization controls, and with respect to fee-for service beneficiaries, coverage for emergency services and care necessary for the treatment of an emergency medical condition and medical care directly related to the emergency medical condition, as specified.

Existing law provides for the licensing and regulation of health facilities by the State Department of Public Health and makes a violation of those provisions a crime. Existing law defines psychiatric emergency medical condition, for purposes of providing treatment for emergency conditions, as a mental disorder that manifests itself by acute symptoms of sufficient severity that it renders the patient as being either an immediate danger to the patient or to others, or immediately unable to provide for, or utilize, food, shelter, or clothing, due to the mental disorder. Existing law includes various circumstances under which a patient is required to be treated by, or may be transferred to, specified health facilities for treatment that is solely necessary to relieve or eliminate a psychiatric emergency medical condition.

This bill would revise the definition of psychiatric emergency medical condition to make that definition applicable regardless of whether the patient is voluntary, or is involuntarily detained for evaluation and treatment. treatment, under prescribed circumstances. The bill would make conforming changes to provisions requiring facilities to provide that treatment. By expanding the definition of a crime with respect to those facilities, the bill would impose a state-mandated local program.

The bill would require the Medi-Cal program to cover emergency services and care necessary to treat an emergency medical condition, as defined, including all professional physical, mental, and substance use treatment services, including screening examinations necessary to determine the presence or absence of an emergency medical condition and, if an emergency medical condition exists, for all services medically necessary to stabilize the beneficiary.

The bill would require coverage, including by a Medi-Cal managed care plan, for emergency services necessary to relieve or eliminate a psychiatric emergency medical condition, regardless of duration, or whether the beneficiary is voluntary, or involuntarily detained for evaluation and treatment, including emergency room professional services. services, as specified.

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

This bill would provide that no reimbursement is required by this act for a specified reason.

Existing law, the Lanterman-Petris-Short Act, provides for the involuntary commitment and treatment of a person who is a danger to themselves or others or who is gravely disabled, as defined.

Existing law provides for the Medi-Cal program, which is administered by the State Department of Health Care Services, under which qualified low-income individuals receive health care services. The Medi-Cal program is, in part, governed and funded by federal Medicaid program provisions. Pursuant to a schedule of covered benefits, existing law requires Medi-Cal coverage for inpatient hospital services, subject to utilization controls, and with respect to fee-for service beneficiaries, coverage for emergency services and care necessary for the treatment of an emergency medical condition and medical care directly related to the emergency medical condition, as specified.

Existing law provides for the licensing and regulation of health facilities by the State Department of Public Health and makes a violation of those provisions a crime. Existing law defines psychiatric emergency medical condition, for purposes of providing treatment for emergency conditions, as a mental disorder that manifests itself by acute symptoms of sufficient severity that it renders the patient as being either an immediate danger to the patient or to others, or immediately unable to provide for, or utilize, food, shelter, or clothing, due to the mental disorder. Existing law includes various circumstances under which a patient is required to be treated by, or may be transferred to, specified health facilities for treatment that is solely necessary to relieve or eliminate a psychiatric emergency medical condition.

This bill would revise the definition of psychiatric emergency medical condition to make that definition applicable regardless of whether the patient is voluntary, or is involuntarily detained for evaluation and treatment. The bill would make conforming changes to provisions requiring facilities to provide that treatment. By expanding the definition of a crime with respect to those facilities, the bill would impose a state-mandated local program.

The bill would require the Medi-Cal program to cover emergency services and care necessary to treat an emergency medical condition, as defined, including all professional physical, mental, and substance use treatment services, including screening examinations necessary to determine the presence or absence of an emergency medical condition and, if an emergency medical condition exists, for all services medically necessary to stabilize the beneficiary.

The bill would require coverage, including by a Medi-Cal managed care plan, for emergency services necessary to relieve or eliminate a psychiatric emergency medical condition, regardless of duration, or whether the beneficiary is voluntary, or involuntarily detained for evaluation and treatment, including emergency room professional services.

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

This bill would provide that no reimbursement is required by this act for a specified reason.

CONCURRENCE IN SENATE AMENDMENTS

CSA1 Bill Id:AB 1316

Author:(Irwin and Ward)

As Amended Ver:August 19, 2024

Majority vote

SUMMARY

Revises the definition of "psychiatric emergency medical condition" to make the definition applicable regardless of whether the patient is voluntary or involuntarily detained for assessment, evaluation and crisis intervention, or placement for evaluation or treatment. Requires the Medi-Cal program and Medi-Cal managed care plans to cover all emergency services and care necessary to treat an emergency medical condition, including post-stabilization care services required under specified federal law, emergency room professional services, and facility charges for emergency room visits.

Senate Amendments

1. Require a Medi-Cal managed care plan to cover and reimburse providers for furnishing emergency care and services, excluding any Medi-Cal specialty mental health services provided once an enrolled beneficiary is admitted for inpatient psychiatric care;
2. Authorize the Department of Health Care Services (DHCS) to implement the provisions of this bill by means of all-plan letters, only until such time that DHCS promulgates regulations; and,
3. Require a provider to notify a patient's health care service plan, or the plans' contracting medical provider of the need for a transfer to another facility if the plans' contact information has been provided.

COMMENTS

The Lanterman-Petris-Short (LPS) Act and designated vs nondesignated facilities. The LPS Act was enacted in the 1960s to develop a statutory process under which individuals could be involuntarily held and treated in a county-designated facility in a manner that safeguarded their constitutional rights. The LPS Act was intended to balance the goals of maintaining the constitutional right to personal liberty and choice in mental health treatment. Existing law, Welfare and Institutions Code (WIC) Section 5150, part of the LPS Act, allows peace officers, staff members of county-designated facilities, or other county-designated professional persons to take an individual into custody and place them in a facility for 72-hour treatment and evaluation to determine if, due to a mental disorder, the individual is a danger to self or others, or is gravely disabled. The LPS Act imposes strict conditions relating to the detention, assessment, and treatment of the detainee. Provided that specified conditions are met, the peace officer and the medical director of the facility, as well as the professional staff responsible for the evaluation and treatment of the person, are granted immunity from civil and criminal liability for releasing the detainee at any time prior to the end of the 72-hour hold or for any actions of the person released before or after the 72-hour hold. Individual counties are responsible for determining whether general acute care hospitals, psychiatric health facilities, acute psychiatric hospitals, and other licensed facilities qualify to be designated facilities. While the intent of the LPS Act is for authorized individuals to take a person who has been placed on a 5150 hold to a designated facility, if one does not exist, or a person is suffering from another condition that requires immediate emergency medical services, the person is transported to the nearest facility, which is often a non-designated facility with an emergency department (ED), which under both federal and state Emergency Medical Treatment and Labor Act (EMTALA) is required to provide emergency medical services to any individual who presents and requires emergency medical attention.

Lack of inpatient psychiatric beds and timeliness of transfers. According to the California Hospital Association (CHA), since 1995 the state has lost at least 37 facilities, either through the elimination of psychiatric inpatient care, or complete hospital closure, representing a 20% drop. CHA states that while there has been an increase in psychiatric beds over the past several years, California has lost nearly 30% of the psychiatric beds it had in 1995. California now has only 17 psychiatric beds for every 100,000 residents, compared to nearly 30 beds per 100,000 in 1995, and well short of the recommended minimum number of 50 psychiatric beds per 100,000. According to information provided by CHA, the sponsor of this bill, in many instances, long stays in hospital EDs are due to hospitals' difficulty finding an available inpatient psychiatric bed. In the case of individuals with Medi-Cal and those who may be on an involuntary psychiatric hold, hospitals are often instructed by the county to hold the patient in the ED until the county finds the patient a bed.

EMTALA. EMTALA was passed to address the problem of hospitals refusing to treat indigent, uninsured, or Medicaid patients, or "dumping" these patients by transferring them to county hospitals or other charity hospitals. Federal EMTALA obligates Medicare-participating hospitals that offer emergency services to provide a medical screening and treatment for an emergency medical condition, including active labor, regardless of an individual's ability to pay. State EMTALA imposes its obligation on any hospital that operates an ED, and has similar requirements to federal EMTALA. Hospitals are required to provide stabilizing treatment for patients with an emergency medical condition. A patient is "stabilized" when the patient's medical condition is such that, within reasonable medical probability, no material deterioration of the patient's condition is likely to result from the release or transfer of the patient. If a hospital is unable to stabilize a patient within its capability, then a patient is required to be transferred to an appropriate facility with the necessary specialized treatment services. Once a patient is stabilized, if the patient needs post-stabilization care, the hospital will typically seek more information about the medical history of the patient, including whether the patient has insurance.

Medi-Cal Managed Care Plan (MCP) Coverage of Emergency Services. The Medi-Cal provisions of this bill reflect current DHCS policy, and appear consistent with DHCS's intention to revise MCP contract language to clarify payment for emergency services. Current contracts between MCPs and DHCS specify MCPs are responsible for coverage and payment of emergency services and post-stabilization care services. However, the current contract language carves out some exceptions to an MCP's responsibility for paying for emergency services, including: 1) services provided by specified mental health providers; and, 2) facility charges for ED visits that result in a psychiatric admission. DHCS is revising the contract to remove these exceptions and clarify MCPs bear financial responsibility for ED services, including behavioral health services. Specifically, updated MCP contracts effective January 1, 2024, require MCPs to pay for emergency room professional services provided by mental health providers, addressing 1) above. However, the 2024 contract language does not require MCPs to pay for facility charges for ED visits that result in a psychiatric admission. DHCS has stated it intends to amend MCP contracts again to codify plan responsibility to cover all facility charges claimed by EDs—essentially removing the exception related to ED visits that result in a psychiatric admission. DHCS has stated, furthermore, that this change would be retroactive. When this change is made, the contract language will align with guidance issued in a 2022 All-Plan Letter titled "No Wrong Door for Mental Health Services." This bill codifies MCPs coverage of ED services without the two exceptions related to behavioral health care.

According to the Author

Hospital EDs are a critical part of the safety net for Californians in a mental health crisis who desperately need psychiatric treatment. This bill supports hospitals and patients by ensuring psychiatric emergencies are treated with the same urgency and reimbursement practices used for patients with any other medical emergency. The author states that, if a person is on an involuntary hold, this bill ensures this legal status is not an impediment to getting them the psychiatric health care they need, while also ensuring ED beds are available for incoming trauma patients. The author concludes that this bill also makes it clear that Medi-Cal managed care plans must cover all hospital ED visits, including psychiatric emergencies.

Arguments in Support

CHA is the sponsor of this bill and states that hospitals are seeing more Californians in crisis, but youth and adults spend disproportionately more time waiting in the ED than other patients. While the national quality standard for emergency hospital care is four hours or less, it is common for people in mental health crisis to languish in a hospital ED for days or even weeks while waiting for an inpatient mental health treatment bed to become available. CHA notes that this bill would make it clear that Medi-Cal MCPs must pay hospital EDs for the care they provide to Medi-Cal beneficiaries experiencing a mental health crisis. Currently, the Medi-Cal managed care plans' contracts and state guidance provide conflicting information about financial obligations for ED visits.

Arguments in Opposition

The California State Association of Psychiatrists (CSAP), is opposed to this bill and states that that assessment under WIC 5150 is, and has until now been universally considered to be, a community standard and essential part of emergency assessment stabilization for suicidal, dangerous, or gravely disabled psychiatric patients before transfer to psychiatric facilities in the absence of other legal grounds for detention. CSAP contends that the language in this bill specifically excepts such assessment. This exception would be especially dangerous to patient and community safety at the point where stabilization and transport are contemplated. In the absence of a legal justification for involuntary detention in a situation where the transferring hospital has already documented the presence of danger to self, danger to others, or grave disability due to mental illness, which is the very justification of an emergency psychiatric condition, situations will certainly arise in which transferred individuals will be detained without legal justification provided by LPS assessment, or will be released and endangered during transfer as a result of the absence of a legal means of detention. CSAP sees no acceptable justification for changing the law to release a transferring hospital from such a reasonable and easily manageable obligation.

FISCAL COMMENTS

According to the Senate Appropriations Committee, pursuant to Senate Rule 28.8, negligible state costs.

VOTES:

ASM HEALTH: 16-0-0

YES: Bonta, Waldron, Aguiar-Curry, Arambula, Wendy Carrillo, Flora, Vince Fong, Haney, Jones-Sawyer, Maienschein, McCarty, Joe Patterson, Rodriguez, Santiago, Schiavo, Weber

ASM APPROPRIATIONS: 15-0-1

YES: Holden, Sanchez, Arambula, Wood, Calderon, Connolly, Dixon, Mike Fong, Grayson, Haney, Hart, Lowenthal, Pellerin, Ta, Villapudua

ABS, ABST OR NV: Megan Dahle

ASSEMBLY FLOOR: 69-0-11

YES: Aguiar-Curry, Alanis, Alvarez, Arambula, Bains, Bauer-Kahan, Bennett, Berman, Boerner, Bryan, Calderon, Juan Carrillo, Cervantes, Chen, Connolly, Davies, Dixon, Essayli, Flora, Mike Fong, Vince Fong, Gabriel, Gallagher, Garcia, Gipson, Grayson, Haney, Hart, Hoover, Irwin, Jackson, Kalra, Lackey, Lee, Low, Lowenthal, Maienschein, Mathis, McCarty, McKinnor, Muratsuchi, Stephanie Nguyen, Ortega, Pacheco, Papan, Joe Patterson, Pellerin, Petrie-Norris, Quirk-Silva, Ramos, Rendon, Reyes, Rodriguez, Blanca Rubio, Sanchez, Santiago, Schiavo, Ta, Ting, Valencia, Waldron, Wallis, Ward, Weber, Wicks, Wilson, Wood, Zbur, Robert Rivas

ABS, ABST OR NV: Addis, Bonta, Wendy Carrillo, Megan Dahle, Friedman, Holden, Jones-Sawyer, Jim Patterson, Luz Rivas, Soria, Villapudua

SENATE FLOOR: 40-0-0

YES: Allen, Alvarado-Gil, Archuleta, Ashby, Atkins, Becker, Blakespear, Bradford, Caballero, Cortese, Dahle, Dodd, Durazo, Eggman, Glazer, Gonzalez, Grove, Hurtado, Jones, Laird, Limón, McGuire, Menjivar, Min, Newman, Nguyen, Niello, Ochoa Bogh, Padilla, Portantino, Roth, Rubio, Seyarto, Skinner, Smallwood-Cuevas, Stern, Umberg, Wahab, Wiener, Wilk

UPDATED

VERSION: August 19, 2024

CONSULTANT: Lara Flynn / HEALTH / (916) 319-2097 FN: 0004176

CONCURRENCE IN SENATE AMENDMENTS

CSA1 Bill Id:AB 1316

Author:(Irwin and Ward)

As Amended Ver:August 19, 2024

Majority vote

SUMMARY

Revises the definition of "psychiatric emergency medical condition" to make the definition applicable regardless of whether the patient is voluntary or involuntarily detained for assessment, evaluation and crisis intervention, or placement for evaluation or treatment. Requires the Medi-Cal program and Medi-Cal managed care plans to cover all emergency services and care necessary to treat an emergency medical condition, including post-stabilization care services required under specified federal law, emergency room professional services, and facility charges for emergency room visits.

Senate Amendments

1. Require a Medi-Cal managed care plan to cover and reimburse providers for furnishing emergency care and services, excluding any Medi-Cal specialty mental health services provided once an enrolled beneficiary is admitted for inpatient psychiatric care;
2. Authorize the Department of Health Care Services (DHCS) to implement the provisions of this bill by means of all-plan letters, only until such time that DHCS promulgates regulations; and,
3. Require a provider to notify a patient's health care service plan, or the plans' contracting medical provider of the need for a transfer to another facility if the plans' contact information has been provided.

COMMENTS

The Lanterman-Petris-Short (LPS) Act and designated vs nondesignated facilities. The LPS Act was enacted in the 1960s to develop a statutory process under which individuals could be involuntarily held and treated in a county-designated facility in a manner that safeguarded their constitutional rights. The LPS Act was intended to balance the goals of maintaining the constitutional right to personal liberty and choice in mental health treatment. Existing law, Welfare and Institutions Code (WIC) Section 5150, part of the LPS Act, allows peace officers, staff members of county-designated facilities, or other county-designated professional persons to take an individual into custody and place them in a facility for 72-hour treatment and evaluation to determine if, due to a mental disorder, the individual is a danger to self or others, or is gravely disabled. The LPS Act imposes strict conditions relating to the detention, assessment, and treatment of the detainee. Provided that specified conditions are met, the peace officer and the medical director of the facility, as well as the professional staff responsible for the evaluation and treatment of the person, are granted immunity from civil and criminal liability for releasing the detainee at any time prior to the end of the 72-hour hold or for any actions of the person released before or after the 72-hour hold. Individual counties are responsible for determining whether general acute care hospitals, psychiatric health facilities, acute psychiatric hospitals, and other licensed facilities qualify to be designated facilities. While the intent of the LPS Act is for authorized individuals to take a person who has been placed on a 5150 hold to a designated facility, if one does not exist, or a person is suffering from another condition that requires immediate emergency medical services, the person is transported to the nearest facility, which is often a non-designated facility with an emergency department (ED), which under both federal and state Emergency Medical Treatment and Labor Act (EMTALA) is required to provide emergency medical services to any individual who presents and requires emergency medical attention.

Lack of inpatient psychiatric beds and timeliness of transfers. According to the California Hospital Association (CHA), since 1995 the state has lost at least 37 facilities, either through the elimination of psychiatric inpatient care, or complete hospital closure, representing a 20% drop. CHA states that while there has been an increase in psychiatric beds over the past several years, California has lost nearly 30% of the psychiatric beds it had in 1995. California now has only 17 psychiatric beds for every 100,000 residents, compared to nearly 30 beds per 100,000 in 1995, and well short of the recommended minimum number of 50 psychiatric beds per 100,000. According to information provided by CHA, the sponsor of this bill, in many instances, long stays in hospital EDs are due to hospitals' difficulty finding an available inpatient psychiatric bed. In the case of individuals with Medi-Cal and those who may be on an involuntary psychiatric hold, hospitals are often instructed by the county to hold the patient in the ED until the county finds the patient a bed.

EMTALA. EMTALA was passed to address the problem of hospitals refusing to treat indigent, uninsured, or Medicaid patients, or "dumping" these patients by transferring them to county hospitals or other charity hospitals. Federal EMTALA obligates Medicare-participating hospitals that offer emergency services to provide a medical screening and treatment for an emergency medical condition, including active labor, regardless of an individual's ability to pay. State EMTALA imposes its obligation on any hospital that operates an ED, and has similar requirements to federal EMTALA. Hospitals are required to provide stabilizing treatment for patients with an emergency medical condition. A patient is "stabilized" when the patient's medical condition is such that, within reasonable medical probability, no material deterioration of the patient's condition is likely to result from the release or transfer of the patient. If a hospital is unable to stabilize a patient within its capability, then a patient is required to be transferred to an appropriate facility with the necessary specialized treatment services. Once a patient is stabilized, if the patient needs post-stabilization care, the hospital will typically seek more information about the medical history of the patient, including whether the patient has insurance.

Medi-Cal Managed Care Plan (MCP) Coverage of Emergency Services. The Medi-Cal provisions of this bill reflect current DHCS policy, and appear consistent with DHCS's intention to revise MCP contract language to clarify payment for emergency services. Current contracts between MCPs and DHCS specify MCPs are responsible for coverage and payment of emergency services and post-stabilization care services. However, the current contract language carves out some exceptions to an MCP's responsibility for paying for emergency services, including: 1) services provided by specified mental health providers; and, 2) facility charges for ED visits that result in a psychiatric admission. DHCS is revising the contract to remove these exceptions and clarify MCPs bear financial responsibility for ED services, including behavioral health services. Specifically, updated MCP contracts effective January 1, 2024, require MCPs to pay for emergency room professional services provided by mental health providers, addressing 1) above. However, the 2024 contract language does not require MCPs to pay for facility charges for ED visits that result in a psychiatric admission. DHCS has stated it intends to amend MCP contracts again to codify plan responsibility to cover all facility charges claimed by EDs—essentially removing the exception related to ED visits that result in a psychiatric admission. DHCS has stated, furthermore, that this change would be retroactive. When this change is made, the contract language will align with guidance issued in a 2022 All-Plan Letter titled "No Wrong Door for Mental Health Services." This bill codifies MCPs coverage of ED services without the two exceptions related to behavioral health care.

According to the Author

Hospital EDs are a critical part of the safety net for Californians in a mental health crisis who desperately need psychiatric treatment. This bill supports hospitals and patients by ensuring psychiatric emergencies are treated with the same urgency and reimbursement practices used for patients with any other medical emergency. The author states that, if a person is on an involuntary hold, this bill ensures this legal status is not an impediment to getting them the psychiatric health care they need, while also ensuring ED beds are available for incoming trauma patients. The author concludes that this bill also makes it clear that Medi-Cal managed care plans must cover all hospital ED visits, including psychiatric emergencies.

Arguments in Support

CHA is the sponsor of this bill and states that hospitals are seeing more Californians in crisis, but youth and adults spend disproportionately more time waiting in the ED than other patients. While the national quality standard for emergency hospital care is four hours or less, it is common for people in mental health crisis to languish in a hospital ED for days or even weeks while waiting for an inpatient mental health treatment bed to become available. CHA notes that this bill would make it clear that Medi-Cal MCPs must pay hospital EDs for the care they provide to Medi-Cal beneficiaries experiencing a mental health crisis. Currently, the Medi-Cal managed care plans' contracts and state guidance provide conflicting information about financial obligations for ED visits.

Arguments in Opposition

The California State Association of Psychiatrists (CSAP), is opposed to this bill and states that that assessment under WIC 5150 is, and has until now been universally considered to be, a community standard and essential part of emergency assessment stabilization for suicidal, dangerous, or gravely disabled psychiatric patients before transfer to psychiatric facilities in the absence of other legal grounds for detention. CSAP contends that the language in this bill specifically excepts such assessment. This exception would be especially dangerous to patient and community safety at the point where stabilization and transport are contemplated. In the absence of a legal justification for involuntary detention in a situation where the transferring hospital has already documented the presence of danger to self, danger to others, or grave disability due to mental illness, which is the very justification of an emergency psychiatric condition, situations will certainly arise in which transferred individuals will be detained without legal justification provided by LPS assessment, or will be released and endangered during transfer as a result of the absence of a legal means of detention. CSAP sees no acceptable justification for changing the law to release a transferring hospital from such a reasonable and easily manageable obligation.

FISCAL COMMENTS

According to the Senate Appropriations Committee, pursuant to Senate Rule 28.8, negligible state costs.

VOTES:

ASM HEALTH: 16-0-0

YES: Bonta, Waldron, Aguiar-Curry, Arambula, Wendy Carrillo, Flora, Vince Fong, Haney, Jones-Sawyer, Maienschein, McCarty, Joe Patterson, Rodriguez, Santiago, Schiavo, Weber

ASM APPROPRIATIONS: 15-0-1

YES: Holden, Sanchez, Arambula, Wood, Calderon, Connolly, Dixon, Mike Fong, Grayson, Haney, Hart, Lowenthal, Pellerin, Ta, Villapudua

ABS, ABST OR NV: Megan Dahle

ASSEMBLY FLOOR: 69-0-11

YES: Aguiar-Curry, Alanis, Alvarez, Arambula, Bains, Bauer-Kahan, Bennett, Berman, Boerner, Bryan, Calderon, Juan Carrillo, Cervantes, Chen, Connolly, Davies, Dixon, Essayli, Flora, Mike Fong, Vince Fong, Gabriel, Gallagher, Garcia, Gipson, Grayson, Haney, Hart, Hoover, Irwin, Jackson, Kalra, Lackey, Lee, Low, Lowenthal, Maienschein, Mathis, McCarty, McKinnor, Muratsuchi, Stephanie Nguyen, Ortega, Pacheco, Papan, Joe Patterson, Pellerin, Petrie-Norris, Quirk-Silva, Ramos, Rendon, Reyes, Rodriguez, Blanca Rubio, Sanchez, Santiago, Schiavo, Ta, Ting, Valencia, Waldron, Wallis, Ward, Weber, Wicks, Wilson, Wood, Zbur, Robert Rivas

ABS, ABST OR NV: Addis, Bonta, Wendy Carrillo, Megan Dahle, Friedman, Holden, Jones-Sawyer, Jim Patterson, Luz Rivas, Soria, Villapudua

UPDATED

VERSION: August 19, 2024

CONSULTANT: Lara Flynn / HEALTH / (916) 319-2097 FN: 0004176

 THIRD READING  

Bill No: AB 1316

Author: Irwin (D) and Ward (D)

Amended: 8/19/24 in Senate

Vote: 21

SENATE HEALTH COMMITTEE: 10-0, 6/12/24

AYES: Roth, Nguyen, Glazer, Gonzalez, Grove, Hurtado, Limón, Menjivar, Rubio, Wiener

NO VOTE RECORDED: Smallwood-Cuevas

SENATE APPROPRIATIONS COMMITTEE: Senate Rule 28.8

ASSEMBLY FLOOR: 69-0, 1/25/24 (Consent) - See last page for vote

SUBJECT: Emergency services: psychiatric emergency medical conditions

SOURCE: California Hospital Association

DIGEST:

This bill revises the definition of “psychiatric emergency medical condition” to make the definition applicable regardless of whether the patient is voluntary or involuntarily detained for evaluation and treatment. Requires the Medi-Cal program and Medi-Cal managed care plans to cover all emergency services and care necessary to relieve or eliminate a psychiatric emergency medical condition, regardless of duration or whether the recipient is voluntary or involuntarily detained for evaluation and treatment.

Senate Floor Amendments of 8/19/24 (1) specify that this bill does not require a patient transfer or admission that would be in conflict with the Laternman-Petris Short (LPS) Act or the federal Emergency Medical Treatment and Labor Act (EMTALA); (2) add clarifying language regarding whether a patient is voluntary or involuntarily detainted; (3) delete the definition of “emergency services and care” from the Medi-Cal portion and instead references existing federal and state definitions and clarifies that emergency room professional services and facility charges for emergency room visits are included; (4) specify that the that the responsibilities outlined for Medi-Cal plans do not reduce the scope of covered services in the Medi-Cal fee-for-service delivery system; and (5) state legislative intent that the Medi-Cal section is intended to clarify, not expand the scope of Medi-Cal covered benefits.

ANALYSIS:

Existing law:

1. Establishes the Medi-Cal program, which is administered by the Department of Health Care Services (DHCS), and under which qualified low-income individuals receive health care services. [WIC §14000, et seq.]
2. Authorizes the DHCS Director to contract, on a bid or nonbid basis, with any qualified individual, organization, or entity to provide services to, arrange for, or case manage the care of Medi-Cal beneficiaries and establishes managed care models that DHCS contracts with in each county. [WIC §14087.3, 14089, 14087.98, 14087.967, 14087.5]
3. Requires DHCS to implement mental health managed care through contracts with mental health plans. Requires DHCS to contract with a county or counties acting jointly for the delivery of specialty mental health services (“specialty services”) to each county’s eligible Medi-Cal beneficiary population. Authorizes mental health plan contracts to be awarded exclusively and on a geographic basis. [WIC §14712]
4. Requires Medi-Cal plans to provide mental health benefits covered in the California’s Medicaid State Plan or the fee-for-service delivery system for beneficiaries not enrolled in a MCMC plan, excluding those benefits provided by mental health plans. [WIC §14184.402, §14189]
5. Establishes a schedule of benefits under Medi-Cal, which includes benefits required under federal law and benefits provided at the state’s option, both of which are funded with federal and state dollars. The schedule of benefits includes emergency services and care that are necessary for the treatment of an emergency medical condition and medical care directly related to the emergency medical condition for Medi-Cal fee-for-service beneficiaries and obligates Medi-Cal plans to provide emergency services and care. [WIC §14132]
6. Requires Medi-Cal plans to cover emergency services needed to evaluate or stabilize an emergency medical condition and poststabilization services related to an emergency medical condition that are provided after an enrollee is stabilized to maintain the stabilized condition or to improve or resolve the recipient’s condition. [42 CFR §438.114]
7. Requires emergency departments (EDs), under EMTALA and similar provisions of state law (state EMTALA), to provide emergency screening and stabilization services without regard to the patient’s insurance status or ability to pay. Federal EMTALA imposes this requirement on any hospital that participates in Medicare. State EMTALA imposes this requirement on any hospital that operates an ED. [42 USC §1395dd; HSC §1317]
8. Defines “emergency services and care” for purposes of a psychiatric emergency under state EMTALA, as medical screening, examination, and evaluation by a physician to determine if an emergency medical condition or active labor exists and, if it does, the care, treatment, and surgery, if within the scope of that person’s license, necessary to relieve or eliminate the emergency medical condition, within the capability of the facility. [HSC §1371.1]
9. Defines “emergency services and care,” under state EMTALA, to also mean an additional screening, examination, and evaluation by a physician, or other personnel to the extent permitted by the scope of their licensure and clinical privileges, to determine if a psychiatric emergency medical condition exists, and the care and treatment necessary to relieve or eliminate the psychiatric emergency medical condition, within the capability of the facility. Specifies that the care and treatment necessary to relieve or eliminate a psychiatric emergency medical condition may include admission or transfer to a psychiatric unit within a general acute care hospital, or to an acute psychiatric hospital. [HSC §1371.1]
10. Exempts Medi-Cal plans from the definitions in 9) above if the services are excluded from coverage under their contracts with DHCS. [HSC §1371.1]
11. Defines “psychiatric emergency medical condition” as a mental disorder that manifests itself by acute symptoms of sufficient severity that it renders the patient as either an immediate danger to themselves or others or immediately unable to provide for, or utilize, food, shelter, or clothing due to the mental disorder. [HSC §1371.1]
12. Requires a psychiatric unit within a general acute care hospital, a psychiatric health facility of more than 16 beds, or an acute psychiatric hospital to accept a transfer of a person with a psychiatric emergency medical condition from a health facility that maintains and operates an ED. Requires the receiving facility to provide emergency services and care to that person, regardless of whether the facility operates an ED, if all of the following are met:
13. The treating physician at the sending facility has determined that the patient is medically stable and appropriate for treatment in a psychiatric setting and has included that determination in the patient’s medical record;
14. The receiving facility has an available bed;
15. The receiving facility has appropriate facilities and qualified personnel available to provide the services or care; and,
16. The receiving facility is not a state hospital or a county owned and operated psychiatric health facility. [HSC §1317.4b]
17. Specifies that the provisions in 12) above do not preempt any county or any other governmental agency acting within its authority from regulating emergency care or patient transfers, including the imposition of more specific duties. Clarifies that any inconsistent requirements imposed by the Medi-Cal program preempt those requirements with respect to Medi-Cal beneficiaries, and to the extent hospitals and physicians enter into contractual relationships with county or other governmental agencies that impose more stringent transfer requirements, those contractual agreements control. [HSC §1317.7]

This bill:

1. Clarifies that the definition of “psychiatric emergency medical condition” in 11) above applies regardless of whether the patient is voluntary or involuntarily detained for assessment, evaluation, and crisis intervention, or placement for evaluation and treatment pursuant to the LPS Act, and makes conforming changes throughout.
2. Prohibits the duties imposed by counties or other governmental agencies, and contractual agreements entered into by hospitals and physicians with counties or other governmental agencies, from unreasonably delaying or denying the provision of medically necessary care to a patient with a psychiatric emergency medical condition, regardless of whether the patient is voluntary or involuntarily detained for assessment, evaluation, and crisis intervention, or placement for evaluation and treatment pursuant to the LPS Act.
3. Specifies that this bill does not require a transfer or admission that is in conflict with the LPS Act or with the federal EMTALA requirements.
4. Specifies that, for Medi-Cal recipients with psychiatric emergency medical conditions, emergency services and care necessary to relieve or eliminate that condition are covered services, regardless of duration, or whether the recipient is voluntary, or involuntarily detained assessment, evaluation, and crisis intervention, or placement for for evaluation and treatment pursuant to the LPS Act.
5. Specifies that emergency services and care includes all professional physical, mental, and substance use treatment services, including screening examinations necessary to determine the presence or absence of an emergency medical condition and, if an emergency medical condition exists, all services medically necessary to stabilize the recipient, and any poststabilization care services required under federal regulation. Specifies that emergency and poststabilization care services for these purposes include facility and professional services and facility charges for EDs. For Medi-Cal patients, also specifies that emergency services and care has the same meaning as in the controlling federal regulation.
6. Requires a Medi-Cal plan to cover and reimburse providers furnishing the emergency services and care described in 3) above for its Medi-Cal recipients, excluding any Medi-Cal specialty mental health services provided once an enrolled beneficiary is admitted for inpatient psychiatric care. Specifies that this does not limit or reduce the scope of covered emergency services and care for Medi-Cal fee-for-service beneficiaries.
7. State legislative intent that the Medi-Cal portion of this bill is intended to clarify, not expand, the scope of Medi-Cal covered benefits.
8. Allows DHCS to implement this bill via guidance without taking regulatory action until such time that DHCS can promulgate any necessary regulations. Conditions implementation of this bill on the continued receipt of federal financial participation.

Comments

1. Author’s statement. According to the author, hospital EDs are a critical part of the safety net for Californians in a behavioral health crisis who desperately need psychiatric treatment. This bill supports hospitals and patients by ensuring psychiatric emergencies are treated with the same urgency and reimbursement practices used for patients with any other medical emergency. If a person is on an involuntary hold, this bill ensures this legal status is not an impediment to getting them the psychiatric health care they need, while also ensuring emergency room beds are available for incoming trauma patients. The bill also makes it clear that Medi-Cal plans must cover all hospital ED visits, including psychiatric emergencies.
2. EMTALA. EMTALA was passed to address the problem of hospitals refusing to treat indigent, uninsured, or Medicaid patients, or “dumping” these patients by transferring them to county hospitals or other charity hospitals. Federal EMTALA obligates Medicare-participating hospitals that offer emergency services, to provide a medical screening and treatment for an emergency medical condition regardless of an individual's ability to pay. State EMTALA imposes its obligation on any hospital that operates an ED, and has similar requirements to federal EMTALA. Hospitals are required to provide stabilizing treatment for patients with an emergency medical condition. A patient is “stabilized” when the patient’s medical condition is such that no material deterioration of the patient’s condition is likely to result from the release or transfer of the patient. If a hospital is unable to stabilize a patient within its capability, then a patient must be transferred to an appropriate facility with the necessary specialized treatment services. Once a patient is stabilized, if the patient needs poststabilization care, the hospital will typically seek more information about the medical history of the patient, including whether the patient has insurance.
3. Background on the LPS Act and designated vs nondesignated facilities. The LPS Act was enacted in the 1960s to develop a statutory process under which individuals could be involuntarily held and treated in a county-designated facility in a manner that safeguarded their constitutional rights. The LPS Act was intended to balance the goals of maintaining the constitutional right to personal liberty and choice in mental health treatment. Welfare and Institutions Code Section 5150, part of the LPS Act, allows peace officers, staff members of county-designated facilities, or other county-designated professional persons to take an individual into custody and place them in a facility for 72-hour treatment and evaluation to determine if, due to a mental disorder, the individual is a danger to self or others, or is gravely disabled. The LPS Act imposes strict conditions relating to the detention, assessment, and treatment of the detainee. Provided that specified conditions are met, the peace officer and the medical director of the facility, as well as the professional staff responsible for the evaluation and treatment of the person, are granted immunity from civil and criminal liability for releasing the detainee at any time prior to the end of the 72-hour hold or for any actions of the person released before or after the 72-hour hold.
   
   Individual counties are responsible for determining whether general acute care hospitals, psychiatric health facilities, acute psychiatric hospitals, and other licensed facilities qualify to be designated facilities. While the intent of the LPS Act is for authorized individuals to take a person who has been placed on a 5150 hold to a designated facility, if one does not exist, or a person is suffering from another condition that requires immediate emergency medical services, the person is transported to the nearest facility, which is often a non-designated facility with an ED, which under both federal and state EMTALA is required to provide emergency medical services to any individual who presents and requires emergency medical attention.
4. Acute psychiatric hospitals, psychiatric health facilities, and crisis stabilization units. Generally speaking, inpatient beds for acute psychiatric patients are either provided in a distinct behavioral health unit of a general acute care hospital, in a freestanding acute psychiatric hospital, or in a psychiatric health facility. All of these can be, and most are, designated LPS facilities. Acute psychiatric hospitals are licensed by the California Department of Public Health (CDPH), and are required to provide medical, nursing, rehabilitative, pharmacy and dietary services, in addition to psychiatric services. Psychiatric health facilities are licensed by DHCS, and while not a hospital, are licensed to provide inpatient acute psychiatric care similar to a psychiatric hospital. However, the requirements for each facility are not the same. For example, psychiatric health facilities are not required to provide general medical services. While these facilities are required to have a physician be on-call at all times, a patient can only be admitted to a psychiatric health facility if the individual’s physical health care could otherwise be managed on an outpatient basis. An acute psychiatric hospital, on the other hand, is required to provide a medical service as part of their basic services, which must include a general medicine component. The general medicine component is required to provide all incidental medical services necessary for the care and support of patients, including general medicine and surgery. Psychiatric health facilities historically are county-run, or under contract by counties, to provide inpatient care to Medi-Cal beneficiaries through a county mental health plan.
   
   In addition to inpatient facilities, counties can designate certain outpatient facilities under the LPS Act, such as crisis stabilization units. A crisis stabilization unit is generally open 24 hours a day, seven days a week, and provides up to 23 hours of psychiatric urgent care intended to stabilize a patient suffering from psychiatric distress, with the goal of stabilizing the patient and avoiding the need for inpatient care.
5. Provision of mental health services in the Medi-Cal program. In 2014, the Medi-Cal program began requiring Medi-Cal plans to provide services for mild-to-moderate impairment of mental, emotional, or behavioral health functioning. As a result, Medi-Cal mental health benefits are now delivered through two separate systems. County mental health plans provide a broad range of specialty services to individuals with more severe mental illnesses, while Medi-Cal plans provide nonspecialty services. The delivery of specialty services through county mental health plans is commonly referred to as a “carve out,” which is when services covered by the Medi-Cal program are delivered outside of an Medi-Cal plan. In addition, a small percentage of Medi-Cal recipients, particularly those new to the program who have not yet enrolled in an Medi-Cal plan, still receive mental health services through the Medi-Cal fee-for-service program.

Further complicating the division of mental health benefits for most Medi-Cal beneficiaries in Medi-Cal plans is how emergency psychiatric services are treated. Existing regulations and Medi-Cal plan contracts with DHCS require the plans to cover emergency medical services without prior authorization, including those provided by EDs or emergency physicians for medical screening examinations necessary to determine the presence or absence of an emergency medical condition. Additionally, if an emergency medical condition exists, all services medically necessary to stabilize the plan member are covered without prior authorization. DHCS guidance found in All-Plan Letter 22-005 also states that emergency services include facility and professional services and facility charges claimed by EDs.

The Medi-Cal plan contract also requires Medi-Cal plans to have a memorandum of understanding with the county mental health plan to refer recipients in need of urgent and emergency mental health services. While most psychiatric inpatient services are carved out of the Medi-Cal plan contract (to be provided by county mental health plans), Medi-Cal plans are required to cover initial health history and physical examinations, consultations, and medically necessary covered services to members less than 21 years of age or age 65 and over.

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

SUPPORT: (Verified 8/16/24)

California Hospital Association (source)

Adventist Health

California Chapter of the American College of Emergency Physicians

Cedars Sinai

Loma Linda University Adventist Health

Providence

Psychiatric Physicians Alliance of California

Rady Children’s Hospital

Steinberg Institute

Tenet Healthcare Corporation

The California Association of Local Behavioral Health Boards and Commissions

2 individuals

OPPOSITION: (Verified 8/16/24)

None received

ARGUMENTS IN SUPPORT: The California Hospital Association write that this bill simply addresses the process of transferring patients to medically necessary care by clarifying that EDs should transfer patients in crisis to accepting inpatient psychiatric hospitals regardless of whether the patient is on an involuntary hold. They also write that the provisions related to MCMC plans simply codify existing state policy for Medi-Cal covered services as outlined in recent state guidance. The Steinberg Institute writes that clarifying that patients should be transferred to psychiatric hospitals regardless of whether they are on an involuntary hold will reduce the time that people in mental health crises languish in hospital EDs.

ASSEMBLY FLOOR: 69-0, 1/25/24

AYES: Aguiar-Curry, Alanis, Alvarez, Arambula, Bains, Bauer-Kahan, Bennett, Berman, Boerner, Bryan, Calderon, Juan Carrillo, Cervantes, Chen, Connolly, Davies, Dixon, Essayli, Flora, Mike Fong, Vince Fong, Gabriel, Gallagher, Garcia, Gipson, Grayson, Haney, Hart, Hoover, Irwin, Jackson, Kalra, Lackey, Lee, Low, Lowenthal, Maienschein, Mathis, McCarty, McKinnor, Muratsuchi, Stephanie Nguyen, Ortega, Pacheco, Papan, Joe Patterson, Pellerin, Petrie-Norris, Quirk-Silva, Ramos, Rendon, Reyes, Rodriguez, Blanca Rubio, Sanchez, Santiago, Schiavo, Ta, Ting, Valencia, Waldron, Wallis, Ward, Weber, Wicks, Wilson, Wood, Zbur, Robert Rivas

NO VOTE RECORDED: Addis, Bonta, Wendy Carrillo, Megan Dahle, Friedman, Holden, Jones-Sawyer, Jim Patterson, Luz Rivas, Soria, Villapudua

Prepared by: Jen Flory / HEALTH / (916) 651-4111

8/20/24 16:01:41

**** END ****

 THIRD READING  

Bill No: AB 1316

Author: Irwin (D) and Ward (D)

Amended: 6/17/24 in Senate

Vote: 21

SENATE HEALTH COMMITTEE: 10-0, 6/12/24

AYES: Roth, Nguyen, Glazer, Gonzalez, Grove, Hurtado, Limón, Menjivar, Rubio, Wiener

NO VOTE RECORDED: Smallwood-Cuevas

SENATE APPROPRIATIONS COMMITTEE: Senate Rule 28.8

ASSEMBLY FLOOR: 69-0, 1/25/24 (Consent) - See last page for vote

SUBJECT: Emergency services: psychiatric emergency medical conditions

SOURCE: California Hospital Association

DIGEST:

This bill revises the definition of “psychiatric emergency medical condition” to make the definition applicable regardless of whether the patient is voluntary or involuntarily detained for evaluation and treatment. Requires the Medi-Cal program and Medi-Cal managed care plans to cover all emergency services and care necessary to relieve or eliminate a psychiatric emergency medical condition, regardless of duration or whether the recipient is voluntary or involuntarily detained for evaluation and treatment.

ANALYSIS:

Existing law:

1. Establishes the Medi-Cal program, which is administered by the Department of Health Care Services (DHCS), and under which qualified low-income individuals receive health care services. [WIC §14000, et seq.]
2. Authorizes the DHCS Director to contract, on a bid or nonbid basis, with any qualified individual, organization, or entity to provide services to, arrange for, or case manage the care of Medi-Cal beneficiaries and establishes managed care models that DHCS contracts with in each county. [WIC §14087.3, 14089, 14087.98, 14087.967, 14087.5]
3. Requires DHCS to implement mental health managed care through contracts with mental health plans. Requires DHCS to contract with a county or counties acting jointly for the delivery of specialty mental health services (“specialty services”) to each county’s eligible Medi-Cal beneficiary population. Authorizes mental health plan contracts to be awarded exclusively and on a geographic basis. [WIC §14712]
4. Requires Medi-Cal managed care (MCMC) plans to provide mental health benefits covered in the California’s Medicaid State Plan or the fee-for-service delivery system for beneficiaries not enrolled in a MCMC plan, excluding those benefits provided by mental health plans. [WIC §14184.402, §14189]
5. Establishes a schedule of benefits under Medi-Cal, which includes benefits required under federal law and benefits provided at the state’s option, both of which are funded with federal and state dollars. The schedule of benefits includes emergency services and care that are necessary for the treatment of an emergency medical condition and medical care directly related to the emergency medical condition for Medi-Cal fee-for-service beneficiaries and obligates MCMC plans to provide emergency services and care. [WIC §14132]
6. Requires MCMC plans to cover emergency services needed to evaluate or stabilize an emergency medical condition and poststabilization services related to an emergency medical condition that are provided after an enrollee is stabilized to maintain the stabilized condition or to improve or resolve the recipient’s condition. [42 CFR §438.114]
7. Requires emergency departments (EDs), under the federal Emergency Medical Treatment and Active Labor Act (EMTALA) and similar provisions of state law (state EMTALA), to provide emergency screening and stabilization services without regard to the patient’s insurance status or ability to pay. Federal EMTALA imposes this requirement on any hospital that participates in Medicare. State EMTALA imposes this requirement on any hospital that operates an ED. [42 USC §1395dd; HSC §1317]
8. Defines “emergency services and care” for purposes of a psychiatric emergency under state EMTALA, as medical screening, examination, and evaluation by a physician to determine if an emergency medical condition or active labor exists and, if it does, the care, treatment, and surgery, if within the scope of that person’s license, necessary to relieve or eliminate the emergency medical condition, within the capability of the facility. [HSC §1371.1]
9. Defines “emergency services and care,” under state EMTALA, to also mean an additional screening, examination, and evaluation by a physician, or other personnel to the extent permitted by the scope of their licensure and clinical privileges, to determine if a psychiatric emergency medical condition exists, and the care and treatment necessary to relieve or eliminate the psychiatric emergency medical condition, within the capability of the facility. Specifies that the care and treatment necessary to relieve or eliminate a psychiatric emergency medical condition may include admission or transfer to a psychiatric unit within a general acute care hospital, or to an acute psychiatric hospital. [HSC §1371.1]
10. Exempts MCMC plans from the definitions in 9) above if the services are excluded from coverage under their contracts with DHCS. [HSC §1371.1]
11. Defines “psychiatric emergency medical condition” as a mental disorder that manifests itself by acute symptoms of sufficient severity that it renders the patient as either an immediate danger to themselves or others or immediately unable to provide for, or utilize, food, shelter, or clothing due to the mental disorder. [HSC §1371.1]
12. Requires a psychiatric unit within a general acute care hospital, a psychiatric health facility of more than 16 beds, or an acute psychiatric hospital to accept a transfer of a person with a psychiatric emergency medical condition from a health facility that maintains and operates an ED. Requires the receiving facility to provide emergency services and care to that person, regardless of whether the facility operates an ED, if all of the following are met:
13. The treating physician at the sending facility has determined that the patient is medically stable and appropriate for treatment in a psychiatric setting and has included that determination in the patient’s medical record;
14. The receiving facility has an available bed;
15. The receiving facility has appropriate facilities and qualified personnel available to provide the services or care; and,
16. The receiving facility is not a state hospital or a county owned and operated psychiatric health facility. [HSC §1317.4b]
17. Specifies that the provisions in 12) above do not preempt any county or any other governmental agency acting within its authority from regulating emergency care or patient transfers, including the imposition of more specific duties. Clarifies that any inconsistent requirements imposed by the Medi-Cal program preempt those requirements with respect to Medi-Cal beneficiaries, and to the extent hospitals and physicians enter into contractual relationships with county or other governmental agencies that impose more stringent transfer requirements, those contractual agreements control. [HSC §1317.7]

This bill:

1. Clarifies that the definition of “psychiatric emergency medical condition” in 11) above applies regardless of whether the patient is voluntary or involuntarily detained for evaluation and treatment pursuant to the Lanterman-Petris-Short Act (LPS Act), and makes conforming changes throughout.
2. Prohibits the duties imposed by counties or other governmental agencies, and contractual agreements entered into by hospitals and physicians with counties or other governmental agencies, from unreasonably delaying or denying the provision of medically necessary care to a patient with a psychiatric emergency medical condition, regardless of whether the patient is voluntary or involuntarily detained for evaluation and treatment pursuant to the LPS Act.
3. Specifies that, for Medi-Cal recipients with psychiatric emergency medical conditions, emergency services and care necessary to relieve or eliminate that condition are covered services, regardless of duration, or whether the recipient is voluntary, or involuntarily detained for evaluation and treatment pursuant to the LPS Act. Specifies that emergency services and care includes all professional physical, mental, and substance use treatment services, including screening examinations necessary to determine the presence or absence of an emergency medical condition and, if an emergency medical condition exists, all services medically necessary to stabilize the recipient, and any poststabilization care services required under federal regulation. Specifies that emergency and poststabilization care services for these purposes include facility and professional services and facility charges for EDs.
4. Requires a MCMC plan to cover and reimburse providers furnishing the emergency services and care described in 3) above for its Medi-Cal recipients, excluding any Medi-Cal specialty mental health services provided once an enrolled beneficiary is admitted for inpatient psychiatric care.
5. Allows DHCS to implement this bill via guidance without taking regulatory action until such time that DHCS can promulgate regulations. Conditions implementation of this bill on the continued receipt of federal financial participation.

Comments

1. Author’s statement. According to the author, hospital EDs are a critical part of the safety net for Californians in a behavioral health crisis who desperately need psychiatric treatment. This bill supports hospitals and patients by ensuring psychiatric emergencies are treated with the same urgency and reimbursement practices used for patients with any other medical emergency. If a person is on an involuntary hold, this bill ensures this legal status is not an impediment to getting them the psychiatric health care they need, while also ensuring emergency room beds are available for incoming trauma patients. The bill also makes it clear that MCMC plans must cover all hospital ED visits, including psychiatric emergencies.
2. EMTALA. EMTALA was passed to address the problem of hospitals refusing to treat indigent, uninsured, or Medicaid patients, or “dumping” these patients by transferring them to county hospitals or other charity hospitals. Federal EMTALA obligates Medicare-participating hospitals that offer emergency services, to provide a medical screening and treatment for an emergency medical condition regardless of an individual's ability to pay. State EMTALA imposes its obligation on any hospital that operates an ED, and has similar requirements to federal EMTALA. Hospitals are required to provide stabilizing treatment for patients with an emergency medical condition. A patient is “stabilized” when the patient’s medical condition is such that, within reasonable medical probability, no material deterioration of the patient’s condition is likely to result from the release or transfer of the patient. If a hospital is unable to stabilize a patient within its capability, then a patient must be transferred to an appropriate facility with the necessary specialized treatment services. Once a patient is stabilized, if the patient needs poststabilization care, the hospital will typically seek more information about the medical history of the patient, including whether the patient has insurance.
3. Background on the LPS Act and designated vs nondesignated facilities. The LPS Act was enacted in the 1960s to develop a statutory process under which individuals could be involuntarily held and treated in a county-designated facility in a manner that safeguarded their constitutional rights. The LPS Act was intended to balance the goals of maintaining the constitutional right to personal liberty and choice in mental health treatment. Since its passage in 1967, the field of mental health has continued to evolve toward even greater legal rights for persons with mental health disorders. Welfare and Institutions Code Section 5150, part of the LPS Act, allows peace officers, staff members of county-designated facilities, or other county-designated professional persons to take an individual into custody and place them in a facility for 72-hour treatment and evaluation to determine if, due to a mental disorder, the individual is a danger to self or others, or is gravely disabled. The LPS Act imposes strict conditions relating to the detention, assessment, and treatment of the detainee. Provided that specified conditions are met, the peace officer and the medical director of the facility, as well as the professional staff responsible for the evaluation and treatment of the person, are granted immunity from civil and criminal liability for releasing the detainee at any time prior to the end of the 72-hour hold or for any actions of the person released before or after the 72-hour hold.
   
   Individual counties are responsible for determining whether general acute care hospitals, psychiatric health facilities, acute psychiatric hospitals, and other licensed facilities qualify to be designated facilities. While the intent of the LPS Act is for authorized individuals to take a person who has been placed on a 5150 hold to a designated facility, if one does not exist, or a person is suffering from another condition that requires immediate emergency medical services, the person is transported to the nearest facility, which is often a non-designated facility with an ED, which under both federal and state EMTALA is required to provide emergency medical services to any individual who presents and requires emergency medical attention.
4. Acute psychiatric hospitals, psychiatric health facilities, and crisis stabilization units. Generally speaking, inpatient beds for acute psychiatric patients are either provided in a distinct behavioral health unit of a general acute care hospital, in a freestanding acute psychiatric hospital, or in a psychiatric health facility. All of these can be, and most are, designated LPS facilities. There are 33 licensed acute psychiatric hospitals in California, and 29 psychiatric health facilities. Acute psychiatric hospitals are licensed by the California Department of Public Health (CDPH), and are required to provide medical, nursing, rehabilitative, pharmacy and dietary services, in addition to psychiatric services. Psychiatric health facilities are licensed by DHCS, and while not a hospital, are licensed to provide inpatient acute psychiatric care similar to a psychiatric hospital. However, the requirements for each facility are not the same. For example, psychiatric health facilities are not required to provide general medical services. While these facilities are required to have a physician be on-call at all times, a patient can only be admitted to a psychiatric health facility if the individual’s physical health care could otherwise be managed on an outpatient basis. An acute psychiatric hospital, on the other hand, is required to provide a medical service as part of their basic services, which must include a general medicine component. The general medicine component is required to provide all incidental medical services necessary for the care and support of patients, including general medicine and surgery. Psychiatric health facilities historically are county-run, or under contract by counties, to provide inpatient care to Medi-Cal beneficiaries through a county mental health plan.
   
   In addition to inpatient facilities, counties can designate certain outpatient facilities under the LPS Act, such as crisis stabilization units. A crisis stabilization unit is generally open 24 hours a day, seven days a week, and provides up to 23 hours of psychiatric urgent care intended to stabilize a patient suffering from psychiatric distress, with the goal of stabilizing the patient and avoiding the need for inpatient care.
5. Provision of mental health services in the Medi-Cal program. In 2014, the Medi-Cal program began requiring MCMC plans to provide services for mild-to-moderate impairment of mental, emotional, or behavioral health functioning. As a result, Medi-Cal mental health benefits are now delivered through two separate systems. County mental health plans provide a broad range of specialty services to individuals with more severe mental illnesses, while MCMC plans provide nonspecialty services (generally known as mental health services for those with mild-to-moderate mental illness). The delivery of specialty services through county mental health plans is commonly referred to as a “carve out,” which is when services covered by the Medi-Cal program are delivered outside of an MCMC plan. In addition, a small percentage of Medi-Cal recipients, particularly those new to the program who have not yet enrolled in an MCMC plan, still receive mental health services through the Medi-Cal fee-for-service program.

Further complicating the division of mental health benefits for most Medi-Cal beneficiaries in MCMC plans is how emergency psychiatric services are treated. Existing regulations and MCMC plan contracts with DHCS require the plans to cover emergency medical services without prior authorization, including those provided by EDs or emergency physicians for medical screening examinations necessary to determine the presence or absence of an emergency medical condition. Additionally, if an emergency medical condition exists, all services medically necessary to stabilize the plan member are covered without prior authorization. DHCS guidance found in All-Plan Letter 22-005 also states that emergency services include facility and professional services and facility charges claimed by EDs.

The MCMC plan contract also requires MCMC plans to have a memorandum of understanding with the county mental health plan to refer recipients in need of urgent and emergency mental health services. While most psychiatric inpatient services are carved out of the MCMC plan contract (to be provided by county mental health plans), MCMC plans are required to cover initial health history and physical examinations, consultations, and medically necessary covered services to members less than 21 years of age or age 65 and over.

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

SUPPORT: (Verified 6/21/24)

California Hospital Association (source)

Adventist Health

California Chapter of the American College of Emergency Physicians

Cedars Sinai

Loma Linda University Adventist Health

Providence

Psychiatric Physicians Alliance of California

Rady Children’s Hospital

Steinberg Institute

Tenet Healthcare Corporation

The California Association of Local Behavioral Health Boards and Commissions

Two individuals

OPPOSITION: (Verified 6/21/24)

California State Association of Psychiatrists

ARGUMENTS IN SUPPORT: The California Hospital Association write that this bill simply addresses the process of transferring patients to medically necessary care by clarifying that EDs should transfer patients in crisis to accepting inpatient psychiatric hospitals regardless of whether the patient is on an involuntary hold. They also write that the provisions related to MCMC plans simply codify existing state policy for Medi-Cal covered services as outlined in recent state guidance. The Steinberg Institute writes that clarifying that patients should be transferred to psychiatric hospitals regardless of whether they are on an involuntary hold will reduce the time that people in mental health crises languish in hospital EDs.

ARGUMENTS IN OPPOSITION: The California State Association of Psychiatrists oppose the portion of the bill that revises the definition of “psychiatric emergency medical condition” to apply, regardless of whether a patient in a health facility is voluntary or involuntarily detained. Their concern is that the stabilization and transport of patients who are suicidal, dangerous, or gravely disabled absent involuntary detention could lead to situations where these patients are detained without an LPS assessment or will be released and endangered during transfer as a result of the lack of authority to involuntarily detain the patient.

ASSEMBLY FLOOR: 69-0, 1/25/24

AYES: Aguiar-Curry, Alanis, Alvarez, Arambula, Bains, Bauer-Kahan, Bennett, Berman, Boerner, Bryan, Calderon, Juan Carrillo, Cervantes, Chen, Connolly, Davies, Dixon, Essayli, Flora, Mike Fong, Vince Fong, Gabriel, Gallagher, Garcia, Gipson, Grayson, Haney, Hart, Hoover, Irwin, Jackson, Kalra, Lackey, Lee, Low, Lowenthal, Maienschein, Mathis, McCarty, McKinnor, Muratsuchi, Stephanie Nguyen, Ortega, Pacheco, Papan, Joe Patterson, Pellerin, Petrie-Norris, Quirk-Silva, Ramos, Rendon, Reyes, Rodriguez, Blanca Rubio, Sanchez, Santiago, Schiavo, Ta, Ting, Valencia, Waldron, Wallis, Ward, Weber, Wicks, Wilson, Wood, Zbur, Robert Rivas

NO VOTE RECORDED: Addis, Bonta, Wendy Carrillo, Megan Dahle, Friedman, Holden, Jones-Sawyer, Jim Patterson, Luz Rivas, Soria, Villapudua

Prepared by: Jen Flory / HEALTH / (916) 651-4111

6/25/24 13:06:28

**** END ****

SENATE COMMITTEE ON HEALTH

Senator Richard Roth, Chair

BILL NO: AB 1316

SUBJECT: Emergency services: psychiatric emergency medical conditions.

SUMMARY:

Revises the definition of “psychiatric emergency medical condition” to make the definition applicable regardless of whether the patient is voluntary or involuntarily detained for evaluation and treatment. Requires the Medi-Cal program and Medi-Cal managed care plans to cover all emergency services and care necessary to relieve or eliminate a psychiatric emergency medical condition, regardless of duration or whether the recipient is voluntary or involuntarily detained for evaluation and treatment.

Existing law:

1. Establishes the Medi-Cal program, which is administered by the Department of Health Care Services (DHCS), and under which qualified low-income individuals receive health care services. [WIC §14000, et seq.]
2. Authorizes the DHCS Director to contract, on a bid or nonbid basis, with any qualified individual, organization, or entity to provide services to, arrange for, or case manage the care of Medi-Cal beneficiaries and establishes managed care models that DHCS contracts with in each county. [WIC §14087.3, 14089, 14087.98, 14087.967, 14087.5]
3. Requires DHCS to implement mental health managed care through contracts with mental health plans. Requires DHCS to contract with a county or counties acting jointly for the delivery of specialty mental health services (“specialty services”) to each county’s eligible Medi-Cal beneficiary population. Authorizes mental health plan contracts to be awarded exclusively and on a geographic basis. [WIC §14712]
4. Requires Medi-Cal managed care (MCMC) plans to provide mental health benefits covered in the California’s Medicaid State Plan or the fee-for-service delivery system for beneficiaries not enrolled in a MCMC plan, excluding those benefits provided by mental health plans. [WIC §14184.402, §14189]
5. Establishes a schedule of benefits under Medi-Cal, which includes benefits required under federal law and benefits provided at the state’s option, both of which are funded with federal and state dollars. The schedule of benefits includes emergency services and care that are necessary for the treatment of an emergency medical condition and medical care directly related to the emergency medical condition for Medi-Cal fee-for-service beneficiaries and obligates MCMC plans to provide emergency services and care. [WIC §14132]
6. Requires MCMC plans to cover emergency services needed to evaluate or stabilize an emergency medical condition and poststabilization services related to an emergency medical condition that are provided after an enrollee is stabilized to maintain the stabilized condition or to improve or resolve the recipient’s condition. [42 CFR §438.114]
7. Requires emergency departments (EDs), under the federal Emergency Medical Treatment and Active Labor Act (EMTALA) and similar provisions of state law (state EMTALA), to provide emergency screening and stabilization services without regard to the patient’s insurance status or ability to pay. Federal EMTALA imposes this requirement on any hospital that participates in Medicare. State EMTALA imposes this requirement on any hospital that operates an ED. [42 USC §1395dd; HSC §1317]
8. Defines “emergency services and care” for purposes of a psychiatric emergency under state EMTALA, as medical screening, examination, and evaluation by a physician to determine if an emergency medical condition or active labor exists and, if it does, the care, treatment, and surgery, if within the scope of that person’s license, necessary to relieve or eliminate the emergency medical condition, within the capability of the facility. [HSC §1371.1]
9. Defines “emergency services and care,” under state EMTALA, to also mean an additional screening, examination, and evaluation by a physician, or other personnel to the extent permitted by the scope of their licensure and clinical privileges, to determine if a psychiatric emergency medical condition exists, and the care and treatment necessary to relieve or eliminate the psychiatric emergency medical condition, within the capability of the facility. Specifies that the care and treatment necessary to relieve or eliminate a psychiatric emergency medical condition may include admission or transfer to a psychiatric unit within a general acute care hospital, or to an acute psychiatric hospital. [HSC §1371.1]
10. Exempts MCMC plans from the definitions in 9) above if the services are excluded from coverage under their contracts with DHCS. [HSC §1371.1]
11. Defines “psychiatric emergency medical condition” as a mental disorder that manifests itself by acute symptoms of sufficient severity that it renders the patient as either an immediate danger to themselves or others or immediately unable to provide for, or utilize, food, shelter, or clothing due to the mental disorder. [HSC §1371.1]
12. Requires a psychiatric unit within a general acute care hospital, a psychiatric health facility of more than 16 beds, or an acute psychiatric hospital to accept a transfer of a person with a psychiatric emergency medical condition from a health facility that maintains and operates an ED. Requires the receiving facility to provide emergency services and care to that person, regardless of whether the facility operates an ED, if all of the following are met:
13. The treating physician at the sending facility has determined that the patient is medically stable and appropriate for treatment in a psychiatric setting and has included that determination in the patient’s medical record;
14. The receiving facility has an available bed;
15. The receiving facility has appropriate facilities and qualified personnel available to provide the services or care; and,
16. The receiving facility is not a state hospital or a county owned and operated psychiatric health facility. [HSC §1317.4b]
17. Specifies that the provisions in 12) above do not preempt any county or any other governmental agency acting within its authority from regulating emergency care or patient transfers, including the imposition of more specific duties. Clarifies that any inconsistent requirements imposed by the Medi-Cal program preempt those requirements with respect to Medi-Cal beneficiaries, and to the extent hospitals and physicians enter into contractual relationships with county or other governmental agencies that impose more stringent transfer requirements, those contractual agreements control. [HSC §1317.7]

This bill:

1. Clarifies that the definition of “psychiatric emergency medical condition” in 11) above applies regardless of whether the patient is voluntary or involuntarily detained for evaluation and treatment pursuant to the Lanterman-Petris-Short Act (LPS Act), and makes conforming changes throughout.
2. Prohibits the duties imposed by counties or other governmental agencies, and contractual agreements entered into by hospitals and physicians with counties or other governmental agencies, from unreasonably delaying or denying the provision of medically necessary care to a patient with a psychiatric emergency medical condition, regardless of whether the patient is voluntary or involuntarily detained for evaluation and treatment pursuant to the LPS Act.
3. Specifies that, for Medi-Cal recipients with psychiatric emergency medical conditions, emergency services and care necessary to relieve or eliminate that condition are covered services, regardless of duration, or whether the recipient is voluntary, or involuntarily detained for evaluation and treatment pursuant to the LPS Act. Specifies that emergency services and care includes all professional physical, mental, and substance use treatment services, including screening examinations necessary to determine the presence or absence of an emergency medical condition and, if an emergency medical condition exists, all services medically necessary to stabilize the recipient, and any poststabilization care services required under federal regulation. Specifies that emergency and poststabilization care services for these purposes include facility and professional services and facility charges for EDs.
4. Requires a MCMC plan to cover and reimburse providers furnishing the emergency services and care described in 3) above for its Medi-Cal recipients.
5. Allows DHCS to implement this bill via guidance without taking regulatory action. Conditions implementation of this bill on the continued receipt of federal financial participation.

FISCAL EFFECT:

According to the Assembly Appropriations Committee, this bill has no state costs.

PRIOR VOTES:

COMMENTS:

1. Author’s statement. According to the author, hospital EDs are a critical part of the safety net for Californians in a behavioral health crisis who desperately need psychiatric treatment. This bill supports hospitals and patients by ensuring psychiatric emergencies are treated with the same urgency and reimbursement practices used for patients with any other medical emergency. If a person is on an involuntary hold, this bill ensures this legal status is not an impediment to getting them the psychiatric health care they need, while also ensuring emergency room beds are available for incoming trauma patients. The bill also makes it clear that MCMC plans must cover all hospital ED visits, including psychiatric emergencies.
2. EMTALA. EMTALA was passed to address the problem of hospitals refusing to treat indigent, uninsured, or Medicaid patients, or “dumping” these patients by transferring them to county hospitals or other charity hospitals. Federal EMTALA obligates Medicare-participating hospitals that offer emergency services, to provide a medical screening and treatment for an emergency medical condition regardless of an individual's ability to pay. State EMTALA imposes its obligation on any hospital that operates an ED, and has similar requirements to federal EMTALA. Hospitals are required to provide stabilizing treatment for patients with an emergency medical condition. A patient is “stabilized” when the patient’s medical condition is such that, within reasonable medical probability, no material deterioration of the patient’s condition is likely to result from the release or transfer of the patient. If a hospital is unable to stabilize a patient within its capability, then a patient must be transferred to an appropriate facility with the necessary specialized treatment services. Once a patient is stabilized, if the patient needs poststabilization care, the hospital will typically seek more information about the medical history of the patient, including whether the patient has insurance.
3. Background on the LPS Act and designated vs nondesignated facilities. The LPS Act was enacted in the 1960s to develop a statutory process under which individuals could be involuntarily held and treated in a county-designated facility in a manner that safeguarded their constitutional rights. The LPS Act was intended to balance the goals of maintaining the constitutional right to personal liberty and choice in mental health treatment. Since its passage in 1967, the field of mental health has continued to evolve toward even greater legal rights for persons with mental health disorders. Welfare and Institutions Code Section 5150, part of the LPS Act, allows peace officers, staff members of county-designated facilities, or other county-designated professional persons to take an individual into custody and place them in a facility for 72-hour treatment and evaluation to determine if, due to a mental disorder, the individual is a danger to self or others, or is gravely disabled. The LPS Act imposes strict conditions relating to the detention, assessment, and treatment of the detainee. Provided that specified conditions are met, the peace officer and the medical director of the facility, as well as the professional staff responsible for the evaluation and treatment of the person, are granted immunity from civil and criminal liability for releasing the detainee at any time prior to the end of the 72-hour hold or for any actions of the person released before or after the 72-hour hold.
   
   Individual counties are responsible for determining whether general acute care hospitals, psychiatric health facilities, acute psychiatric hospitals, and other licensed facilities qualify to be designated facilities. While the intent of the LPS Act is for authorized individuals to take a person who has been placed on a 5150 hold to a designated facility, if one does not exist, or a person is suffering from another condition that requires immediate emergency medical services, the person is transported to the nearest facility, which is often a non-designated facility with an ED, which under both federal and state EMTALA is required to provide emergency medical services to any individual who presents and requires emergency medical attention.
4. Acute psychiatric hospitals, psychiatric health facilities, and crisis stabilization units. Generally speaking, inpatient beds for acute psychiatric patients are either provided in a distinct behavioral health unit of a general acute care hospital, in a freestanding acute psychiatric hospital, or in a psychiatric health facility. All of these can be, and most are, designated LPS facilities. There are 33 licensed acute psychiatric hospitals in California, and 29 psychiatric health facilities. Acute psychiatric hospitals are licensed by the California Department of Public Health (CDPH), and are required to provide medical, nursing, rehabilitative, pharmacy and dietary services, in addition to psychiatric services. Psychiatric health facilities are licensed by DHCS, and while not a hospital, are licensed to provide inpatient acute psychiatric care similar to a psychiatric hospital. However, the requirements for each facility are not the same. For example, psychiatric health facilities are not required to provide general medical services. While these facilities are required to have a physician be on-call at all times, a patient can only be admitted to a psychiatric health facility if the individual’s physical health care could otherwise be managed on an outpatient basis. An acute psychiatric hospital, on the other hand, is required to provide a medical service as part of their basic services, which must include a general medicine component. The general medicine component is required to provide all incidental medical services necessary for the care and support of patients, including general medicine and surgery. Psychiatric health facilities historically are county-run, or under contract by counties, to provide inpatient care to Medi-Cal beneficiaries through a county mental health plan.
   
   In addition to inpatient facilities, counties can designate certain outpatient facilities under the LPS Act, such as crisis stabilization units. A crisis stabilization unit is generally open 24 hours a day, seven days a week, and provides up to 23 hours of psychiatric urgent care intended to stabilize a patient suffering from psychiatric distress, with the goal of stabilizing the patient and avoiding the need for inpatient care.
5. Provision of mental health services in the Medi-Cal program. In 2014, the Medi-Cal program began requiring MCMC plans to provide services for mild-to-moderate impairment of mental, emotional, or behavioral health functioning. As a result, Medi-Cal mental health benefits are now delivered through two separate systems. County mental health plans provide a broad range of specialty services to individuals with more severe mental illnesses, while MCMC plans provide nonspecialty services (generally known as mental health services for those with mild-to-moderate mental illness). The delivery of specialty services through county mental health plans is commonly referred to as a “carve out,” which is when services covered by the Medi-Cal program are delivered outside of an MCMC plan. In addition, a small percentage of Medi-Cal recipients, particularly those new to the program who have not yet enrolled in an MCMC plan, still receive mental health services through the Medi-Cal fee-for-service program.

Further complicating the division of mental health benefits for most Medi-Cal beneficiaries in MCMC plans is how emergency psychiatric services are treated. Existing regulations and MCMC plan contracts with DHCS require the plans to cover emergency medical services without prior authorization, including those provided by EDs or emergency physicians for medical screening examinations necessary to determine the presence or absence of an emergency medical condition. Additionally, if an emergency medical condition exists, all services medically necessary to stabilize the plan member are covered without prior authorization. DHCS guidance found in All-Plan Letter 22-005 also states that emergency services include facility and professional services and facility charges claimed by EDs.

The MCMC plan contract also requires MCMC plans to have a memorandum of understanding with the county mental health plan to refer recipients in need of urgent and emergency mental health services. While most psychiatric inpatient services are carved out of the MCMC plan contract (to be provided by county mental health plans), MCMC plans are required to cover initial health history and physical examinations, consultations, and medically necessary covered services to members less than 21 years of age or age 65 and over.

1. Related legislation. AB 1001 (Haney) would require general acute care hospitals to adopt policies for behavioral health personnel to respond to patients with a mental health or substance use crisis. AB 1001 is pending in this Committee.
2. Prior legislation. AB 1164 (Lowenthal of 2023) would have required a general acute care hospital with an ED to calculate and record a crowding score, as specified, for its ED and file its full-capacity protocol with the Department of Health Care Access and Information. AB 1164 was held on the Assembly Appropriations suspense file.

AB 451 (Arambula, Chapter 438, Statutes of 2021) requires a psychiatric unit of a general acute care hospital, a psychiatric health facility of more than 16 beds that is not county operated, and an acute psychiatric hospital, to accept a transfer of a person with a psychiatric emergency medical condition, regardless of whether the facility operates an ED, if the facility has appropriate facilities and qualified personnel available to provide the services.

1. Support. Sponsor the California Hospital Association write that this bill simply addresses the process of transferring patients to medically necessary care by clarifying that EDs should transfer patients in crisis to accepting inpatient psychiatric hospitals regardless of whether the patient is on an involuntary hold. They also write that the provisions related to MCMC plans simply codify existing state policy for Medi-Cal covered services as outlined in recent state guidance. The Steinberg Institute writes that clarifying that patients should be transferred to psychiatric hospitals regardless of whether they are on an involuntary hold will reduce the time that people in mental health crises languish in hospital EDs.
2. Oppose. The California State Association of Psychiatrists oppose the portion of the bill that revises the definition of “psychiatric emergency medical condition” to apply, regardless of whether a patient in a health facility is voluntary or involuntarily detained. Their concern is that the stabilization and transport of patients who are suicidal, dangerous, or gravely disabled absent involuntary detention could lead to situations where these patients are detained without an LPS assessment or will be released and endangered during transfer as a result of the lack of authority to involuntarily detain the patient.
3. Policy comments. The author, sponsor, and DHCS agree that when a MCMC enrollee has a psychiatric emergency medical condition, that the MCMC plan should cover all emergency and poststabilization services provided up until the point that the recipient is admitted for inpatient care, if the recipient is admitted at all. However, given the complexity of the specialty behavioral health services carve out in the Medi-Cal program, the reference to federal regulation and other existing state law does not make this clear. The committee recommends adding specific language to Section 6 of this bill that excludes the MCMC plan’s obligation for services provided after a recipient is admitted for inpatient care.

Additionally, while implementing this bill via guidance, rather than regulatory action, may ensure a timely implementation, exempting DHCS from ever promulgating regulations on the matter will make it harder for stakeholders such as hospitals, managed care plans, and Medi-Cal recipients to find or enforce DHCS policy in the future.

1. Amendments. The author and the committee have agreed to amendments addressing the policy comments above:

Sec. 6, WIC 14132.025

(c) A Medi-Cal managed care plan, as defined in subdivision (j) of Section 14184.101, shall be responsible for covering, and reimbursing providers furnishing, the emergency services and care described in subdivision (b) for its enrolled Medi-Cal beneficiaries, excluding any Medi-Cal specialty mental health services provided once an enrolled beneficiary is admitted for inpatient psychiatric care.

. . .

(d) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department, without taking any further regulatory action, may implement, interpret, or make specific this section by means of all-plan letters, information notices, plan or provider bulletins, or similar instructions, until such time that the department can promulgate regulations.

SUPPORT AND OPPOSITION:

Support: California Hospital Association (sponsor)

Adventist Health

California Chapter of the American College of Emergency Physicians

Cedars Sinai

Loma Linda University Adventist Health

Providence

Psychiatric Physicians Alliance of California

Rady Children’s Hospital

Steinberg Institute

Tenet Healthcare Corporation

The California Association of Local Behavioral Health Boards and Commissions

Two individuals

Oppose: California State Association of Psychiatrists

-- END --

SENATE COMMITTEE ON HEALTH

Senator Richard Roth, Chair

BILL NO: AB 1316

SUBJECT: Emergency services: psychiatric emergency medical conditions.

SUMMARY:

Revises the definition of “psychiatric emergency medical condition” to make the definition applicable regardless of whether the patient is voluntary or involuntarily detained for evaluation and treatment. Requires the Medi-Cal program and Medi-Cal managed care plans to cover all emergency services and care necessary to relieve or eliminate a psychiatric emergency medical condition, regardless of duration or whether the recipient is voluntary or involuntarily detained for evaluation and treatment.

Existing law:

1. Establishes the Medi-Cal program, which is administered by the Department of Health Care Services (DHCS), and under which qualified low-income individuals receive health care services. [WIC §14000, et seq.]
2. Authorizes the DHCS Director to contract, on a bid or nonbid basis, with any qualified individual, organization, or entity to provide services to, arrange for, or case manage the care of Medi-Cal beneficiaries and establishes managed care models that DHCS contracts with in each county. [WIC §14087.3, 14089, 14087.98, 14087.967, 14087.5]
3. Requires DHCS to implement mental health managed care through contracts with mental health plans. Requires DHCS to contract with a county or counties acting jointly for the delivery of specialty mental health services (“specialty services”) to each county’s eligible Medi-Cal beneficiary population. Authorizes mental health plan contracts to be awarded exclusively and on a geographic basis. [WIC §14712]
4. Requires Medi-Cal managed care (MCMC) plans to provide mental health benefits covered in the California’s Medicaid State Plan or the fee-for-service delivery system for beneficiaries not enrolled in a MCMC plan, excluding those benefits provided by mental health plans. [WIC §14184.402, §14189]
5. Establishes a schedule of benefits under Medi-Cal, which includes benefits required under federal law and benefits provided at the state’s option, both of which are funded with federal and state dollars. The schedule of benefits includes emergency services and care that are necessary for the treatment of an emergency medical condition and medical care directly related to the emergency medical condition for Medi-Cal fee-for-service beneficiaries and obligates MCMC plans to provide emergency services and care. [WIC §14132]
6. Requires MCMC plans to cover emergency services needed to evaluate or stabilize an emergency medical condition and poststabilization services related to an emergency medical condition that are provided after an enrollee is stabilized to maintain the stabilized condition or to improve or resolve the recipient’s condition. [42 CFR §438.114]
7. Requires emergency departments (EDs), under the federal Emergency Medical Treatment and Active Labor Act (EMTALA) and similar provisions of state law (state EMTALA), to provide emergency screening and stabilization services without regard to the patient’s insurance status or ability to pay. Federal EMTALA imposes this requirement on any hospital that participates in Medicare. State EMTALA imposes this requirement on any hospital that operates an ED. [42 USC §1395dd; HSC §1317]
8. Defines “emergency services and care” for purposes of a psychiatric emergency under state EMTALA, as medical screening, examination, and evaluation by a physician to determine if an emergency medical condition or active labor exists and, if it does, the care, treatment, and surgery, if within the scope of that person’s license, necessary to relieve or eliminate the emergency medical condition, within the capability of the facility. [HSC §1371.1]
9. Defines “emergency services and care,” under state EMTALA, to also mean an additional screening, examination, and evaluation by a physician, or other personnel to the extent permitted by the scope of their licensure and clinical privileges, to determine if a psychiatric emergency medical condition exists, and the care and treatment necessary to relieve or eliminate the psychiatric emergency medical condition, within the capability of the facility. Specifies that the care and treatment necessary to relieve or eliminate a psychiatric emergency medical condition may include admission or transfer to a psychiatric unit within a general acute care hospital, or to an acute psychiatric hospital. [HSC §1371.1]
10. Exempts MCMC plans from the definitions in 9) above if the services are excluded from coverage under their contracts with DHCS. [HSC §1371.1]
11. Defines “psychiatric emergency medical condition” as a mental disorder that manifests itself by acute symptoms of sufficient severity that it renders the patient as either an immediate danger to themselves or others or immediately unable to provide for, or utilize, food, shelter, or clothing due to the mental disorder. [HSC §1371.1]
12. Requires a psychiatric unit within a general acute care hospital, a psychiatric health facility of more than 16 beds, or an acute psychiatric hospital to accept a transfer of a person with a psychiatric emergency medical condition from a health facility that maintains and operates an ED. Requires the receiving facility to provide emergency services and care to that person, regardless of whether the facility operates an ED, if all of the following are met:
13. The treating physician at the sending facility has determined that the patient is medically stable and appropriate for treatment in a psychiatric setting and has included that determination in the patient’s medical record;
14. The receiving facility has an available bed;
15. The receiving facility has appropriate facilities and qualified personnel available to provide the services or care; and,
16. The receiving facility is not a state hospital or a county owned and operated psychiatric health facility. [HSC §1317.4b]
17. Specifies that the provisions in 12) above do not preempt any county or any other governmental agency acting within its authority from regulating emergency care or patient transfers, including the imposition of more specific duties. Clarifies that any inconsistent requirements imposed by the Medi-Cal program preempt those requirements with respect to Medi-Cal beneficiaries, and to the extent hospitals and physicians enter into contractual relationships with county or other governmental agencies that impose more stringent transfer requirements, those contractual agreements control. [HSC §1317.7]

This bill:

1. Clarifies that the definition of “psychiatric emergency medical condition” in 11) above applies regardless of whether the patient is voluntary or involuntarily detained for evaluation and treatment pursuant to the Lanterman-Petris-Short Act (LPS Act), and makes conforming changes throughout.
2. Prohibits the duties imposed by counties or other governmental agencies, and contractual agreements entered into by hospitals and physicians with counties or other governmental agencies, from unreasonably delaying or denying the provision of medically necessary care to a patient with a psychiatric emergency medical condition, regardless of whether the patient is voluntary or involuntarily detained for evaluation and treatment pursuant to the LPS Act.
3. Specifies that, for Medi-Cal recipients with psychiatric emergency medical conditions, emergency services and care necessary to relieve or eliminate that condition are covered services, regardless of duration, or whether the recipient is voluntary, or involuntarily detained for evaluation and treatment pursuant to the LPS Act. Specifies that emergency services and care includes all professional physical, mental, and substance use treatment services, including screening examinations necessary to determine the presence or absence of an emergency medical condition and, if an emergency medical condition exists, all services medically necessary to stabilize the recipient, and any poststabilization care services required under federal regulation. Specifies that emergency and poststabilization care services for these purposes include facility and professional services and facility charges for EDs.
4. Requires a MCMC plan to cover and reimburse providers furnishing the emergency services and care described in 3) above for its Medi-Cal recipients.
5. Allows DHCS to implement this bill via guidance without taking regulatory action. Conditions implementation of this bill on the continued receipt of federal financial participation.

FISCAL EFFECT:

According to the Assembly Appropriations Committee, this bill has no state costs.

PRIOR VOTES:

COMMENTS:

1. Author’s statement. According to the author, hospital EDs are a critical part of the safety net for Californians in a behavioral health crisis who desperately need psychiatric treatment. This bill supports hospitals and patients by ensuring psychiatric emergencies are treated with the same urgency and reimbursement practices used for patients with any other medical emergency. If a person is on an involuntary hold, this bill ensures this legal status is not an impediment to getting them the psychiatric health care they need, while also ensuring emergency room beds are available for incoming trauma patients. The bill also makes it clear that MCMC plans must cover all hospital ED visits, including psychiatric emergencies.
2. EMTALA. EMTALA was passed to address the problem of hospitals refusing to treat indigent, uninsured, or Medicaid patients, or “dumping” these patients by transferring them to county hospitals or other charity hospitals. Federal EMTALA obligates Medicare-participating hospitals that offer emergency services, to provide a medical screening and treatment for an emergency medical condition regardless of an individual's ability to pay. State EMTALA imposes its obligation on any hospital that operates an ED, and has similar requirements to federal EMTALA. Hospitals are required to provide stabilizing treatment for patients with an emergency medical condition. A patient is “stabilized” when the patient’s medical condition is such that, within reasonable medical probability, no material deterioration of the patient’s condition is likely to result from the release or transfer of the patient. If a hospital is unable to stabilize a patient within its capability, then a patient must be transferred to an appropriate facility with the necessary specialized treatment services. Once a patient is stabilized, if the patient needs poststabilization care, the hospital will typically seek more information about the medical history of the patient, including whether the patient has insurance.
3. Background on the LPS Act and designated vs nondesignated facilities. The LPS Act was enacted in the 1960s to develop a statutory process under which individuals could be involuntarily held and treated in a county-designated facility in a manner that safeguarded their constitutional rights. The LPS Act was intended to balance the goals of maintaining the constitutional right to personal liberty and choice in mental health treatment. Since its passage in 1967, the field of mental health has continued to evolve toward even greater legal rights for persons with mental health disorders. Welfare and Institutions Code Section 5150, part of the LPS Act, allows peace officers, staff members of county-designated facilities, or other county-designated professional persons to take an individual into custody and place them in a facility for 72-hour treatment and evaluation to determine if, due to a mental disorder, the individual is a danger to self or others, or is gravely disabled. The LPS Act imposes strict conditions relating to the detention, assessment and treatment of the detainee. Provided that specified conditions are met, the peace officer and the medical director of the facility, as well as the professional staff responsible for the evaluation and treatment of the person, are granted immunity from civil and criminal liability for releasing the detainee at any time prior to the end of the 72-hour hold or for any actions of the person released before or after the 72-hour hold.
   
   Individual counties are responsible for determining whether general acute care hospitals, psychiatric health facilities, acute psychiatric hospitals, and other licensed facilities qualify to be designated facilities. While the intent of the LPS Act is for authorized individuals to take a person who has been placed on a 5150 hold to a designated facility, if one does not exist, or a person is suffering from another condition that requires immediate emergency medical services, the person is transported to the nearest facility, which is often a non-designated facility with an ED, which under both federal and state EMTALA is required to provide emergency medical services to any individual who presents and requires emergency medical attention.
4. Acute psychiatric hospitals, psychiatric health facilities, and crisis stabilization units. Generally speaking, inpatient beds for acute psychiatric patients are either provided in a distinct behavioral health unit of a general acute care hospital, in a freestanding acute psychiatric hospital, or in a psychiatric health facility. All of these can be, and most are, designated LPS facilities. There are 33 licensed acute psychiatric hospitals in California, and 29 psychiatric health facilities. Acute psychiatric hospitals are licensed by the California Department of Public Health (CDPH), and are required to provide medical, nursing, rehabilitative, pharmacy and dietary services, in addition to psychiatric services. Psychiatric health facilities are licensed by DHCS, and while not a hospital, are licensed to provide inpatient acute psychiatric care similar to a psychiatric hospital. However, the requirements for each facility are not the same. For example, psychiatric health facilities are not required to provide general medical services. While these facilities are required to have a physician be on-call at all times, a patient can only be admitted to a psychiatric health facility if the individual’s physical health care could otherwise be managed on an outpatient basis. An acute psychiatric hospital, on the other hand, is required to provide a medical service as part of their basic services, which must include a general medicine component. The general medicine component is required to provide all incidental medical services necessary for the care and support of patients, including general medicine and surgery. Psychiatric health facilities historically are county-run, or under contract by counties, to provide inpatient care to Medi-Cal beneficiaries through a county mental health plan.
   
   In addition to inpatient facilities, counties can designate certain outpatient facilities under the LPS Act, such as crisis stabilization units. A crisis stabilization unit is generally open 24 hours a day, seven days a week, and provides up to 23 hours of psychiatric urgent care intended to stabilize a patient suffering from psychiatric distress, with the goal of stabilizing the patient and avoiding the need for inpatient care.
5. Provision of mental health services in the Medi-Cal program. In 2014, the Medi-Cal program began requiring MCMC plans to provide services for mild-to-moderate impairment of mental, emotional, or behavioral health functioning. As a result, Medi-Cal mental health benefits are now delivered through two separate systems. County mental health plans provide a broad range of specialty services to individuals with more severe mental illnesses, while MCMC plans provide nonspecialty services (generally known as mental health services for those with mild-to-moderate mental illness). The delivery of specialty services through county mental health plans is commonly referred to as a “carve out,” which is when services covered by the Medi-Cal program are delivered outside of an MCMC plan. In addition, a small percentage of Medi-Cal recipients, particularly those new to the program who have not yet enrolled in an MCMC plan, still receive mental health services through the Medi-Cal fee-for-service program.

Further complicating the division of mental health benefits for most Medi-Cal beneficiaries in MCMC plans is how emergency psychiatric services are treated. Existing regulations and MCMC plan contracts with DHCS require the plans to cover emergency medical services without prior authorization, including those provided by EDs or emergency physicians for medical screening examinations necessary to determine the presence or absence of an emergency medical condition. Additionally, if an emergency medical condition exists, all services medically necessary to stabilize the plan member are covered without prior authorization. DHCS guidance found in All-Plan Letter 22-005 also states that emergency services include facility and professional services and facility charges claimed by EDs.

The MCMC plan contract also requires MCMC plans to have an memorandum of understanding with the county mental health plan to refer recipients in need of urgent and emergency mental health services. While most psychiatric inpatient services are carved out of the MCMC plan contract (to be provided by county mental health plans), MCMC plans are required to cover initial health history and physical examinations, consultations, and medically necessary covered services to members less than 21 years of age or age 65 and over.

1. Related legislation. AB 1001 (Haney) would require general acute care hospitals to adopt policies for behavioral health personnel to respond to patients with a mental health or substance use crisis. AB 1001 is pending in this Committee.
2. Prior legislation. AB 1164 (Lowenthal of 2023) would have required a general acute care hospital with an ED to calculate and record a crowding score, as specified, for its ED and file its full-capacity protocol with the Department of Health Care Access and Information. AB 1164 was held on the Assembly Appropriations suspense file.

AB 451 (Arambula, Chapter 438, Statutes of 2021) requires a psychiatric unit of a general acute care hospital, a psychiatric health facility of more than 16 beds that is not county operated, and an acute psychiatric hospital, to accept a transfer of a person with a psychiatric emergency medical condition, regardless of whether the facility operates an ED, if the facility has appropriate facilities and qualified personnel available to provide the services.

1. Support. Sponsors the California Hospital Association write that this bill simply addresses the process of transferring patients to medically necessary care by clarifying that EDs should transfer patients in crisis to accepting inpatient psychiatric hospitals regardless of whether the patient is on an involuntary hold. They also write that the provisions related to MCMC plans simply codify existing state policy for Medi-Cal covered services as outlined in recent state guidance. The Steinberg Institute writes that clarifying that patients should be transferred to psychiatric hospitals regardless of whether they are on an involuntary hold will reduce the time that people in mental health crises languish in hospital EDs.
2. Oppose. The California State Association of Psychiatrists oppose the portion of the bill that revises the definition of “psychiatric emergency medical condition” to apply, regardless of whether a patient in a health facility is voluntary or involuntarily detained. Their concern is that the stabilization and transport of patients who are suicidal, dangerous, or gravely disabled absent involuntary detention could lead to situations where these patients are detained without an LPS assessment or will be released and endangered during transfer as a result of the lack of authority to involuntarily detain the patient.
3. Policy comments. The author, sponsor, and DHCS agree that when a MCMC enrollee has a psychiatric emergency medical condition, that the MCMC plan should cover all emergency and poststabilization services provided up until the point that the recipient is admitted for inpatient care, if the recipient is admitted at all. However, given the complexity of the specialty behavioral health services carve out in the Medi-Cal program, the reference to federal regulation and other existing state law does not make this clear. The committee recommends adding specific language to Section 6 of this bill that excludes the MCMC plan’s obligation for services provided after a recipient is admitted for inpatient care.

Additionally, while implementing this bill via guidance, rather than regulatory action, may ensure a timely implementation, exempting DHCS from ever promulgating regulations on the matter will make it harder for stakeholders such as hospitals, managed care plans, and Medi-Cal recipients to find or enforce DHCS policy in the future.

1. Amendments. The author and the committee have agreed to amendments addressing the policy comments above:

Sec. 6, WIC 14132.025

(b) For a beneficiary with a psychiatric emergency medical condition, as defined in Section 1317.1 of the Health and Safety Code, emergency services and care necessary to relieve or eliminate that condition are covered, regardless of duration, or whether the beneficiary is voluntary, or involuntarily detained for evaluation and treatment pursuant to the Lanterman-Petris-Short Act (Part 1 (commencing with Section 5000) of Division 5 of the Welfare and Institutions Code). Emergency services and care includes all professional physical, mental, and substance use treatment services, including screening examinations necessary to determine the presence or absence of an emergency medical condition and, if an emergency medical condition exists, all services medically necessary to stabilize the beneficiary, and any poststabilization care services required under Section 438.114 of Title 42 of the Code of Federal Regulations, excluding any Medi-Cal specialty mental health services received once a beneficiary is admitted for inpatient psychiatric care. Emergency and poststabilization care services for these purposes include facility and professional services and facility charges for emergency departments.

. . .

(d) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department, without taking any further regulatory action, may implement, interpret, or make specific this section by means of all-plan letters, information notices, plan or provider bulletins, or similar instructions, until such time that the department can promulgate regulations.

SUPPORT AND OPPOSITION:

Support: California Hospital Association (sponsor)

California Chapter of the American College of Emergency Physicians

Providence

Steinberg Institute

The California Association of Local Behavioral Health Boards and Commissions

Two individuals

Oppose: California State Association of Psychiatrists

-- END --

Date of Hearing: January 18, 2024

ASSEMBLY COMMITTEE ON APPROPRIATIONS

Chris Holden, Chair

ABPCA Bill Id:AB 1316

Author:(Irwin) – As Amended Ver:January 3, 2024

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

SUMMARY:

This bill revises the definition of “psychiatric emergency medical condition” to apply, regardless of whether a patient in a health facility is voluntary or is involuntarily detained for evaluation and requires the Medi-Cal program to cover all services and care necessary to treat an emergency medical condition, including a psychiatric emergency medical condition.

Specifically, this bill:

1. Revises the definition of “psychiatric emergency medical condition” to apply, under specified circumstances, regardless of whether the patient is voluntary or is involuntarily detained for evaluation and treatment under the Lanterman Petris-Short (LPS) Act.
   
2. Requires the Medi-Cal program, including Medi-Cal managed care plans (MCPs), to cover all professional physical, mental, and substance use treatment services, including screening examinations necessary to determine the presence or absence of an emergency medical condition, as defined, and all services medically necessary to stabilize a beneficiary with an emergency medical condition, regardless of duration.
   
3. Prohibits a county or other governmental agency and contracting physician or hospital from entering into contractual agreements that unreasonably delay or deny necessary care to a patient with a psychiatric emergency condition.

FISCAL EFFECT:

No state costs.

COMMENTS:

1. Purpose. This bill is sponsored by the California Hospital Association (CHA). According to the author:

[This bill] supports hospitals and patients by ensuring psychiatric emergencies are treated with the same urgency and reimbursement practices used for patients with any other medical emergency. If a person is on an involuntary hold, [this bill] ensures this legal status is not an impediment to getting them the psychiatric health care they need, while also ensuring emergency room beds are available for trauma patients. The bill also makes it clear that Medi-Cal managed care plans must cover all hospital emergency department visits, including psychiatric emergencies.

1. Background.

The LPS Act. The LPS Act was enacted to develop a process by which an individual could be involuntarily held and treated in a county-designated facility in a manner that safeguarded their constitutional rights. While the intent of the LPS Act is for an authorized individual to take a person who has been detained for a psychiatric emergency to a county-designated facility, if such a facility does not exist, or the person is suffering from another condition that requires immediate emergency medical care, the person is transported to the nearest facility, which is often a non-designated facility with an emergency department (ED). EDs are required to provide emergency medical services to any individual who presents requiring emergency medical attention.

Shortage of psychiatric beds and timeliness of transfers. According to CHA, California has only 17 psychiatric beds for every 100,000 residents, while the recommended minimum is 50 psychiatric beds per 100,000. CHA contends that, in many instances, long stays in hospital EDs are due to hospitals’ difficulty finding an available inpatient psychiatric bed. For an individual with Medi-Cal or on an involuntary psychiatric hold, CHA contends the county often instructs the hospital to hold the patient in the ED until the county finds the patient a bed, and the county often takes longer to find a bed than the hospital.

1. Medi-Cal MCP Coverage of Emergency Services. The Department of Health Care Services (DHCS) states MCPs are responsible for coverage and payment of emergency services and post-stabilization care services for Medi-Cal MCP enrollees. However, Medi-Cal MCP contract language carved out exceptions for: (a) services provided by specified mental health providers and (b) facility charges for ED visits that result in a psychiatric admission. DHCS has been revising contracts to align with guidance it issued in a 2022 All-Plan Letter titled “No Wrong Door for Mental Health Services.” This bill codifies MCPs’ responsibility to cover ED services without the exceptions related to mental health care.
   
2. Related Legislation. AB 1001 (Haney) creates a new definition of “behavioral health emergency condition” which applies specifically to patients in hospital EDs, and requires hospitals to adopt policies to respond to a patient requiring behavioral health emergency services, as defined. AB 1001 was referred to Senate Health Committee but was not heard.
3. Prior Legislation. AB 451 (Arambula), Chapter 438, Statutes of 2021, requires a facility to accept a transfer of a person with a psychiatric emergency medical condition, regardless of whether the facility operates an ED, if the facility has appropriate facilities and personnel.

Analysis Prepared by: Allegra Kim / APPR. / (916) 319-2081

Date of Hearing: January 9, 2024

ASSEMBLY COMMITTEE ON HEALTH

Mia Bonta, Chair

ABPCA Bill Id:AB 1316 (

Author:(Irwin and Ward) – As Amended Ver:January 3, 2024

SUBJECT: Emergency services: psychiatric emergency medical conditions.

SUMMARY: Revises the definition of “psychiatric emergency medical condition” to apply that definition regardless of whether the patient is voluntary, or is involuntarily detained for evaluation and treatment, under certain circumstances. Requires the Medi-Cal program to cover emergency services and care necessary to treat an emergency medical condition, as defined, including all professional physical, mental, and substance use treatment services, including screening examinations necessary to determine the presence or absence of an emergency medical condition and, if an emergency medical condition exists, for all services medically necessary to stabilize the beneficiary. Specifically, this bill:

1. Revises the definition of “psychiatric emergency medical condition” to clarify that the definition applies regardless of whether the patient is voluntary or involuntarily detained for evaluation and treatment pursuant to the Lanterman-Petris-Short Act (LPS Act).
2. Requires the Medi-Cal program to cover emergency services and care necessary to treat an emergency medical condition, as defined, including all professional physical, mental, and substance use treatment services, including screening examinations necessary to determine the presence or absence of an emergency medical condition.
3. Prohibits Medi-Cal requirements, duties or contractual agreements from unreasonably delaying or denying the provision of medically necessary care to a patient with a psychiatric emergency medical condition, regardless of whether the patient is voluntary or involuntarily detained for evaluation and treatment pursuant to the LPS Act.

EXISTING LAW:

1. Licenses and regulates hospitals, including GACHs and APH, by the Department of Public Health (DPH). Permits GACHs, in addition to the basic services all hospitals are required to offer, to be approved by DPH to offer special services, including, among other services, an ED, and psychiatric services. [Health and Safety Code (HSC) §1250 and §1255, et seq.]
   
2. Licenses PHFs by the Department of Health Care Services (DHCS), which are defined as health facilities that provide 24-hour inpatient care for people with mental health disorders, whose physical health needs can be met in an affiliated hospital or in outpatient settings. [HSC §1250.2]
   
3. Requires EDs, under the federal Emergency Medical Treatment and Active Labor Act (EMTALA) and also under similar provisions of state law (state EMTALA), to provide emergency screening and stabilization services without regard to the patient’s insurance status or ability to pay. Federal EMTALA imposes this requirement on any hospital that participates in Medicare. State EMTALA imposes this requirement on any hospital that operates an ED. [42 United States Code §1395dd; HSC §1317]
   
4. Defines “emergency services and care,” under state EMTALA, as medical screening, examination, and evaluation by a physician to determine if an emergency medical condition or active labor exists and, if it does, the care, treatment, and surgery, if within the scope of that person’s license, necessary to relieve or eliminate the emergency medical condition, within the capability of the facility. [HSC §1317.1 (a)(1)]
5. Defines “emergency services and care,” under state EMTALA, to also mean an additional screening, examination, and evaluation by a physician, or other personnel to the extent permitted by the scope of their licensure and clinical privileges, to determine if a psychiatric emergency medical condition exists, and the care and treatment necessary to relieve or eliminate the psychiatric emergency medical condition, within the capability of the facility. Specifies that the care and treatment necessary to relieve or eliminate a psychiatric emergency medical condition may include admission or transfer to a psychiatric unit within a GACH, or to an APH. [HSC §1317.1 (a)(2)]
6. Defines “emergency medical condition” to mean a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following:
   1. Placing the patient’s health in serious jeopardy;
   2. Serious impairment to bodily functions; or,
   3. Serious dysfunction of any bodily organ or part. [HSC §1317.1 (b)]
7. Prohibits a person needing emergency services and care from being transferred from a hospital to another hospital for any nonmedical reason (such as the person’s inability to pay for any emergency service or care) unless certain conditions are met, including that the person has been provided with emergency services so that it can be determined, within reasonable medical probability, that the transfer will not create a medical hazard to the person. [HSC §1317.2]
8. Requires a psychiatric unit within a GACH, a PHF of more than 16 beds, or an APH, to accept a transfer of a person with a psychiatric emergency medical condition, as defined, from a health facility that maintains and operates an ED and the receiving facility to provide emergency services and care to that person, regardless of whether the facility operates an ED, if all of the following requirements are met:
   1. The treating physician at the sending facility has determined that the patient is medically stable and appropriate for treatment in a psychiatric setting and has included that determination in the patient’s medical record;
   2. The receiving facility has an available bed; and,
   3. The receiving facility has appropriate facilities and qualified personnel available to provide the services or care. [HSC §1317.4b]
9. Specifies that the provisions described in 8) above do not apply to a PHF that is county owned and operated. [Id.]
10. Specifies that the provisions in 8) above do not preempt any county or any other governmental agency acting within its authority from regulating emergency care or patient transfers, including the imposition of more specific duties. Clarifies that any inconsistent requirements imposed by the Medi-Cal program preempt the requirements in 8) above with respect to Medi-Cal beneficiaries, and to the extent hospitals and physicians enter into contractual relationships with county or other governmental agencies that impose more stringent transfer requirements, those contractual agreements control. [HSC §1317.7]
11. Establishes the LPS Act and declares the intent of the Legislature to end the inappropriate, indefinite, and involuntary commitment of persons with mental health disorders, developmental disabilities, and chronic alcoholism, as well as to safeguard a person’s rights, provide prompt evaluation and treatment, and provide services in the least restrictive setting appropriate to the needs of each person. [Welfare and Institutions Code (WIC) §5000, et seq.]
12. Authorizes a peace officer, member of the attending staff of a “designated facility,” as defined, member of the attending staff of a designated facility, or other professional person designated by the county, upon probable cause, to take a person with a mental disorder who is a danger to self or others, or is gravely disabled, into custody (referred to as a “5150” hold) and place them in a designated facility. [WIC §5150]
    
13. Defines “designated facility” or “facility designated by the county for evaluation and treatment” as a facility that is licensed or certified as a mental health treatment facility or a hospital, as defined, and includes, but is not limited to, a licensed psychiatric hospital, a licensed psychiatric health facility, and a certified crisis stabilization unit. [WIC §5008]
    
14. Authorizes a county behavioral health director to develop procedures for the county’s designation and training of professionals who will be designated to perform functions under Section 5150. Authorizes these procedures to include, but not be limited to, the following:
    1. The license types, practice disciplines, and clinical experience of professionals eligible to be designated by the county;
    2. The initial and ongoing training and testing requirements for professionals eligible to be designated by the county;
    3. The application and approval processes for professionals seeking to be designated by the county, including the timeframe for initial designation and procedures for renewal of the designation; and,
    4. The county’s process for monitoring and reviewing professionals designated by the county to ensure appropriate compliance with state law, regulations, and county procedures. [WIC §5121]
       
15. Requires a health care service plan that covers hospital, medical, or surgical expenses, or its contracting medical providers, to provide 24-hour access for enrollees and providers, including, but not limited to, noncontracting hospitals, to obtain timely authorization for medically necessary care, for circumstances where the enrollee has received emergency services and care is stabilized, but the treating provider believes that the enrollee may not be discharged safely. [HSC §1371.4 (a)]
    
16. Requires a health care service plan, or its contracting medical providers, to reimburse providers for emergency services and care provided to its enrollees, until the care results in stabilization of the enrollee, except as provided in 17) below. Prohibits, as long as federal or state law requires that emergency services and care be provided without first questioning the patient’s ability to pay, a health care service plan from requiring a provider to obtain authorization prior to the provision of emergency services and care necessary to stabilize the enrollee’s emergency medical condition. [HSC §1371.4 (b)]
    
17. Allows payment for emergency services and care to be denied only if the health care service plan, or its contracting medical providers, reasonably determines that the emergency services and care were never performed, in cases when the plan enrollee did not require emergency services and care; and, the enrollee reasonably should have known that an emergency did not exist. Authorizes a health care service plan to require prior authorization as a prerequisite for payment for necessary medical care following stabilization of an emergency medical condition. [HSC §1371.4 (c)]
    
18. Requires a health care service plan, if there is a disagreement between the health care service plan and the provider regarding the need for necessary medical care, following stabilization of the enrollee, to assume responsibility for the care of the patient either by having medical personnel contracting with the plan personally take over the care of the patient within a reasonable amount of time after the disagreement, or by having another GACH under contract with the plan agree to accept the transfer of the patient as provided in existing law. Prohibits this requirement from applying to necessary medical care provided in hospitals outside the service area of the health care service plan. [HSC §1371.4 (d)]
    

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

COMMENTS:

1. PURPOSE OF THIS BILL. According to the author, hospital EDs are a critical part of the safety net for Californians in a mental health crisis who desperately need psychiatric treatment. This bill supports hospitals and patients by ensuring psychiatric emergencies are treated with the same urgency and reimbursement practices used for patients with any other medical emergency. The author states that, if a person is on an involuntary hold, this bill ensures this legal status is not an impediment to getting them the psychiatric health care they need, while also ensuring ED beds are available for incoming trauma patients. The author concludes that this bill also makes it clear that Medi-Cal managed care plans must cover all hospital ED visits, including psychiatric emergencies.
2. BACKGROUND.
   1. The LPS Act and designated vs nondesignated facilities. The LPS Act was enacted in the 1960s to develop a statutory process under which individuals could be involuntarily held and treated in a county-designated facility in a manner that safeguarded their constitutional rights. The LPS Act was intended to balance the goals of maintaining the constitutional right to personal liberty and choice in mental health treatment. Since its passage in 1967, the field of mental health has continued to evolve toward even greater legal rights for mentally disordered persons. WIC Section 5150, part of the LPS Act, allows peace officers, staff members of county-designated facilities, or other county-designated professional persons to take an individual into custody and place them in a facility for 72-hour treatment and evaluation to determine if, due to a mental disorder, the individual is a danger to self or others, or is gravely disabled. The LPS Act imposes strict conditions relating to the detention, assessment, and treatment of the detainee. Provided that specified conditions are met, the peace officer and the medical director of the facility, as well as the professional staff responsible for the evaluation and treatment of the person, are granted immunity from civil and criminal liability for releasing the detainee at any time prior to the end of the 72-hour hold or for any actions of the person released before or after the 72-hour hold.

Individual counties are responsible for determining whether GACHs, PHFs, APHs, and other licensed facilities qualify to be designated facilities. While the intent of the LPS Act is for authorized individuals to take a person who has been placed on a 5150 hold to a designated facility, if one does not exist, or a person is suffering from another condition that requires immediate emergency medical services, the person is transported to the nearest facility, which is often a non-designated facility with an ED, which under both federal and state EMTALA is required to provide emergency medical services to any individual who presents and requires emergency medical attention.

• 1. Lack of inpatient psychiatric beds and timeliness of transfers. According to the California Hospital Association (CHA), since 1995 the state has lost at least 37 facilities, either through the elimination of psychiatric inpatient care, or complete hospital closure, representing a 20% drop. CHA states that while there has been an increase in psychiatric beds over the past several years, California has lost nearly 30% of the psychiatric beds it had in 1995. On a per capita basis, accounting for the growth in California’s population, this translates into a loss of more than 42% of the psychiatric inpatient beds per capita since 1995. California now has only 17 psychiatric beds for every 100,000 residents, compared to nearly 30 beds per 100,000 in 1995, and well short of the recommended minimum number of 50 psychiatric beds per 100,000.
     
     According to information provided by CHA, the sponsor of this bill, in many instances, long stays in hospital EDs are due to hospitals’ difficulty finding an available inpatient psychiatric bed. In the case of individuals with Medi-Cal and those who may be on an involuntary psychiatric hold, hospitals are often instructed by the county to hold the patient in the ED until the county finds the patient a bed. CHA states that hospitals report that it often takes disproportionately longer when awaiting the county to find an inpatient psychiatric bed than it does when the hospital makes the arrangements for all its other patients. This could be due to county workforce challenges that make it difficult to manage the bed finding process on a 24/7 basis. Since inpatient psychiatric services are a Medi-Cal benefit administered by the counties, they may also prefer waiting for an available bed to open up in only those hospitals with which they hold a contract.
     
  2. APHs, PHFs, and crisis stabilization units. Generally, inpatient beds for acute psychiatric patients are either provided in a distinct behavioral health unit of a GACH, in a freestanding APH, or in a PHF. All of these can be, and most are, designated LPS facilities. There are 33 licensed APHs and 29 PHFs in California. APHs are licensed by DPH, and are required to provide medical, nursing, rehabilitative, pharmacy and dietary services, in addition to psychiatric services. PHFs are licensed by DHCS, and while not a hospital, are licensed to provide inpatient acute psychiatric care similar to a psychiatric hospital. However, the requirements for PHFs are not the same as those for APHs. For example, PHFs are not required to provide general medical services. While a PHF is required to have a physician on-call at all times, a patient can only be admitted to a PHF if the individual’s physical health care could otherwise be managed on an outpatient basis. An APH, on the other hand, is required to provide a medical service as part of their basic services, which must include a general medicine component. The general medicine component is required to provide all incidental medical services necessary for the care and support of patients, including general medicine and surgery. PHFs historically are county-run, or under contract by counties, to provide inpatient care to Medi-Cal beneficiaries through a county mental health plan.
     
     In addition to inpatient facilities, counties can designate certain outpatient facilities under the LPS Act, such as crisis stabilization units. A crisis stabilization unit is generally open 24 hours a day, seven days a week, and provides up to 23 hours of psychiatric urgent care intended to stabilize a patient suffering from psychiatric distress, with the goal of stabilizing the patient and avoiding the need for inpatient care.
  3. EMTALA. EMTALA was passed to address the problem of hospitals refusing to treat indigent, uninsured, or Medicaid patients, or “dumping” these patients by transferring them to county hospitals or other charity hospitals. Federal EMTALA obligates Medicare-participating hospitals that offer emergency services to provide a medical screening and treatment for an emergency medical condition, including active labor, regardless of an individual's ability to pay. State EMTALA imposes its obligation on any hospital that operates an ED, and has similar requirements to federal EMTALA. Hospitals are required to provide stabilizing treatment for patients with an emergency medical condition. A patient is “stabilized” when the patient’s medical condition is such that, within reasonable medical probability, no material deterioration of the patient’s condition is likely to result from the release or transfer of the patient. If a hospital is unable to stabilize a patient within its capability, then a patient is required to be transferred to an appropriate facility with the necessary specialized treatment services. Once a patient is stabilized, if the patient needs post-stabilization care, the hospital will typically seek more information about the medical history of the patient, including whether the patient has insurance.
  4. Medi-Cal Managed Care Plan (MCP) Coverage of Emergency Services. The Medi-Cal provisions of this bill reflect current DHCS policy, and appear consistent with DHCS’s intention to revise MCP contract language to clarify payment for emergency services.
     
     Current contracts between MCPs and DHCS specify MCPs are responsible for coverage and payment of emergency services and post-stabilization care services. However, the current contract language carves out some exceptions to an MCP’s responsibility for paying for emergency services, including: a) services provided by specified mental health providers; and, b) facility charges for ED visits that result in a psychiatric admission.
     DHCS is revising the contract to remove these exceptions and clarify MCPs bear financial responsibility for ED services, including behavioral health services. Specifically, updated MCP contracts effective January 1, 2024, require MCPs to pay for emergency room professional services provided by mental health providers, addressing a) above. However, the 2024 contract language does not require MCPs to pay for facility charges for emergency room visits that result in a psychiatric admission, as described in b) above. To address b) above, DHCS has stated it intends to amend MCP contracts again to codify plan responsibility to cover all facility charges claimed by EDs—essentially removing the exception related to ED visits that result in a psychiatric admission. DHCS has stated, furthermore, that this change would be retroactive. When this change is made, the contract language will align with guidance issued in a 2022 All-Plan Letter (APL) titled “No Wrong Door for Mental Health Services.” This bill codifies MCPs coverage of ED services without the two exceptions related to behavioral health care.
     
  5. Modernizing California’s Mental Health System. In March 2023, Governor Newsom announced in his plan to modernize California’s mental health system. With the passage of AB 531 (Irwin), Chapter 789, Statutes of 2023, and SB 326 (Eggman), Chapter 790, Statutes of 2023 (and the placement of Proposition 1 on the March 2024 ballot) several new initiatives will be undertaken to:
     1. Build thousands of new behavioral health beds in state-of-the-art residential settings to house Californians with mental illness and substance use disorders, which could serve over 10,000 people every year in residential-style settings that have on-site services, including some locked facility beds;
     2. Provide more funding specifically for housing for homeless veterans;
     3. Amend the Mental Health Services Act (MHSA), leading to approximately $1 billion every year in local assistance for housing and residential services for people experiencing mental illness and substance use disorders, and allowing MHSA funds to serve people with substance use disorders; and,
     4. Include new accountability and oversight measures for counties to improve performance.

1. SUPPORT. CHA is the sponsor of this bill and states that hospitals are seeing more Californians in crisis, but youth and adults spend disproportionately more time waiting in the ED than other patients. While the national quality standard for emergency hospital care is four hours or less, it is common for people in mental health crisis to languish in a hospital ED for days or even weeks while waiting for an inpatient mental health treatment bed to become available. CHA contends that while California’s lack of inpatient psychiatric beds is a major reason for these delays, hospitals at times also are requested to retain a patient on an involuntary psychiatric hold rather than transfer the patient to a facility where they can get the care they need. This bill would clarify that hospital EDs should transfer patients in crisis to accepting inpatient psychiatric hospitals, regardless of whether the patient is on an involuntary hold.
   

CHA notes that this bill would also make it clear that Medi-Cal MCPs must pay hospital EDs for the care they provide to Medi-Cal beneficiaries experiencing a mental health crisis. Currently, the Medi-Cal managed care plans’ contracts and state guidance provide conflicting information about financial obligations for ED visits. CHA concludes that this bill would codify the intent of the DHCS’ APL 22-005, “No Wrong Door for Mental Health Services,” which clarifies that Medi-Cal MCPs must cover and pay for all facility and professional services claimed by EDs for beneficiaries experiencing a behavioral health crisis.

1. RELATED LEGISLATION. AB 1001 (Haney) creates a new definition of “behavioral health emergency condition” which applies specifically to patients in the ED of GACHs. Requires GACHs to adopt policies to respond to a patient requiring behavioral health emergency services, as defined. Requires that these protocols meet standards established by DPH and consist of various parameters such as minimum staffing requirements for behavioral health emergency services, procedures for response by behavioral health emergency services personnel in a timely manner, and annual training. Creates the Behavioral Health Emergency Response and Training Fund to provide grants to fund new programs or support existing programs that increases the staffing of direct care personnel who are trained in behavioral health care and behavioral health emergency services response or intervention, in specified hospitals. AB 1001 is currently pending in the Senate Health Committee.
2. PREVIOUS LEGISLATION.
   1. AB 1164 (Lowenthal) of 2023 would have required a licensed GACH with an ED to determine the range of crowding scores that constitute each category of the crowding scale, as provided, for its ED. Would have required the hospital to calculate and record a crowding score at a minimum every four hours, except as specified, to assess the crowding condition of the hospital’s ED. Would have required, by January 1, 2025, the hospital to develop and implement a full-capacity protocol for each of the categories of the crowding scale, and requires the hospital to file its protocol with the Department of Health Care Access and Information and to annually report any revisions to its protocol. AB 1164 was held on the Assembly Appropriations Committee suspense file.
   2. AB 451 (Arambula), Chapter 438, Statutes of 2021, requires a psychiatric unit of a GACH, a PHF with more than 16 beds that is not county operated, and an APH, to accept a transfer of a person with a psychiatric emergency medical condition, regardless of whether the facility operates an ED, if the facility has appropriate facilities and qualified personnel available to provide the services.

REGISTERED SUPPORT / OPPOSITION:

Support

California Hospital Association (sponsor)

Adventist Health
Cedars Sinai
Disability Rights California
Loma Linda University Adventist Health Sciences Center and Its Affiliated Entities
Providence
Rady Children's Hospital
Tenet Healthcare Corporation

Opposition

None on file.

Analysis Prepared by: Lara Flynn / HEALTH / (916) 319-2097