Existing law establishes the Medi-Cal program, which is administered by the State Department of Health Care Services and under which qualified low-income individuals receive health care services, including behavioral health services. The Medi-Cal program is, in part, governed and funded by federal Medicaid program provisions. Existing law establishes the California Advancing and Innovating Medi-Cal (CalAIM) initiative, subject to receipt of any necessary federal approvals and the availability of federal financial participation, in order to, among other things, improve quality outcomes and reduce health disparities.

The bill, as part of CalAIM, and with respect to behavioral health services provided under the Medi-Cal program, would require the department to standardize data elements relating to documentation requirements, including, but not limited to, medically necessary criteria, and would require the department to develop standard forms containing information necessary to properly adjudicate claims pursuant to CalAIM Terms and Conditions. The bill would require the department to consult with representatives of specified associations and programs for purposes of implementing these provisions.

The bill would require the department to conduct, on or before July 1, 2025, regional trainings for personnel and provider networks of applicable entities, including county mental health plans, Medi-Cal managed care plans, and entities within the fee-for-service delivery system, on proper completion of the standard forms. The bill would require each applicable entity to distribute the training material and standard forms to its provider networks, and to commence, no later than July 1, 2025, using the standard forms. The bill would require providers of applicable entities to use those forms, as specified. The bill would authorize the department to restrict the imposition of additional documentation requirements beyond those included on standard forms, as specified.

The bill would require the department to conduct an analysis on the status of utilization of the standard forms by applicable entities, and on the status of the trainings and training material, in order to determine the effectiveness of implementation of the above-described provisions. The bill would require the department to prepare a report containing findings from the analysis no later than July 1, 2026, and a followup report no later than July 1, 2028, and to submit each report to the Legislature and post it on the departments internet website.

Existing law establishes the Medi-Cal program, which is administered by the State Department of Health Care Services and under which qualified low-income individuals receive health care services, including behavioral health services. The Medi-Cal program is, in part, governed and funded by federal Medicaid program provisions. Existing law establishes the California Advancing and Innovating Medi-Cal (CalAIM) initiative, subject to receipt of any necessary federal approvals and the availability of federal financial participation, in order to, among other things, improve quality outcomes and reduce health disparities.

The bill, as part of CalAIM, and with respect to behavioral health services provided under the Medi-Cal program, would require the department to standardize data elements relating to documentation requirements, including, but not limited to, medically necessary criteria, and would require the department to develop standard forms containing information necessary to properly adjudicate claims pursuant to CalAIM Terms and Conditions. The bill would require the department to consult with representatives of specified associations and programs for purposes of implementing these provisions.

The bill would require the department to conduct, on or before July 1, 2025, regional trainings for personnel and provider networks of applicable entities, including county mental health plans, Medi-Cal managed care plans, and entities within the fee-for-service delivery system, on proper completion of the standard forms. The bill would require each applicable entity to distribute the training material and standard forms to its provider networks, and to commence, no later than July 1, 2025, using the standard forms. The bill would require providers of applicable entities to use those forms, as specified. The bill would authorize the department to restrict the imposition of additional documentation requirements beyond those included on standard forms, as specified.

The bill would require the department to conduct an analysis on the status of utilization of the standard forms by applicable entities, and on the status of the trainings and training material, in order to determine the effectiveness of implementation of the above-described provisions. The bill would require the department to prepare annual reports a report containing findings from the analysis, and, commencing on July 1, 2026, and each year thereafter, to submit the most recent analysis no later than July 1, 2026, and a followup report no later than July 1, 2028, and to submit each report to the Legislature and to post it on the departments internet website.

Existing law establishes the Medi-Cal program, which is administered by the State Department of Health Care Services and under which qualified low-income individuals receive health care services, including behavioral health services. The Medi-Cal program is, in part, governed and funded by federal Medicaid program provisions. Existing law establishes the California Advancing and Innovating Medi-Cal (CalAIM) initiative, subject to receipt of any necessary federal approvals and the availability of federal financial participation, in order to, among other things, improve quality outcomes and reduce health disparities.

The bill, as part of CalAIM, and with respect to behavioral health services provided under the Medi-Cal program, would require the department to develop standard forms, including intake and assessment forms, relating to medical necessity criteria, mandatory screening and transition of care tools, and documentation requirements standardize data elements relating to documentation requirements, including, but not limited to, medically necessary criteria, and would require the department to develop standard forms containing information necessary to properly adjudicate claims pursuant to CalAIM Terms and Conditions. The bill would require the department to consult with representatives of specified associations and programs for purposes of implementing these provisions. The bill would authorize the department to develop and maintain a list of department-approved nonstandard forms.

The bill would require the department to conduct, on or before July 1, 2025, regional trainings for personnel and provider networks of applicable entities, including county mental health plans, Medi-Cal managed care plans, and entities within the fee-for-service delivery system, on proper completion of the standard forms. The bill would require each applicable entity to distribute the training material and standard forms to its provider networks, and to commence, no later than July 1, 2025, exclusively using the standard forms, unless it uses department-approved nonstandard forms. forms. The bill would require providers of applicable entities to use those forms, as specified. The bill would authorize the department to restrict the imposition of additional documentation requirements beyond those included on standard forms, as specified.

The bill would require the department to conduct an analysis on the status of utilization of the standard forms by applicable entities, and on the status of the trainings and training material, in order to determine the effectiveness of implementation of the above-described provisions. The bill would require the department to prepare annual reports containing findings from the analysis, and, commencing on July 1, 2026, and each year thereafter, to submit the most recent report to the Legislature and to post it on the departments internet website.

Existing law establishes the Medi-Cal program, which is administered by the State Department of Health Care Services and under which qualified low-income individuals receive health care services, including certain behavioral health services. The Medi-Cal program is, in part, governed and funded by federal Medicaid program provisions.

This bill would declare the intent of the Legislature to enact legislation to require the State Department of Health Care Services to take specified actions with respect to documentation requirements for behavioral health billing requirements under the Medi-Cal program.

GOVERNOR'S VETO

GV Bill Id:AB 1470

Author:(Quirk-Silva)

As Enrolled Ver:August 19, 2024

2/3 vote

SUMMARY

Requires the Department of Health Care Services (DHCS) to adopt, require the use of, and report on the use of standardized forms for purposes of provider billing for Medi-Cal behavioral health services, including county-administered specialty mental health and substance use services, as well as non-specialty mental health services provided by Medi-Cal managed care plans.

Senate Amendments Modify the reporting requirement on the use of standardized forms from an annual requirement to a requirement for DHCS to report twice, once in July, 2026, and once in July, 2028.

Governor's Veto Message

This bill would require the Department of Health Care Services (DHCS) to consult with stakeholders on the standardization of data elements and forms for behavioral health services provided under the Medi-Cal program. The department would also be required to conduct regional training on the use of the forms, complete an analysis of the utilization, and prepare reports to the Legislature with the findings.

While I agree with the author's intent to improve documentation standards and reduce administrative burdens, this bill is duplicative. The Behavioral Health Documentation Redesign effort, implemented as part of the California Advancing and Innovating Medi-Cal (CalAIM) initiative, included a stakeholder engagement process that resulted in updated documentation guidance that became effective January 1, 2024. This bill would, therefore, negate existing efforts to engage with stakeholders and address documentation standardization challenges.

COMMENTS

1. Medi-Cal's Delivery System for Behavioral Health Services. Under Medi-Cal, behavioral health services are largely delivered under two systems. Counties administer mental health plans that provide specialty mental health services to those with severe mental illness, as well as substance use disorder treatment services through Drug Medi-Cal-Organized Delivery System (DMC-ODS). Medi-Cal managed care plans provide services for those with less severe needs. DHCS generally sets minimum requirements and ensures through audits that its requirements are met, but does not dictate the use of specific forms. Thus, each plan may interpret and implement guidance on forms and documentation differently, as long as it meets its contractual requirements with DHCS. This bill applies to all of the delivery systems and services noted below:
   1. Specialty Mental Health Services (SMHS). As the single state Medicaid agency, DHCS is responsible for administering the Medi-Cal SMHS waiver program, which provides SMHS to Medi-Cal beneficiaries through county mental health plans (MHPs). The MHPs are required to provide or arrange for the provision of SMHS to beneficiaries in their counties that meet medical necessity criteria, consistent with the beneficiaries' mental health treatment needs and goals.

County MHPs are required to provide SMHS to adults when they have significant impairment and/or a reasonable probability of significant deterioration in an important area of life functioning, and the condition is due to a diagnosed mental health disorder or a suspected, undiagnosed mental disorder. Criteria for children are more expansive.

• 1. Drug Medi-Cal (DMC). With the broader Medi-Cal program, DHCS administers the DMC Program. DMC reimbursement is issued to counties and direct providers that have a contract with DHCS for approved DMC services provided to Medi-Cal beneficiaries.

The DMC-ODS is a Medi-Cal benefit that is available only to counties that choose to opt in. Most counties, representing over 95% of the state's population, have opted in to provide DMC-ODS services.

1. Medi-Cal's Delivery System for Behavioral Health Services. Under Medi-Cal, behavioral health services are largely delivered under two systems. Counties administer mental health plans that provide specialty mental health services to those with severe mental illness, as well as substance use disorder treatment services through Drug Medi-Cal-Organized Delivery System (DMC-ODS). Medi-Cal managed care plans provide services for those with less severe needs. DHCS generally sets minimum requirements and ensures through audits that its requirements are met, but does not dictate the use of specific forms. Thus, each plan may interpret and implement guidance on forms and documentation differently, as long as it meets its contractual requirements with DHCS. This bill applies to all of the delivery systems and services noted below:
   1. Specialty Mental Health Services (SMHS). As the single state Medicaid agency, DHCS is responsible for administering the Medi-Cal SMHS waiver program, which provides SMHS to Medi-Cal beneficiaries through county mental health plans (MHPs). The MHPs are required to provide or arrange for the provision of SMHS to beneficiaries in their counties that meet medical necessity criteria, consistent with the beneficiaries' mental health treatment needs and goals.

County MHPs are required to provide SMHS to adults when they have significant impairment and/or a reasonable probability of significant deterioration in an important area of life functioning, and the condition is due to a diagnosed mental health disorder or a suspected, undiagnosed mental disorder. Criteria for children are more expansive.

• 1. Drug Medi-Cal (DMC). With the broader Medi-Cal program, DHCS administers the DMC Program. DMC reimbursement is issued to counties and direct providers that have a contract with DHCS for approved DMC services provided to Medi-Cal beneficiaries.

The DMC-ODS is a Medi-Cal benefit that is available only to counties that choose to opt in. Most counties, representing over 95% of the state's population, have opted in to provide DMC-ODS services.

• 1. Non-Specialty Mental Health Services (NSMHS). Medi-Cal managed care plans cover a set of mental health benefits that DHCS used to refer to as "mild to moderate" mental health services, but are now called NSMHS.

1. California Advancing and Innovating Medi-Cal (CalAIM) behavioral health proposals. In October 2019, DHCS released a broad, sweeping, multi-year initiative aimed at improving the health outcomes of beneficiaries in Medi-Cal, known as CalAIM. CalAIM implementation was originally scheduled to begin in January 2021, but was delayed due the impact of the COVID-19 public health emergency. The behavioral health system reforms under CalAIM include, among other proposals, standardizing screening tools, reforming documentation requirements and standards, and changing reimbursement methodologies and medical claiming codes. AB 133 (Committee on Budget), Chapter 143, Statutes of 2021, implements various components of the CalAIM initiative, including those providing authority for DHCS to develop and implement documentation standards.
2. Clinical documentation requirements. On April 22, 2022, DHCS released BHIN No: 22-019 which established, effective July 1, 2022, new chart documentation requirements for SMHS, DMC, and DMC-ODS services. The BHIN intends to streamline and standardize clinical documentation requirements across Medi-Cal SMHS, DMC, and DMC-ODS services to align with medical provider requirements, improve efficiency, and decrease provider burnout. According to DHCS, the new criteria were developed based on significant feedback from stakeholders, including county behavioral health directors, consumer advocates, labor organizations representing county behavioral health workers, and mental health and substance use disorder treatment providers. The BHIN addresses a number of items, including standardized assessment requirements; SMHS, DMC, and DMC-ODS problem list and progress notes; treatment and care planning requirements; and telehealth consent.
   1. November 30, 2022 Coalition Letter. In late 2022, a coalition of behavioral health stakeholders, including County Behavioral Health Directors of California, the California Association of Social Rehabilitation Agencies, and the three cosponsors of this bill, wrote to DHCS to share concerns with the collective efforts to reform specialty behavioral health documentation reform under CalAIM. The letter acknowledges the documentation reform efforts that culminated in the April 2022 BHIN, but communicates a shared understanding there is significant work left to do to realize the vision of documentation reform under CalAIM. The coalition indicated it had been working together to develop an inventory of additional federal and state policies impacting specialty behavioral health documentation practices, and corresponding recommendations for state guidance that would support more effective implementation of CalAIM reforms. The coalition indicated it anticipated sharing those recommendations as well in the weeks ahead and reiterated its willingness to partner on these efforts with DHCS and each other.
   2. Ongoing work. DHCS has acknowledged that although the BHIN 22-019 issued in April 2022 was intended to reduce documentation burden, it did not address all the issues in the community that lead to excessive documentation burden. Accordingly, DHCS is actively soliciting stakeholder input on revisions to the BHIN that will further assist providers and county MHP and DMC-ODS plans to reduce documentation burden. Based on this additional analysis and in consultation with stakeholders, DHCS expects to release an updated notice in September 2023 that will supersede the BHIN and take effect in 2024. The revised BHIN will seek to address challenges that prevented the April 2022 BHIN from having its intended effect of reducing paperwork, and provide further clarity about DHCS requirements. This increased clarity should, in turn, reduce the tendency for counties averse to fiscal risk of recoupments based on DHCS audits, from requesting excessive documentation from contracted providers.

According to the Author

A large percent of a medical provider's time is spent maintaining health records of their patients. The author notes a high percentage of doctors believe clinical documentation requirements are excessive and compromise their time for direct patient care. The author asserts this bill, through streamlining and standardizing intake, assessment, and treatment forms for use with contracted behavioral health providers statewide would directly increase access to Medi-Cal behavioral health programs. This bill is cosponsored by the California Council of Community Behavioral Health Agencies, the California Alliance of Child and Family Services, and the California Association of Alcohol and Drug Program Executives.

Arguments in Support

A coalition of health care providers supports this bill, generally expressing acknowledgement of DHCS's efforts in this area, but also frustration with the pace of reform. Providers emphasize the day-to-day toll behavioral health documentation has on the ability of individual providers to see more patients and the negative effect it has on morale. For instance, Seneca Family of Agencies (Seneca) indicates that just the intake packet required for an initial appointment with a child or adolescent in need of mental health services can exceed 30 pages. Seneca asserts California is suffering from a behavioral health provider shortage, and we simply cannot afford to have the providers California does have spending half of their time filling out forms and navigating different requirements across counties instead of providing clinical services. California Health+ Advocates (CH+A), representing community clinics, estimate that paperwork for patients consumes 40-50% of their time to complete, which leaves them with even less time to provide health care services. CH+A indicates community health centers that contract with counties to provide specialty mental health and substance use disorder services to children, adults, and older adults in the Medi-Cal program bear an enormous paperwork burden, which is a significant driver of provider burnout and attrition.

Arguments in Opposition

There is no known opposition.

Concerns.

CBHDA believes that because of progress made to date and the ongoing partnership with providers and DHCS, the effort to impose new standardization requirements is premature and fails to account for the progress already made, as well as the partnerships underway on further documentation reform and relief. CBHDA is concerned that efforts to mandate specific forms for all clinical processes would have unintended consequences of recreating documentation standards that are unique to county behavioral health. In addition, CBHDA notes, clinical practice changes over time, and counties

FISCAL COMMENTS

According to the Senate Appropriations Committee, unknown costs, likely hundreds of thousands (General Fund and federal funds), for DHCS to develop the standardized forms, conduct trainings, and complete reports.

VOTES

ASM HEALTH: 15-0-0

YES: Wood, Waldron, Aguiar-Curry, Arambula, Boerner, Wendy Carrillo, Flora, Vince Fong, Maienschein, McCarty, Joe Patterson, Rodriguez, Santiago, Villapudua, Weber

ASM APPROPRIATIONS: 15-0-1

YES: Holden, Megan Dahle, Bryan, Calderon, Wendy Carrillo, Dixon, Mike Fong, Hart, Lowenthal, Mathis, Papan, Pellerin, Sanchez, Weber, Ortega

ABS, ABST OR NV: Robert Rivas

ASSEMBLY FLOOR: 79-0-1

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

ABS, ABST OR NV: Gabriel

SENATE FLOOR: 37-0-3

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

ABS, ABST OR NV: Caballero, Grove, Ochoa Bogh

ASSEMBLY FLOOR: 75-0-4

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

ABS, ABST OR NV: Alvarez, Berman, Chen, Holden

UPDATED

VERSION: August 19, 2024

CONSULTANT: Lisa Murawski / HEALTH / (916) 319-2097 FN: 0005079

CONCURRENCE IN SENATE AMENDMENTS

CSA1 Bill Id:AB 1470

Author:(Quirk-Silva)

As Amended Ver:July 3, 2023

Majority vote

SUMMARY

Requires the Department of Health Care Services (DHCS) to adopt, require the use of, and report on the use of standardized forms for purposes of provider billing for Medi-Cal behavioral health services, including county-administered specialty mental health and substance use services, as well as non-specialty mental health services provided by Medi-Cal managed care plans.

Senate Amendments

Modify the reporting requirement on the use of standardized forms from an annual requirement to a requirement for DHCS to report twice, once in July, 2026, and once in July, 2028.

COMMENTS

1. Medi-Cal's Delivery System for Behavioral Health Services. Under Medi-Cal, behavioral health services are largely delivered under two systems. Counties administer mental health plans that provide specialty mental health services to those with severe mental illness, as well as substance use disorder treatment services through Drug Medi-Cal-Organized Delivery System (DMC-ODS). Medi-Cal managed care plans provide services for those with less severe needs. DHCS generally sets minimum requirements and ensures through audits that its requirements are met, but does not dictate the use of specific forms. Thus, each plan may interpret and implement guidance on forms and documentation differently, as long as it meets its contractual requirements with DHCS. This bill applies to all of the delivery systems and services noted below:
   1. Specialty Mental Health Services (SMHS). As the single state Medicaid agency, DHCS is responsible for administering the Medi-Cal SMHS waiver program, which provides SMHS to Medi-Cal beneficiaries through county mental health plans (MHPs). The MHPs are required to provide or arrange for the provision of SMHS to beneficiaries in their counties that meet medical necessity criteria, consistent with the beneficiaries' mental health treatment needs and goals.

County MHPs are required to provide SMHS to adults when they have significant impairment and/or a reasonable probability of significant deterioration in an important area of life functioning, and the condition is due to a diagnosed mental health disorder or a suspected, undiagnosed mental disorder. Criteria for children are more expansive.

• 1. Drug Medi-Cal (DMC). With the broader Medi-Cal program, DHCS administers the DMC Program. DMC reimbursement is issued to counties and direct providers that have a contract with DHCS for approved DMC services provided to Medi-Cal beneficiaries.

The DMC-ODS is a Medi-Cal benefit that is available only to counties that choose to opt in. Most counties, representing over 95% of the state's population, have opted in to provide DMC-ODS services.

• 1. Non-Specialty Mental Health Services (NSMHS). Medi-Cal managed care plans cover a set of mental health benefits that DHCS used to refer to as "mild to moderate" mental health services, but are now called NSMHS.

1. California Advancing and Innovating Medi-Cal (CalAIM) behavioral health proposals. In October 2019, DHCS released a broad, sweeping, multi-year initiative aimed at improving the health outcomes of beneficiaries in Medi-Cal, known as CalAIM. CalAIM implementation was originally scheduled to begin in January 2021, but was delayed due the impact of the COVID-19 public health emergency. The behavioral health system reforms under CalAIM include, among other proposals, standardizing screening tools, reforming documentation requirements and standards, and changing reimbursement methodologies and medical claiming codes. AB 133 (Committee on Budget), Chapter 143, Statutes of 2021, implements various components of the CalAIM initiative, including those providing authority for DHCS to develop and implement documentation standards.
2. Clinical documentation requirements. On April 22, 2022, DHCS released BHIN No: 22-019 which established, effective July 1, 2022, new chart documentation requirements for SMHS, DMC, and DMC-ODS services. The BHIN intends to streamline and standardize clinical documentation requirements across Medi-Cal SMHS, DMC, and DMC-ODS services to align with medical provider requirements, improve efficiency, and decrease provider burnout. According to DHCS, the new criteria were developed based on significant feedback from stakeholders, including county behavioral health directors, consumer advocates, labor organizations representing county behavioral health workers, and mental health and substance use disorder treatment providers. The BHIN addresses a number of items, including standardized assessment requirements; SMHS, DMC, and DMC-ODS problem list and progress notes; treatment and care planning requirements; and telehealth consent.
   1. November 30, 2022 Coalition Letter. In late 2022, a coalition of behavioral health stakeholders, including County Behavioral Health Directors of California, the California Association of Social Rehabilitation Agencies, and the three cosponsors of this bill, wrote to DHCS to share concerns with the collective efforts to reform specialty behavioral health documentation reform under CalAIM. The letter acknowledges the documentation reform efforts that culminated in the April 2022 BHIN, but communicates a shared understanding there is significant work left to do to realize the vision of documentation reform under CalAIM. The coalition indicated it had been working together to develop an inventory of additional federal and state policies impacting specialty behavioral health documentation practices, and corresponding recommendations for state guidance that would support more effective implementation of CalAIM reforms. The coalition indicated it anticipated sharing those recommendations as well in the weeks ahead and reiterated its willingness to partner on these efforts with DHCS and each other.
   2. Ongoing work. DHCS has acknowledged that although the BHIN 22-019 issued in April 2022 was intended to reduce documentation burden, it did not address all the issues in the community that lead to excessive documentation burden. Accordingly, DHCS is actively soliciting stakeholder input on revisions to the BHIN that will further assist providers and county MHP and DMC-ODS plans to reduce documentation burden. Based on this additional analysis and in consultation with stakeholders, DHCS expects to release an updated notice in September 2023 that will supersede the BHIN and take effect in 2024. The revised BHIN will seek to address challenges that prevented the April 2022 BHIN from having its intended effect of reducing paperwork, and provide further clarity about DHCS requirements. This increased clarity should, in turn, reduce the tendency for counties averse to fiscal risk of recoupments based on DHCS audits, from requesting excessive documentation from contracted providers.

According to the Author

A large percent of a medical provider's time is spent maintaining health records of their patients. The author notes a high percentage of doctors believe clinical documentation requirements are excessive and compromise their time for direct patient care. The author asserts this bill, through streamlining and standardizing intake, assessment, and treatment forms for use with contracted behavioral health providers statewide would directly increase access to Medi-Cal behavioral health programs. This bill is cosponsored by the California Council of Community Behavioral Health Agencies, the California Alliance of Child and Family Services, and the California Association of Alcohol and Drug Program Executives.

Arguments in Support

A coalition of health care providers supports this bill, generally expressing acknowledgement of DHCS's efforts in this area, but also frustration with the pace of reform. Providers emphasize the day-to-day toll behavioral health documentation has on the ability of individual providers to see more patients and the negative effect it has on morale. For instance, Seneca Family of Agencies (Seneca) indicates that just the intake packet required for an initial appointment with a child or adolescent in need of mental health services can exceed 30 pages. Seneca asserts California is suffering from a behavioral health provider shortage, and we simply cannot afford to have the providers California does have spending half of their time filling out forms and navigating different requirements across counties instead of providing clinical services. California Health+ Advocates (CH+A), representing community clinics, estimate that paperwork for patients consumes 40-50% of their time to complete, which leaves them with even less time to provide health care services. CH+A indicates community health centers that contract with counties to provide specialty mental health and substance use disorder services to children, adults, and older adults in the Medi-Cal program bear an enormous paperwork burden, which is a significant driver of provider burnout and attrition.

Arguments in Opposition

There is no known opposition.

Concerns.

CBHDA believes that because of progress made to date and the ongoing partnership with providers and DHCS, the effort to impose new standardization requirements is premature and fails to account for the progress already made, as well as the partnerships underway on further documentation reform and relief. CBHDA is concerned that efforts to mandate specific forms for all clinical processes would have unintended consequences of recreating documentation standards that are unique to county behavioral health. In addition, CBHDA notes, clinical practice changes over time, and counties need the ability to adapt to best clinical practice without having to go through the state.

FISCAL COMMENTS

According to the Senate Appropriations Committee, unknown costs, likely hundreds of thousands (General Fund and federal funds), for DHCS to develop the standardized forms, conduct trainings, and complete reports.

VOTES:

ASM HEALTH: 15-0-0

YES: Wood, Waldron, Aguiar-Curry, Arambula, Boerner, Wendy Carrillo, Flora, Vince Fong, Maienschein, McCarty, Joe Patterson, Rodriguez, Santiago, Villapudua, Weber

ASM APPROPRIATIONS: 15-0-1

YES: Holden, Megan Dahle, Bryan, Calderon, Wendy Carrillo, Dixon, Mike Fong, Hart, Lowenthal, Mathis, Papan, Pellerin, Sanchez, Weber, Ortega

ABS, ABST OR NV: Robert Rivas

ASSEMBLY FLOOR: 79-0-1

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

ABS, ABST OR NV: Gabriel

UPDATED

VERSION: July 3, 2023

CONSULTANT: Lisa Murawski / HEALTH / (916) 319-2097 FN: 0001744

 THIRD READING  

Bill No: AB 1470

Author: Quirk-Silva (D)

Amended: 7/3/23 in Senate

Vote: 21

SENATE HEALTH COMMITTEE: 11-0, 6/28/23

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

NO VOTE RECORDED: Grove

SENATE APPROPRIATIONS COMMITTEE: 7-0, 9/1/23

AYES: Portantino, Jones, Ashby, Bradford, Seyarto, Wahab, Wiener

ASSEMBLY FLOOR: 79-0, 6/1/23 - See last page for vote

SUBJECT: Medi-Cal: behavioral health services: documentation standards

SOURCE: California Alliance of Child and Family Services

California Association of Alcohol and Drug Executives

California Council of Community Behavioral Health Agencies

DIGEST:

This bill requires the Department of Health Care Services (DHCS) to adopt and require the use of standardized intake, assessment, and treatment planning forms for Medi-Cal behavioral health services, including specialty mental health services, non-specialty mental health services, and substance use disorder services. Requires DHCS to prepare an annual report on the implementation of these forms.

ANALYSIS:

Existing law:

1. Establishes the Medi-Cal program, which is administered by the DHCS, under which low-income individuals receive health care services. [Welfare & Institutions Code (WIC) §14000, et seq.]
2. Establishes a schedule of benefits under the Medi-Cal program, which includes federally required and optional Medicaid benefits. [WIC §14132, et seq.]
3. Includes mental health and substance use services in the essential health benefits package established under state law as Medi-Cal benefits. [WIC §14132.03]
4. 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]
5. 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]
6. Authorizes DHCS to enter into contracts for the provision of Drug Medi-Cal Treatment Program services with certified Drug Medi-Cal providers directly or through qualifying individual counties or counties acting jointly. [WIC §14124.21]
7. Requires DHCS to develop the following, in consultation with county behavioral health directors, consumer advocates, labor organizations representing county behavioral health workers, mental health and substance use disorder treatment providers, and MCMC plans: standardized screening tools to guide a referral to a Medi-Cal behavioral health delivery system, standardized statewide transition tools to ensure timely coordinated care when transitioning between delivery systems, and documentation standards and changes to the department’s clinical auditing standards. [WIC §14184.402]
8. Authorizes DHCS to require the use of standardized screening tools, standardized statewide transition tools, and documentation standards by Medi-Cal behavioral health delivery systems, including restrictions developed in consultation with representatives of Medi-Cal behavioral health delivery systems on what Medi-Cal behavioral health delivery systems impose on their contract providers, consistent with MCMC plans and taking into account the need to ensure quality and program integrity and to address equity and disparities. [WIC §14184.402]

This bill:

1. Requires DHCS to standardize data elements relating to documentation requirements, including but not limited to, medically necessary criteria with respect to behavioral health services provided under the Medi-Cal program, including specialty services, nonspecialty mental health services (“nonspecialty services”), and substance use disorder services.
2. Requires DHCS to develop standard forms containing information necessary to properly adjudicate claims for specialty and nonspecialty services in a manner that is consistent with the existing California Advancing and Innovating Medi-Cal (CalAIM) requirements as approved by the federal Centers for Medicare and Medicaid Services (CMS). Requires the standard forms to include intake, assessment, and treatment planning forms. Requires the forms to comply with state and federal health privacy law.
3. Requires DHCS to consult with the representatives of all of the following for the purposes of implementing this bill:
4. The County Behavioral Health Directors Association of California;
5. The California State Association of Counties;
6. The County Welfare Directors Association of California;
7. Behavioral health programs in at least one small (population less than 300,000), medium (population between 300,000-700,000), and large (population over 700,000) county; and,
8. Associations that represent children’s hospitals, foster youth, parents and caregivers, community-based children’s behavioral health providers, children’s health legal advocates, providers of adult and older adult care, and providers of substance use disorder treatment.
9. Requires DHCS to conduct regional trainings for the personnel and provider networks of Medi-Cal behavioral health systems, MCMC plans, and other behavioral health entities on or before July 1, 2025, on proper completion of the standard forms. Requires DHCS to make training material available for the use in local trainings and for mental health plans, MCMC plans, and other behavioral health entities serving Medi-Cal patients to distribute the forms to their provider networks.
10. Requires Medi-Cal behavioral health systems, MCMC plans, and other behavioral health entities serving Medi-Cal patients and provider networks of those entities to utilize the standard forms for performing the intake of, assessment of, and treatment planning for, Medi-Cal beneficiaries who are eligible for behavioral health services under the Medi-Cal program no later than July 1, 2025.
11. Authorizes DHCS to restrict the imposition of additional documentation requirements beyond those requirements included on standard forms, including, but not limited to, restrictions developed in consultation with representatives of Medi-Cal behavioral health delivery systems on what Medi-Cal behavioral health delivery systems impose on their contract providers, consistent with MCMC plans and taking into account the need to ensure quality and program integrity and to address equity and disparities.
12. Requires DHCS to conduct an analysis on the utilization of the standard forms by Medi-Cal behavioral health systems, MCMC plans, and other behavioral health entities serving Medi-Cal patients, and on the status of the trainings and training material in order to determine the effectiveness of implementation of this section. Requires DHCS to prepare annual reports containing findings from the analysis starting July 1, 2026 and each year thereafter. Requires the report to be submitted to the Legislature and posted on DHCS’s website.
13. Makes legislative findings that behavioral health providers have less time to serve clients with behavioral health issues due to excessive and varying paperwork requirements in the Medi-Cal program, leading to client harm and exacerbating the behavioral health provider shortage. Makes findings that the Legislature intends to dramatically reduce and standardize the paperwork burden on Medi-Cal behavioral health providers to serve more Medi-Cal beneficiaries, ensure consistent reimbursement, provide clear guidance, and minimize the risk of negative audit findings and retroactive disallowances.

Comments

1. Author’s statement. According to the author, a large percent of a medical provider's time is spent maintaining health records of their patients. In fact, a high percentage of doctors feel that clinical documentation requirements are excessive and compromises their time for direct patient care. California is suffering a severe shortage of mental health and substance use professionals. Even pre-pandemic, Medi-Cal beneficiaries experienced challenges accessing mental health and substance use disorder services because of the workforce crisis. Additionally, the COVID-19 pandemic has dramatically increased the incidence of serious mental health and substance use issues in California, making access to mental health and substance use disorder services more crucial than ever. Addressing the need created by the pandemic will require existing providers to serve more Medi-Cal enrollees in communities throughout California. Streamlining and standardizing intake, assessment, and treatment plans for use with contracted behavioral health providers statewide would directly increase access to Medi-Cal behavioral health programs.
2. 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 and under a separate statutory framework from the drug Medi-Cal benefit. 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 a MCMC plan. Counties also provide substance use disorder services, including those in the Drug Medi-Cal Organized Delivery System plans. This bill applies to all of these delivery systems.

Documentation requirements within these delivery systems has been a longstanding issue as individual counties and MCMC plans interpret DHCS documentation rules differently and often, in an effort to avoid having funds recouped through a DHCS audit, require significant detail in intake, assessment, and treatment planning forms. Sponsors of this bill have shared years’ worth of correspondence with DHCS on the issue, including a study they had commissioned with an outside consulting firm comparing the medical necessity documentation requirements in California, New York, and Massachusetts by comparing the requirements in outpatient progress notes. The study found California’s audit guide definition of medical necessity requires each component of the definition to be documented in every progress note. This audit expectation that requires a direct care staff to document medical necessity over and over in each progress note for each event of service results in excessive and redundant documentation, which takes time away from patient care, as well as makes it more likely that other elements such as treatment progress will not be captured.

1. Efforts to improve service delivery. DHCS, through the CalAIM initiative, has made efforts to improve access to behavioral health care. DHCS implemented CalAIM through the California’s Medicaid State Plan, the 1115 waiver, and the 1915(b) waiver. CalAIM transferred DHCS’s authority to implement the Medi-Cal managed care program from the previous 1115 waiver to a 1915(b) waiver. Under the 1915(b) waiver, DHCS also renewed its authority to provide specialty services through county mental health plans. One of the aims of the CalAIM initiative has been to standardize statewide screening and transition tools and streamline criteria for accessing services to reduce barriers to care as is required by AB 133 (Committee on Budget, Chapter 143, Statutes of 2021), the health trailer bill that established CalAIM. The focus of these efforts thus far has been on the adult and youth screening form used to determine which delivery system an individual should be referred to in an effort to avoid sending individuals back and forth between the mental health plans for specialty services and MCMC plans for nonspecialty services. The form used to facilitate a referral between the two delivery systems while avoiding a break in care has also been modified. These forms have been implemented statewide as of January 1, 2023. DHCS has also implemented new chart documentation requirements for the specialty and substance use disorder services, effective July 1, 2022, to streamline documentation requirements and better align with CMS coding standards. DHCS is also required to revise its documentation standards for its audits. DHCS has stated its intent to limit its audits to issues suggesting fraud, waste, or abuse rather than more minor issues such as the formatting of documentation.

However, just as CalAIM has provided opportunity to simplify documentation, the additional efforts to transform the behavioral health system through CalAIM have also compounded documentation requirements due to the variance in county interpretation of these requirements, largely out of concerns regarding DHCS audits. Sponsors of this bill have shared examples of counties continuing to have varying interpretations of DHCS requirements and in some cases not implementing changes mandated by DHCS. DHCS is currently seeking stakeholder input on further revisions to its clinical guidance to reduce documentation burden and expects to release an updated guidance in September to take effect in 2024. Sponsors and other stakeholders have been actively engaged in these documentation reform efforts with DHCS. This bill models the language used to revise the delivery system screening and transition forms and applies it to intake, assessment, and treatment planning forms used to adjudicate claims in the various behavioral health delivery systems with a particular focus on how the medical necessity criteria is required to be documented.

1. Concerns. While this bill has no formal opposition, the County Behavioral Health Directors Association submitted a letter of concerns stating that under the CalAIM initiative, DHCS has implemented standardized screening and transition tools effective January 1, 2023, streamlined documentation requirements effective July 1, 2022, and is currently in the process of developing changes to clinical audit practices to move away from provider recoupments tied to documentation and instead focus on quality and program integrity. Outstanding CalAIM Behavioral Health Initiatives which will further simplify and streamline documentation requirements include behavioral health payment reform, which will be Implemented in July 2023, and administration integration, which will be implemented gradually over the next three years. They also state concern that efforts to mandate specific forms would have the unintended consequence of recreating documentation standards that are unique to county behavioral health which will continue to put their providers on an unlevel playing field with other health care delivery systems. In addition, clinical practice changes over time, and counties need the ability to adapt to best clinical practice without having to go through the state

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

According to the Senate Appropriations Committee, this bill has unknown costs, likely hundreds of thousands (General Fund and federal funds), for DHCS to develop the standardized forms, conduct trainings, and complete reports.

SUPPORT: (Verified 9/1/23)

California Alliance of Child and Family Services (co-source)
California Council of Community Behavioral Health Agencies (co-source)

California Association of Alcohol and Drug Executives (co-source)

Association of Community Human Service Agencies

Behavioral Health Contractors' Association
California Access Coalition
California Assisted Living Association
California Association of Social Rehabilitation Agencies
California Children's Hospital Association

California Council of Community Behavioral Health Agencies

California Consortium of Addiction Programs and Professionals

California Democratic Party
California Health+ Advocates

California State Association of Psychiatrists

Children’s Health Council

Children's Hospital of Orange County

Children's Institute

Didi Hirsch Mental Health Services

Health RIGHT 360
Pacific Clinics
Seneca Family of Agencies

Shields for Families
Sierra Vista Child and Family Services

Steinberg Institute
Sycamores
WestCoast Children's Clinic

One individual

OPPOSITION: (Verified 9/1/23)

None received

ARGUMENTS IN SUPPORT: Co-sponsor of this bill, the California Council of Community Behavioral Health Agencies writes that providers estimate that Medi-Cal paperwork consumes 40% to 50% of their time, time that could be spent providing services to those in need. The paperwork is complex, requiring hours of training to complete properly, and is a significant driver of provider burnout and attrition. Just the intake packet required for an initial appointment with a child or adolescent in need of mental health services can exceed 30 pages.

Co-sponsor of this bill, the California Association of Alcohol and Drug Program Executives writes that under CalAIM, counties receive limited guidance from DHCS on documentation requirements related to mental health and substance use disorder services. As a result, documentation requirements vary, with each of the 58 counties mandating different sets of paperwork to administer the same types of services. This creates substantial confusion for providers and results in people experiencing critical gaps in coordinated care, while also increasing overall costs to the entire healthcare delivery system.

Co-sponsor of this bill, the California Alliance of Child and Family Services writes that California is suffering from a behavioral health provider shortage, and they simply cannot afford to have the providers California does have spending half of their time filling out forms and navigating different requirements across counties instead of providing clinical services.

ASSEMBLY FLOOR: 79-0, 6/1/23

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

NO VOTE RECORDED: Gabriel

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

9/4/23 9:40:18

**** END ****

SENATE COMMITTEE ON

Senator Anthony Portantino, Chair

2023 - 2024 Regular Session

AB 1470 (Quirk-Silva) - Medi-Cal: behavioral health services: documentation standards

Bill Summary:

AB 1470 would require the Department of Health Care Services (DHCS) to adopt and require the use of standardized intake, assessment, and treatment planning forms for Medi-Cal behavioral health services, including specialty mental health services, non-specialty mental health services, and substance use disorder services.

Fiscal Impact:

Unknown costs, likely hundreds of thousands (General Fund and federal funds), for DHCS to develop the standardized forms, conduct trainings, and complete reports.

Background:

DHCS, through its California Advancing and Innovating Medi-Cal (CalAIM) initiative, has made efforts to improve access to behavioral health care. One of the goals of the CalAIM initiative has been to standardize statewide screening and transition tools and streamline criteria for accessing services to reduce barriers to care.

The focus of these efforts thus far has been on the adult and youth screening form used to determine which delivery system an individual should be referred to in an effort to avoid sending individuals back and forth between the mental health plans for specialty services and managed care health plans for non-specialty services. The form used to facilitate a referral between the two delivery systems while avoiding a break in care has also been modified. DHCS has also implemented new chart documentation requirements for the specialty and substance use disorder services to streamline documentation requirements and better align with federal coding standards. DHCS is also required to revise its documentation standards for its audits. However, just as CalAIM has provided opportunity to simplify documentation, the additional efforts to transform the behavioral health system through CalAIM have also compounded documentation requirements due to the variance in county interpretation of these requirements, largely out of concerns regarding DHCS audits.

Proposed Law:

Specific provisions of the bill would:

• Require DHCS to adopt and require the use of standardized intake, assessment, and treatment planning forms for Medi-Cal behavioral health services, including specialty mental health services, non-specialty mental health services, and substance use disorder services, as specified.
• Require DHCS to conduct regional trainings for personnel and providers on proper completion of the standard forms.
• Require DHCS to conduct an analysis on the utilization of the standard forms and on the status of trainings and training materials and submit reports to the Legislature, as specified.

-- END --

SENATE COMMITTEE ON HEALTH

Senator Dr. Susan Talamantes Eggman, Chair

BILL NO: AB 1470

SUBJECT: Medi-Cal: behavioral health services: documentation standards

SUMMARY:

Requires the Department of Health Care Services (DHCS) to adopt and require the use of standardized intake, assessment, and treatment planning forms for Medi-Cal behavioral health services, including specialty mental health services, non-specialty mental health services, and substance use disorder services. Requires DHCS to prepare an annual report on the implementation of these forms.

Existing law:

1. Establishes the Medi-Cal program, which is administered by the DHCS, under which low-income individuals receive health care services. [WIC §14000, et seq.]
2. Establishes a schedule of benefits under the Medi-Cal program, which includes federally required and optional Medicaid benefits. [WIC §14132, et seq.]
3. Includes mental health and substance use services in the essential health benefits package established under state law as Medi-Cal benefits. [WIC §14132.03]
4. 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]
5. 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]
6. Authorizes DHCS to enter into contracts for the provision of Drug Medi-Cal Treatment Program services with certified Drug Medi-Cal providers directly or through qualifying individual counties or counties acting jointly. [WIC §14124.21]
7. Requires DHCS to develop the following, in consultation with county behavioral health directors, consumer advocates, labor organizations representing county behavioral health workers, mental health and substance use disorder treatment providers, and MCMC plans: standardized screening tools to guide a referral to a Medi-Cal behavioral health delivery system, standardized statewide transition tools to ensure timely coordinated care when transitioning between delivery systems, and documentation standards and changes to the department’s clinical auditing standards. [WIC §14184.402]
8. Authorizes DHCS to require the use of standardized screening tools, standardized statewide transition tools, and documentation standards by Medi-Cal behavioral health delivery systems, including restrictions developed in consultation with representatives of Medi-Cal behavioral health delivery systems on what Medi-Cal behavioral health delivery systems impose on their contract providers, consistent with MCMC plans and taking into account the need to ensure quality and program integrity and to address equity and disparities. [WIC §14184.402]

This bill:

1. Requires DHCS to standardize data elements relating to documentation requirements, including but not limited to, medically necessary criteria with respect to behavioral health services provided under the Medi-Cal program, including specialty services, nonspecialty mental health services (“nonspecialty services”), and substance use disorder services.
2. Requires DHCS to develop standard forms containing information necessary to properly adjudicate claims for specialty and nonspecialty services in a manner that is consistent with the existing CalAIM requirements as approved by the federal Centers for Medicare and Medicaid Services (CMS). Requires the standard forms to include intake, assessment, and treatment planning forms. Requires the forms to comply with state and federal health privacy law.
3. Requires DHCS to consult with the representatives of all of the following for the purposes of implementing this bill:
4. The County Behavioral Health Directors Association of California;
5. The California State Association of Counties;
6. The County Welfare Directors Association of California;
7. Behavioral health programs in at least one small (less than 300,000), medium (300,000-700,000), and large (over 700,000) county; and,
8. Associations that represent children’s hospitals, foster youth, parents and caregivers, community-based children’s behavioral health providers, children’s health legal advocates, providers of adult and older adult care, and providers of substance use disorder treatment.
9. Requires DHCS to conduct regional trainings for the personnel and provider networks of Medi-Cal behavioral health systems, MCMC plans, and other behavioral health entities on or before July 1, 2025, on proper completion of the standard forms. Requires DHCS to make training material available for the use in local trainings and for mental health plans, MCMC plans, and other behavioral health entities serving Medi-Cal patients to distribute the forms to their provider networks.
10. Requires Medi-Cal behavioral health systems, MCMC plans, and other behavioral health entities serving Medi-Cal patients and provider networks of those entities to utilize the standard forms for performing the intake of, assessment of, and treatment planning for, Medi-Cal beneficiaries who are eligible for behavioral health services under the Medi-Cal program no later than July 1, 2025.
11. Authorizes DHCS to restrict the imposition of additional documentation requirements beyond those requirements included on standard forms, including, but not limited to, restrictions developed in consultation with representatives of Medi-Cal behavioral health delivery systems on what Medi-Cal behavioral health delivery systems impose on their contract providers, consistent with MCMC plans and taking into account the need to ensure quality and program integrity and to address equity and disparities.
12. Requires DHCS to conduct an analysis on the utilization of the standard forms by Medi-Cal behavioral health systems, MCMC plans, and other behavioral health entities serving Medi-Cal patients, and on the status of the trainings and training material in order to determine the effectiveness of implementation of this section. Requires DHCS to prepare annual reports containing findings from the analysis starting July 1, 2026 and each year thereafter. Requires the report to be submitted to the Legislature and posted on DHCS’s website.
13. Makes legislative findings that behavioral health providers have less time to serve clients with behavioral health issues due to excessive and varying paperwork requirements in the Medi-Cal program, leading to client harm and exacerbating the behavioral health provider shortage. Makes findings that the Legislature intends to dramatically reduce and standardize the paperwork burden on Medi-Cal behavioral health providers to serve more Medi-Cal beneficiaries, ensure consistent reimbursement, provide clear guidance, and minimize the risk of negative audit findings and retroactive disallowances.

FISCAL EFFECT:

According to the Assembly Appropriations Committee, this bill has one-time costs of an unknown amount to DHCS, possibly in the hundreds of thousands of dollars (General Fund and federal funds).

PRIOR VOTES:

COMMENTS:

1. Author’s statement. According to the author, a large percent of a medical provider's time is spent maintaining health records of their patients. In fact, a high percentage of doctors feel that clinical documentation requirements are excessive and compromises their time for direct patient care. California is suffering a severe shortage of mental health and substance use professionals. Even pre-pandemic, Medi-Cal beneficiaries experienced challenges accessing mental health and substance use disorder services because of the workforce crisis. Additionally, the COVID-19 pandemic has dramatically increased the incidence of serious mental health and substance use issues in California, making access to mental health and substance use disorder services more crucial than ever. Addressing the need created by the pandemic will require existing providers to serve more Medi-Cal enrollees in communities throughout California. Streamlining and standardizing intake, assessment, and treatment plans for use with contracted behavioral health providers statewide would directly increase access to Medi-Cal behavioral health programs.
2. 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 and under a separate statutory framework from the drug Medi-Cal benefit. 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 a MCMC plan. Counties also provide substance use disorder services, including those in the Drug Medi-Cal Organized Delivery System plans. This bill applies to all of these delivery systems.

Documentation requirements within these delivery systems has been a longstanding issue as individual counties and MCMC plans interpret DHCS documentation rules differently and often, in an effort to avoid having funds recouped through a DHCS audit, require significant detail in intake, assessment, and treatment planning forms. Sponsors of this bill have shared years’ worth of correspondence with DHCS on the issue, including a study they had commissioned with an outside consulting firm comparing the medical necessity documentation requirements in California, New York, and Massachusetts by comparing the requirements in outpatient progress notes. The study found California’s audit guide definition of medical necessity requires each component of the definition to be documented in every progress note. This audit expectation that requires a direct care staff to document medical necessity over and over in each progress note for each event of service results in excessive and redundant documentation, which takes time away from patient care, as well as makes it more likely that other elements such as treatment progress will not be captured.

1. Efforts to improve service delivery. DHCS, through its California Advancing and Innovating Medi-Cal (CalAIM) initiative, has made efforts to improve access to behavioral health care. DHCS implemented CalAIM through the California’s Medicaid State Plan, the 1115 waiver, and the 1915(b) waiver. CalAIM transferred DHCS’s authority to implement the Medi-Cal managed care program from the previous 1115 waiver to a 1915(b) waiver. Under the 1915(b) waiver, DHCS also renewed its authority to provide specialty services through county mental health plans. One of the aims of the CalAIM initiative has been to standardize statewide screening and transition tools and streamline criteria for accessing services to reduce barriers to care as is required by AB 133 (Committee on Budget, Chapter 143, Statutes of 2021), the health trailer bill that established CalAIM. The focus of these efforts thus far has been on the adult and youth screening form used to determine which delivery system an individual should be referred to in an effort to avoid sending individuals back and forth between the mental health plans for specialty services and MCMC plans for nonspecialty services. The form used to facilitate a referral between the two delivery systems while avoiding a break in care has also been modified. These forms have been implemented statewide as of January 1, 2023. DHCS has also implemented new chart documentation requirements for the specialty and substance use disorder services, effective July 1, 2022, to streamline documentation requirements and better align with CMS coding standards. DHCS is also required to revise its documentation standards for its audits. DHCS has stated its intent to limit its audits to issues suggesting fraud, waste, or abuse rather than more minor issues such as the formatting of documentation.

However, just as CalAIM has provided opportunity to simplify documentation, the additional efforts to transform the behavioral health system through CalAIM have also compounded documentation requirements due to the variance in county interpretation of these requirements, largely out of concerns regarding DHCS audits. Sponsors of this bill have shared examples of counties continuing to have varying interpretations of DHCS requirements and in some cases not implementing changes mandated by DHCS. DHCS is currently seeking stakeholder input on further revisions to its clinical guidance to reduce documentation burden and expects to release an updated guidance in September to take effect in 2024. Sponsors and other stakeholders have been actively engaged in these documentation reform efforts with DHCS. This bill models the language used to revise the delivery system screening and transition forms and applies it to intake, assessment, and treatment planning forms used to adjudicate claims in the various behavioral health delivery systems with a particular focus on how the medical necessity criteria is required to be documented.

1. Prior legislation. SB 293 (Limon) of 2021 would have required DHCS, with respect to the EPSDT specialty services benefit, to develop standard forms relating to medical necessity criteria, mandatory screening and transition of care tools, and documentation requirements; allowed DHCS to develop and maintain a list of DHCS-approved nonstandard forms; and allowed forms on the nonstandard forms list to be used by county mental health plan contractors, in addition to the standard forms, to determine eligibility and reimbursement for specialty mental health services. SB 293 was not heard at the request of the author in the Assembly Committee on Appropriations.

AB 826 (Reyes of 2019), among other provisions, would have required DHCS, in consultation with the Department of Social Services and other stakeholders, to develop standardized forms and processes to be used by counties in the presumptive transfers of foster youth, in order to facilitate provision of specialty services to foster youth. These provisions were amended out of AB 826. AB 826 was vetoed by the Governor.

AB 133 (Committee on Budget, Chapter 143, Statutes of 2021) implements various components of the CalAIM initiative, including those providing authority for DHCS to develop and implement documentation standards.

AB 763 (Gray of 2019) was substantially similar to SB 293. AB 763 was held on the Senate Appropriations suspense file.

1. Support. Co-sponsor the California Council of Community Behavioral Health Agencies write that providers estimate that Medi-Cal paperwork consumes 40% to 50% of their time, time that could be spent providing services to those in need. The paperwork is complex, requiring hours of training to complete properly, and is a significant driver of provider burnout and attrition. Just the intake packet required for an initial appointment with a child or adolescent in need of mental health services can exceed 30 pages. Co-sponsor the California Association of Alcohol and Drug Program Executives writes that under CalAIM, counties receive limited guidance from DHCS on documentation requirements related to mental health and substance use disorder services. As a result, documentation requirements vary, with each of the 58 counties mandating different sets of paperwork to administer the same types of services. This creates substantial confusion for providers and results in people experiencing critical gaps in coordinated care, while also increasing overall costs to the entire healthcare delivery system. Co-sponsor the California Alliance of Child and Family Services writes that California is suffering from a behavioral health provider shortage, and they simply cannot afford to have the providers California does have spending half of their time filling out forms and navigating different requirements across counties instead of providing clinical services.
2. Concerns. The County Behavioral Health Directors Association submitted a letter of concerns stating that under the CalAIM initiative, DHCS has implemented standardized screening and transition tools effective January 1, 2023, streamlined documentation requirements effective July 1, 2022, and is currently in the process of developing changes to clinical audit practices to move away from provider recoupments tied to documentation and instead focus on quality and program integrity. Outstanding CalAIM Behavioral Health Initiatives which will further simplify and streamline documentation requirements include: behavioral health payment reform, which will be Implemented in July 2023, and administration integration, which will be implemented gradually over the next three years. They also state concern that efforts to mandate specific forms would have the unintended consequence of recreating documentation standards that are unique to county behavioral health which will continue to put their providers on an unlevel playing field with other health care delivery systems. In addition, clinical practice changes over time, and counties need the ability to adapt to best clinical practice without having to go through the state.
3. Amendments. While requiring DHCS to conduct an analysis and publish a report on the use of the standardized forms and status of the trainings makes sense from an oversight perspective, this provision should be time-limited so that DHCS does not have reporting requirements on form use in perpetuity.

SUPPORT AND OPPOSITION:

Support: California Association of Alcohol and Drug Executives (co-sponsor)

California Alliance of Child and Family Services (co-sponsor)
California Council of Community Behavioral Health Agencies (co-sponsor)

Association of Community Human Service Agencies

Behavioral Health Contractors' Association
California Access Coalition
California Assisted Living Association
California Association of Social Rehabilitation Agencies
California Children's Hospital Association

California Council of Community Behavioral Health Agencies
California Health+ Advocates

Children’s Health Council

Children's Hospital of Orange County

Children's Institute

Didi Hirsch Mental Health Services

Health RIGHT 360
Pacific Clinics
Seneca Family of Agencies

Shields for Families
Sierra Vista Child and Family Services

Steinberg Institute
Sycamores
WestCoast Children's Clinic

One individual

Oppose: None received.

-- END --

SENATE COMMITTEE ON HEALTH

Senator Dr. Susan Talamantes Eggman, Chair

BILL NO: AB 1470

SUBJECT: Medi-Cal: behavioral health services: documentation standards

SUMMARY:

Requires the Department of Health Care Services (DHCS) to adopt and require the use of standardized intake, assessment, and treatment planning forms for Medi-Cal behavioral health services, including specialty mental health services, non-specialty mental health services, and substance use disorder services. Requires DHCS to prepare an annual report on the implementation of these forms.

Existing law:

1. Establishes the Medi-Cal program, which is administered by the DHCS, under which low-income individuals receive health care services. [WIC §14000, et seq.]
2. Establishes a schedule of benefits under the Medi-Cal program, which includes federally required and optional Medicaid benefits. [WIC §14132, et seq.]
3. Includes mental health and substance use services in the essential health benefits package established under state law as Medi-Cal benefits. [WIC §14132.03]
4. 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]
5. 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]
6. Authorizes DHCS to enter into contracts for the provision of Drug Medi-Cal Treatment Program services with certified Drug Medi-Cal providers directly or through qualifying individual counties or counties acting jointly. [WIC §14124.21]
7. Requires DHCS to develop the following, in consultation with county behavioral health directors, consumer advocates, labor organizations representing county behavioral health workers, mental health and substance use disorder treatment providers, and MCMC plans: standardized screening tools to guide a referral to a Medi-Cal behavioral health delivery system, standardized statewide transition tools to ensure timely coordinated care when transitioning between delivery systems, and documentation standards and changes to the department’s clinical auditing standards. [WIC §14184.402]
8. Authorizes DHCS to require the use of standardized screening tools, standardized statewide transition tools, and documentation standards by Medi-Cal behavioral health delivery systems, including restrictions developed in consultation with representatives of Medi-Cal behavioral health delivery systems on what Medi-Cal behavioral health delivery systems impose on their contract providers, consistent with MCMC plans and taking into account the need to ensure quality and program integrity and to address equity and disparities. [WIC §14184.402]

This bill:

1. Requires DHCS to standardize data elements relating to documentation requirements, including but not limited to, medically necessary criteria with respect to behavioral health services provided under the Medi-Cal program, including specialty services, nonspecialty mental health services (“nonspecialty services”), and substance use disorder services.
2. Requires DHCS to develop standard forms containing information necessary to properly adjudicate claims for specialty and nonspecialty services in a manner that is consistent with the existing CalAIM requirements as approved by the federal Centers for Medicare and Medicaid Services (CMS). Requires the standard forms to include intake, assessment, and treatment planning forms. Requires the forms to comply with state and federal health privacy law.
3. Requires DHCS to consult with the representatives of all of the following for the purposes of implementing this bill:
4. The County Behavioral Health Directors Association of California;
5. The California State Association of Counties;
6. The County Welfare Directors Association of California;
7. Behavioral health programs in at least one small (less than 300,000), medium (300,000-700,000), and large (over 700,000) county; and,
8. Associations that represent children’s hospitals, foster youth, parents and caregivers, community-based children’s behavioral health providers, children’s health legal advocates, providers of adult and older adult care, and providers of substance use disorder treatment.
9. Requires DHCS to conduct regional trainings for the personnel and provider networks of Medi-Cal behavioral health systems, MCMC plans, and other behavioral health entities on or before July 1, 2025, on proper completion of the standard forms. Requires DHCS to make training material available for the use in local trainings and for mental health plans, MCMC plans, and other behavioral health entities serving Medi-Cal patients to distribute the forms to their provider networks.
10. Requires Medi-Cal behavioral health systems, MCMC plans, and other behavioral health entities serving Medi-Cal patients and provider networks of those entities to utilize the standard forms for performing the intake of, assessment of, and treatment planning for, Medi-Cal beneficiaries who are eligible for behavioral health services under the Medi-Cal program no later than July 1, 2025.
11. Authorizes DHCS to restrict the imposition of additional documentation requirements beyond those requirements included on standard forms, including, but not limited to, restrictions developed in consultation with representatives of Medi-Cal behavioral health delivery systems on what Medi-Cal behavioral health delivery systems impose on their contract providers, consistent with MCMC plans and taking into account the need to ensure quality and program integrity and to address equity and disparities.
12. Requires DHCS to conduct an analysis on the utilization of the standard forms by Medi-Cal behavioral health systems, MCMC plans, and other behavioral health entities serving Medi-Cal patients, and on the status of the trainings and training material in order to determine the effectiveness of implementation of this section. Requires DHCS to prepare annual reports containing findings from the analysis starting July 1, 2026 and each year thereafter. Requires the report to be submitted to the Legislature and posted on DHCS’s website.
13. Makes legislative findings that behavioral health providers have less time to serve clients with behavioral health issues due to excessive and varying paperwork requirements in the Medi-Cal program, leading to client harm and exacerbating the behavioral health provider shortage. Makes findings that the Legislature intends to dramatically reduce and standardize the paperwork burden on Medi-Cal behavioral health providers to serve more Medi-Cal beneficiaries, ensure consistent reimbursement, provide clear guidance, and minimize the risk of negative audit findings and retroactive disallowances.

FISCAL EFFECT:

According to the Assembly Appropriations Committee, this bill has one-time costs of an unknown amount to DHCS, possibly in the hundreds of thousands of dollars (General Fund and federal funds).

PRIOR VOTES:

COMMENTS:

1. Author’s statement. According to the author, a large percent of a medical provider's time is spent maintaining health records of their patients. In fact, a high percentage of doctors feel that clinical documentation requirements are excessive and compromises their time for direct patient care. California is suffering a severe shortage of mental health and substance use professionals. Even pre-pandemic, Medi-Cal beneficiaries experienced challenges accessing mental health and substance use disorder services because of the workforce crisis. Additionally, the COVID-19 pandemic has dramatically increased the incidence of serious mental health and substance use issues in California, making access to mental health and substance use disorder services more crucial than ever. Addressing the need created by the pandemic will require existing providers to serve more Medi-Cal enrollees in communities throughout California. Streamlining and standardizing intake, assessment, and treatment plans for use with contracted behavioral health providers statewide would directly increase access to Medi-Cal behavioral health programs.
2. 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 and under a separate statutory framework from the drug Medi-Cal benefit. 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 a MCMC plan. Counties also provide substance use disorder services, including those in the Drug Medi-Cal Organized Delivery System plans. This bill applies to all of these delivery systems.

Documentation requirements within these delivery systems has been a longstanding issue as individual counties and MCMC plans interpret DHCS documentation rules differently and often, in an effort to avoid having funds recouped through a DHCS audit, require significant detail in intake, assessment, and treatment planning forms. Sponsors of this bill have shared years’ worth of correspondence with DHCS on the issue, including a study they had commissioned with an outside consulting firm comparing the medical necessity documentation requirements in California, New York, and Massachusetts by comparing the requirements in outpatient progress notes. The study found California’s audit guide definition of medical necessity requires each component of the definition to be documented in every progress note. This audit expectation that requires a direct care staff to document medical necessity over and over in each progress note for each event of service results in excessive and redundant documentation, which takes time away from patient care, as well as makes it more likely that other elements such as treatment progress will not be captured.

1. Efforts to improve service delivery. DHCS, through its California Advancing and Innovating Medi-Cal (CalAIM) initiative, has made efforts to improve access to behavioral health care. DHCS implemented CalAIM through the California’s Medicaid State Plan, the 1115 waiver, and the 1915(b) waiver. CalAIM transferred DHCS’s authority to implement the Medi-Cal managed care program from the previous 1115 waiver to a 1915(b) waiver. Under the 1915(b) waiver, DHCS also renewed its authority to provide specialty services through county mental health plans. One of the aims of the CalAIM initiative has been to standardize statewide screening and transition tools and streamline criteria for accessing services to reduce barriers to care as is required by AB 133 (Committee on Budget, Chapter 143, Statutes of 2021), the health trailer bill that established CalAIM. The focus of these efforts thus far has been on the adult and youth screening form used to determine which delivery system an individual should be referred to in an effort to avoid sending individuals back and forth between the mental health plans for specialty services and MCMC plans for nonspecialty services. The form used to facilitate a referral between the two delivery systems while avoiding a break in care has also been modified. These forms have been implemented statewide as of January 1, 2023. DHCS has also implemented new chart documentation requirements for the specialty and substance use disorder services, effective July 1, 2022, to streamline documentation requirements and better align with CMS coding standards. DHCS is also required to revise its documentation standards for its audits. DHCS has stated its intent to limit its audits to issues suggesting fraud, waste, or abuse rather than more minor issues such as the formatting of documentation.

However, just as CalAIM has provided opportunity to simplify documentation, the additional efforts to transform the behavioral health system through CalAIM have also compounded documentation requirements due to the variance in county interpretation of these requirements, largely out of concerns regarding DHCS audits. Sponsors of this bill have shared examples of counties continuing to have varying interpretations of DHCS requirements and in some cases not implementing changes mandated by DHCS. DHCS is currently seeking stakeholder input on further revisions to its clinical guidance to reduce documentation burden and expects to release an updated guidance in September to take effect in 2024. Sponsors and other stakeholders have been actively engaged in these documentation reform efforts with DHCS. This bill models the language used to revise the delivery system screening and transition forms and applies it to intake, assessment, and treatment planning forms used to adjudicate claims in the various behavioral health delivery systems with a particular focus on how the medical necessity criteria is required to be documented.

1. Prior legislation. SB 293 (Limon) of 2021 would have required DHCS, with respect to the EPSDT specialty services benefit, to develop standard forms relating to medical necessity criteria, mandatory screening and transition of care tools, and documentation requirements; allowed DHCS to develop and maintain a list of DHCS-approved nonstandard forms; and allowed forms on the nonstandard forms list to be used by county mental health plan contractors, in addition to the standard forms, to determine eligibility and reimbursement for specialty mental health services. SB 293 was not heard at the request of the author in the Assembly Committee on Appropriations.

AB 826 (Reyes of 2019), among other provisions, would have required DHCS, in consultation with the Department of Social Services and other stakeholders, to develop standardized forms and processes to be used by counties in the presumptive transfers of foster youth, in order to facilitate provision of specialty services to foster youth. These provisions were amended out of AB 826. AB 826 was vetoed by the Governor.

AB 133 (Committee on Budget, Chapter 143, Statutes of 2021) implements various components of the CalAIM initiative, including those providing authority for DHCS to develop and implement documentation standards.

AB 763 (Gray of 2019) was substantially similar to SB 293. AB 763 was held on the Senate Appropriations suspense file.

1. Support. Co-sponsor the California Council of Community Behavioral Health Agencies write that providers estimate that Medi-Cal paperwork consumes 40% to 50% of their time, time that could be spent providing services to those in need. The paperwork is complex, requiring hours of training to complete properly, and is a significant driver of provider burnout and attrition. Just the intake packet required for an initial appointment with a child or adolescent in need of mental health services can exceed 30 pages. Co-sponsor the California Association of Alcohol and Drug Program Executives writes that under CalAIM, counties receive limited guidance from DHCS on documentation requirements related to mental health and substance use disorder services. As a result, documentation requirements vary, with each of the 58 counties mandating different sets of paperwork to administer the same types of services. This creates substantial confusion for providers and results in people experiencing critical gaps in coordinated care, while also increasing overall costs to the entire healthcare delivery system. Co-sponsor the California Alliance of Child and Family Services writes that California is suffering from a behavioral health provider shortage, and they simply cannot afford to have the providers California does have spending half of their time filling out forms and navigating different requirements across counties instead of providing clinical services.
2. Concerns. The County Behavioral Health Directors Association submitted a letter of concerns stating that under the CalAIM initiative, DHCS has implemented standardized screening and transition tools effective January 1, 2023, streamlined documentation requirements effective July 1, 2022, and is currently in the process of developing changes to clinical audit practices to move away from provider recoupments tied to documentation and instead focus on quality and program integrity. Outstanding CalAIM Behavioral Health Initiatives which will further simplify and streamline documentation requirements include: behavioral health payment reform, which will be Implemented in July 2023, and administration integration, which will be implemented gradually over the next three years. They also state concern that efforts to mandate specific forms would have the unintended consequence of recreating documentation standards that are unique to county behavioral health which will continue to put their providers on an unlevel playing field with other health care delivery systems. In addition, clinical practice changes over time, and counties need the ability to adapt to best clinical practice without having to go through the state.
3. Amendments. While requiring DHCS to conduct an analysis and publish a report on the use of the standardized forms and status of the trainings makes sense from an oversight perspective, this provision should be time-limited so that DHCS does not have reporting requirements on form use in perpetuity.

SUPPORT AND OPPOSITION:

Support: California Association of Alcohol and Drug Executives (co-sponsor)

California Alliance of Child and Family Services (co-sponsor)
California Council of Community Behavioral Health Agencies (co-sponsor)

Association of Community Human Service Agencies

Behavioral Health Contractors' Association
California Access Coalition
California Assisted Living Association
California Association of Social Rehabilitation Agencies
California Children's Hospital Association

California Council of Community Behavioral Health Agencies
California Health+ Advocates

Children's Hospital of Orange County

Children's Institute

Didi Hirsch Mental Health Services

Health RIGHT 360
Pacific Clinics
Seneca Family of Agencies

Shields for Families
Sierra Vista Child and Family Services

Steinberg Institute
Sycamores
WestCoast Children's Clinic

Two individuals

Oppose: None received.

-- END --

ASSEMBLY THIRD READING

ATR Bill Id:AB 1470

Author:(Quirk-Silva)

As Amended Ver:April 27, 2023

Majority vote

SUMMARY

Requires the Department of Health Care Services (DHCS) to adopt and require the use of standardized forms for purposes of provider billing for Medi-Cal behavioral health services, including county-administered specialty mental health and substance use services, as well as non-specialty mental health services provided by Medi-Cal managed care plans.

Major Provisions

COMMENTS

1. Medi-Cal's Delivery System for Behavioral Health Services. Under Medi-Cal, behavioral health services are largely delivered under two systems. Counties administer mental health plans that provide specialty mental health services to those with severe mental illness, as well as substance use disorder treatment services through Drug Medi-Cal-Organized Delivery System (DMC-ODS). Medi-Cal managed care plans provide services for those with less severe needs. DHCS generally sets minimum requirements and ensures through audits that its requirements are met, but does not dictate the use of specific forms. Thus, each plan may interpret and implement guidance on forms and documentation differently, as long as it meets its contractual requirements with DHCS. This bill applies to all of the delivery systems and services noted below:
   1. Specialty Mental Health Services (SMHS). As the single state Medicaid agency, DHCS is responsible for administering the Medi-Cal SMHS waiver program, which provides SMHS to Medi-Cal beneficiaries through county mental health plans (MHPs). The MHPs are required to provide or arrange for the provision of SMHS to beneficiaries in their counties that meet medical necessity criteria, consistent with the beneficiaries' mental health treatment needs and goals.​​

County MHPs are required to provide SMHS to adults when they have significant impairment and/or a reasonable probability of significant deterioration in an important area of life functioning, and the condition is due to a diagnosed mental health disorder or a suspected, undiagnosed mental disorder. Criteria for children are more expansive.

• 1. Drug Medi-Cal (DMC). With the broader Medi-Cal program, DHCS administers the DMC Program. DMC reimbursement is issued to counties and direct providers that have a contract with DHCS for approved DMC services provided to Medi-Cal beneficiaries.

The DMC-ODS is a Medi-Cal benefit that is available only to counties that choose to opt in. Most counties, representing over 95% of the state's population, have opted in to provide DMC-ODS services.

• 1. Non-Specialty Mental Health Services (NSMHS). Medi-Cal managed care plans cover a set of mental health benefits that DHCS used to refer to as "mild to moderate" mental health services, but are now called NSMHS.

1. California Advancing and Innovating Medi-Cal (CalAIM) behavioral health proposals. In October 2019, DHCS released a broad, sweeping, multi-year initiative aimed at improving the health outcomes of beneficiaries in Medi-Cal, known as CalAIM. CalAIM implementation was originally scheduled to begin in January 2021, but was delayed due the impact of the COVID-19 public health emergency. The behavioral health system reforms under CalAIM include, among other proposals, standardizing screening tools, reforming documentation requirements and standards, and changing reimbursement methodologies and medical claiming codes. AB 133 (Committee on Budget), Chapter 143, Statutes of 2021, implements various components of the CalAIM initiative, including those providing authority for DHCS to develop and implement documentation standards.
   1. Screening and transition tools. On December 22, 2022, DHCS released Behavioral Health Information Notice (BHIN) No: 22-065 on standardized, statewide Adult and Youth Screening and Transition of Care Tools to guide referrals of adult and youth beneficiaries to the appropriate Medi-Cal mental health delivery system and ensure that beneficiaries requiring transition between delivery systems receive timely, coordinated care. Effective January 1, 2023, the BHIN requires MHPs to implement both the standardized Screening and Transition of Care Tools for Medi-Cal mental health services.
   2. Clinical documentation requirements. On April 22, 2022, DHCS released BHIN No: 22-019 which established, effective July 1, 2022, new chart documentation requirements for SMHS, DMC, and DMC-ODS services. The BHIN intends to streamline and standardize clinical documentation requirements across Medi-Cal SMHS, DMC, and DMC-ODS services to align with medical provider requirements, improve efficiency, and decrease provider burnout. DHCS states that existing requirements for provider documentation are confusing and may lead to provider burden and risk of payment disallowance during audits. DHCS states these updated documentation requirements better align with Centers for Medicare and Medicaid Services' national coding standards and physical health care documentation practices.

According to DHCS, the new criteria were developed based on significant feedback from stakeholders, including county behavioral health directors, consumer advocates, labor organizations representing county behavioral health workers, and mental health and substance use disorder treatment providers.

The BHIN states DHCS will monitor plans and counties for compliance with the new documentation standards, and deviations from the standards will require corrective action plans. DHCS also indicates recoupment will be focused on fraud, waste, and abuse. The BHIN addresses a number of items, including standardized assessment requirements; SMHS, DMC, and DMC-ODS problem list and progress notes; treatment and care planning requirements; and telehealth consent.

DHCS states counties are required to implement the documentation requirements established in BHIN 2022-019, effective July 1, 2022. According to DHCS, implementation includes updating policies and procedures, as well as supporting materials for triennial (SMHS) or annual (DMC/DMC-ODS) reviews to ensure compliance. DHCS also requires that counties communicate these updates to providers as necessary.

1. November 30, 2022 Coalition Letter. In late 2022, a coalition of behavioral health stakeholders, including County Behavioral Health Directors of California, the California Association of Social Rehabilitation Agencies, and the three cosponsors of this bill, wrote to DHCS to share concerns with the collective efforts to reform specialty behavioral health documentation reform under CalAIM. The letter acknowledges the documentation reform efforts that culminated in the April 2022 BHIN, but communicates a shared understanding there is significant work left to do to realize the vision of documentation reform under CalAIM. The coalition indicated it had been working together to develop an inventory of additional federal and state policies impacting specialty behavioral health documentation practices, and corresponding recommendations for state guidance that would support more effective implementation of CalAIM reforms. The coalition indicated it anticipated sharing those recommendations as well in the weeks ahead and reiterated its willingness to partner on these efforts with DHCS and each other.
2. Ongoing work. DHCS has acknowledged that although the BHIN 22-019 issued in April 2022 was intended to reduce documentation burden, it did not address all the issues in the community that lead to excessive documentation burden. Accordingly, DHCS is actively soliciting stakeholder input on revisions to the BHIN that will further assist providers and county MHP and DMC-ODS plans to reduce documentation burden. Based on this additional analysis and in consultation with stakeholders, DHCS expects to release an updated notice in September 2023 that will supersede the BHIN and take effect in 2024. The revised BHIN will seek to address challenges that prevented the April 2022 BHIN from having its intended effect of reducing paperwork, and provide further clarity about DHCS requirements. This increased clarity should, in turn, reduce the tendency for counties averse to fiscal risk of recoupments based on DHCS audits, from requesting excessive documentation from contracted providers.

According to the Author

A large percent of a medical provider's time is spent maintaining health records of their patients. The author notes a high percentage of doctors believe clinical documentation requirements are excessive and compromise their time for direct patient care. The author asserts this bill, through streamlining and standardizing intake, assessment, and treatment forms for use with contracted behavioral health providers statewide would directly increase access to Medi-Cal behavioral health programs. This bill is cosponsored by the California Council of Community Behavioral Health Agencies, the California Alliance of Child and Family Services, and the California Association of Alcohol and Drug Program Executives.

Arguments in Support

A coalition of health care providers supports this bill, generally expressing acknowledgement of DHCS's efforts in this area, but also frustration with the pace of reform. Providers emphasize the day-to-day toll behavioral health documentation has on the ability of individual providers to see more patients and the negative effect it has on morale. For instance, Seneca Family of Agencies (Seneca) indicates that just the intake packet required for an initial appointment with a child or adolescent in need of mental health services can exceed 30 pages. Seneca asserts California is suffering from a behavioral health provider shortage, and we simply cannot afford to have the providers California does have spending half of their time filling out forms and navigating different requirements across counties instead of providing clinical services. California Health+ Advocates (CH+A), representing community clinics, estimate that paperwork for patients consumes 40-50% of their time to complete, which leaves them with even less time to provide health care services. CH+A indicates community health centers that contract with counties to provide specialty mental health and substance use disorder services to children, adults, and older adults in the Medi-Cal program bear an enormous paperwork burden, which is a significant driver of provider burnout and attrition.

Arguments in Opposition

There is no known opposition.

FISCAL COMMENTS

According to the Assembly Appropriations Committee, this bill would have one-time costs of an unknown amount to DHCS, possibly in the hundreds of thousands of dollars (General Fund and federal funds).

VOTES

ASM HEALTH: 15-0-0

YES: Wood, Waldron, Aguiar-Curry, Arambula, Boerner, Wendy Carrillo, Flora, Vince Fong, Maienschein, McCarty, Joe Patterson, Rodriguez, Santiago, Villapudua, Weber

ASM APPROPRIATIONS: 15-0-1

YES: Holden, Megan Dahle, Bryan, Calderon, Wendy Carrillo, Dixon, Mike Fong, Hart, Lowenthal, Mathis, Papan, Pellerin, Sanchez, Weber, Ortega

ABS, ABST OR NV: Robert Rivas

UPDATED

VERSION: April 27, 2023

CONSULTANT: Lisa Murawski / HEALTH / (916) 319-2097 FN: 0000799

Date of Hearing: May 17, 2023

ASSEMBLY COMMITTEE ON APPROPRIATIONS

Chris Holden, Chair

ABPCA Bill Id:AB 1470

Author:(Quirk-Silva) – As Amended Ver:April 27, 2023

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

SUMMARY:

This bill, with respect to behavioral health services provided under the Medi-Cal program, requires the Department of Health Care Services (DHCS) to work with stakeholders to standardize documentation requirements and conduct regional trainings for personnel and provider networks on proper completion of the standard forms. The bill requires each applicable entity to use the standard forms and to distribute the training material and standard forms to its provider networks. This bill requires DHCS to evaluate the implementation of the bill’s provisions, report the findings of the analysis to the Legislature, and post the reports on DHCS’ website.

FISCAL EFFECT:

One-time costs of an unknown amount to DHCS, possibly in the hundreds of thousands of dollars (General Fund and federal funds).

COMMENTS:

1. Purpose. The sponsors of this bill are the California Council of Community Behavioral Health Agencies, California Alliance of Child and Family Services, and the California Association of Alcohol and Drug Program Executives. According to the author:

A large percent of a medical provider's time is spent maintaining health records of their patients. In fact, a high percentage of doctors feel that clinical documentation requirements are excessive and compromises their time for direct patient care. California is suffering a severe shortage of mental health and substance use professionals. Even pre-pandemic, Medi-Cal beneficiaries experienced challenges accessing [mental health services (MHS)] and [substance use disorder (SUD)] services because of the workforce crisis. Additionally, the COVID-19 pandemic has dramatically increased the incidence of serious mental health and substance use issues in California, making access to MHS and SUDS more crucial than ever. Addressing the need created by the pandemic will require existing providers to serve more Medi-Cal enrollees in communities throughout California. Streamlining and standardizing intake, assessment, and treatment plans for use with contracted behavioral health providers statewide would directly increase access to Medi-Cal behavioral health programs.

1. Background.
   
   Clinical Documentation Requirements. The author cites a report they say shows California’s outpatient paperwork completion time is five times longer than the other states in the study. In April 2022, DHCS released Behavioral Health Information Notice (BHIN) No: 22-019 establishing, effective July 1, 2022, new chart documentation requirements for specialty mental health services (SMHS), Drug Medi-Cal (DMC), and Drug Medi-Cal Organized Delivery System (DMC-ODS) services. The BHIN intends to streamline and standardize clinical documentation requirements across Medi-Cal SMHS, DMC, and DMC-ODS services to align with medical provider requirements, improve efficiency, and decrease provider burnout. DHCS states existing requirements for provider documentation are confusing and may lead to provider burden and risk of payment disallowance during audits. DHCS states these updated documentation requirements better align with the federal Centers for Medicare and Medicaid Services’ national coding standards and physical health care documentation practices. According to DHCS, the new criteria were developed based on significant feedback from stakeholders, including county behavioral health directors, consumer advocates, labor organizations representing county behavioral health workers, and mental health and substance use disorder treatment providers.
   
   DHCS states counties are required to implement the documentation requirements established in BHIN 2022-019, effective July 1, 2022. According to DHCS, implementation includes updating policies and procedures, as well as supporting materials for triennial (SMHS) or annual (DMC/DMC-ODS) reviews to ensure compliance. DHCS also requires that counties communicate these updates to providers as necessary.

Ongoing Work. DHCS has acknowledged that although the BHIN 22-019 issued in April 2022 was intended to reduce documentation burden, it did not address all the issues that lead to excessive documentation burden. Accordingly, DHCS is soliciting stakeholder input on revisions to the BHIN that will further assist providers and county mental health plan and DMC-ODS plans to reduce documentation burden. In consultation with stakeholders, DHCS expects to release an updated notice in September 2023 that will supersede the BHIN and take effect in 2024. The revised BHIN will seek to address challenges that prevented the April 2022 BHIN from having its intended effect of reducing paperwork, and provide further clarity about DHCS requirements. This increased clarity should, in turn, reduce the tendency for counties averse to fiscal risk of recoupments based on DHCS audits, from requesting excessive documentation from contracted providers.

>

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

Date of Hearing: April 25, 2023

ASSEMBLY COMMITTEE ON HEALTH

Jim Wood, Chair

ABPCA Bill Id:AB 1470

Author:(Quirk-Silva) – As Amended Ver:March 23, 2023

SUBJECT: Medi-Cal: behavioral health services: documentation standards.

SUMMARY: Requires the Department of Health Care Services (DHCS) to adopt and require the use of standardized forms for purposes of provider billing for Medi-Cal behavioral health services, including county-administered specialty mental health and substance use services, as well as non-specialty mental health services provided by Medi-Cal managed care plans. Specifically, this bill:

1. Requires, DHCS to develop standard forms relating to medical necessity criteria, mandatory screening, transition of care tools, and documentation requirements for behavioral health services provided under the Medi-Cal program, including specialty mental health services, non-specialty mental health services, and substance use disorder services.
2. Requires DHCS to consult with representatives from all of the following:
   1. The County Behavioral Health Directors Association of California;
   2. The California State Association of Counties;
   3. The County Welfare Directors Association of California;
   4. Behavioral health programs in at least one small, medium, and large county; and,
   5. Associations that represent children’s hospitals, foster youth, parents and caregivers, community-based children’s behavioral health providers, children’s health legal advocates, providers of adult and older adult care, and providers of substance use disorder treatment.
3. Allows DHCS to develop, maintain, and annually update a list of DHCS-approved nonstandard forms. Allows the use of nonstandard forms, in addition to the standard forms developed pursuant to 1) above.
4. Requires, no later than July 1, 2025, each behavioral health payer to commence using standard and/or DHCS-approved non-standard forms for, and prohibits the use of any other forms related to intake, assessment, treatment planning, eligibility determination, or reimbursement for Medi-Cal behavioral health services.
5. Requires DHCS to require any provider of behavioral health services to an eligible Medi-Cal beneficiary, a Medi-Cal specialty mental health plan, Drug Medi-Cal Organized Delivery System (DMC-ODS) plans, a Medi-Cal managed care plan, or fee-for-service delivery system, if they provide behavioral health services under the Medi-Cal program, to use the standard forms and DHCS-approved nonstandard forms, as specified.
6. Requires DHCS to ensure forms comply with federal and state laws and regulations, and other federal requirements.
7. Requires, on or before July 1, 2025, DHCS to develop training material and conduct regional trainings for providers on proper completion of the standard forms, and requires counties and managed care plans to distribute training materials to providers.
8. Requires DHCS to conduct an analysis on the status of utilization of the forms and on the status of the trainings and training material described in 7) above, to determine the effectiveness of implementation, and submit to the Legislature annual reports containing findings from such analysis, beginning on July 1, 2026.

EXISTING LAW:

1. Establishes the Medi-Cal program, which is administered by the DHCS and under which qualified low-income individuals receive health care services. [Welfare and Institutions Code (WIC) § 14000, et seq.]
2. Establishes a schedule of benefits under the Medi-Cal program, which includes federally required and optional Medicaid benefits. [WIC § 14131 - 14138]
3. Includes mental health and substance use services in the essential health benefits package established under state law as Medi-Cal benefits. [WIC § 14132.03]
4. 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 (SMHS) to each county’s eligible Medi-Cal beneficiary population. Authorizes mental health plan (MHP) contracts to be awarded exclusively and on a geographic basis. [WIC §14712]
5. Requires DHCS to develop, in consultation with county behavioral health directors, consumer advocates, labor organizations representing county behavioral health workers, mental health and substance use disorder treatment providers, and Medi-Cal managed care plans:
   1. Standardized screening tools to guide a referral to a Medi-Cal behavioral health delivery system;
   2. Standardized statewide transition tools to ensure that Medi-Cal beneficiaries requiring transition between delivery systems receive timely coordinated care; and,
   3. Documentation standards and changes to the department’s clinical auditing standards. [WIC 14184.402 (h)]
      
6. Allows DHCS to require the use of standardized screening tools, standardized statewide transition tools, and documentation standards by Medi-Cal behavioral health delivery systems. [Ibid.]
7. Specifies documentation standards pursuant to 5) above can include, but are not limited to, restrictions developed in consultation with representatives of Medi-Cal behavioral health delivery systems on what Medi-Cal behavioral health delivery systems impose on their contract providers, consistent with Medi-Cal managed care plans and taking into account the need to ensure quality and program integrity and to address equity and disparities. [Ibid.]

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

COMMENTS:

1. PURPOSE OF THIS BILL. According to the author, a large percent of a medical provider's time is spent maintaining health records of their patients. The author notes a high percentage of doctors believe clinical documentation requirements are excessive and compromise their time for direct patient care. The author asserts this bill, through streamlining and standardizing intake, assessment, and treatment forms for use with contracted behavioral health providers statewide would directly increase access to Medi-Cal behavioral health programs. This bill is cosponsored by the California Council of Community Behavioral Health Agencies (CBHA), the California Alliance of Child and Family Services (Alliance), the California Association of Alcohol and Drug Program Executives (CAADPE).
2. BACKGROUND.
   1. Medi-Cal’s Delivery System for Behavioral Health Services. Under Medi-Cal, behavioral health services are largely delivered under two systems. Counties administer mental health plans that provide specialty mental health services to those with severe mental illness, as well as substance use disorder treatment services through DMC-ODS. Medi-Cal managed care plans provide services for those with less severe needs. DHCS generally sets minimum requirements and ensures through audits that its requirements are met, but does not dictate the use of specific forms. Thus, each plan may interpret and implement guidance on forms and documentation differently, as long as it meets its contractual requirements with DHCS. This bill applies to all of the delivery systems and services noted below:
      1. SMHS. As the single state Medicaid agency, DHCS is responsible for administering the Medi-Cal SMHS waiver program, which provides SMHS to Medi-Cal beneficiaries through county MHPs. The MHPs are required to provide or arrange for the provision of SMHS to beneficiaries in their counties that meet medical necessity criteria, consistent with the beneficiaries' mental health treatment needs and goals.​​

County MHPs are required to provide SMHS to adults when they have significant impairment and/or a reasonable probability of significant deterioration in an important area of life functioning, and the condition is due to a diagnosed mental health disorder or a suspected, undiagnosed mental disorder. Criteria for children are more expansive.

SMHS include the following services: mental health services, medication support services; day treatment intensive and rehabilitation; crisis intervention, stabilization, and residential treatment services; adult residential treatment services; psychiatric health facility services; psychiatric inpatient hospital services; targeted case management; peer support services, if the county has opted in to the provision of the services; and service specific to beneficiaries under the age of 21, including intensive care coordination, intensive home based services therapeutic behavioral services, therapeutic foster care, and all other medically necessary specialty mental health services for beneficiaries under the age of 21.

• • 1. Drug Medi-Cal (DMC). With the broader Medi-Cal program, DHCS administers the DMC Program. DMC reimbursement is issued to counties and direct providers that have a contract with DHCS for approved DMC services provided to Medi-Cal beneficiaries. DMC services include Narcotic Treatment Program (NTP) Services; outpatient drug free treatment services including physical examinations, group counseling, and individual counseling; intensive outpatient treatment; perinatal residential services; residential services under the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Benefit; and, Naltrexone treatment services.

The DMC-ODS is a Medi-Cal benefit that is available only to counties that choose to opt in. Most counties, representing over 95% of the state’s population, have opted in to provide DMC-ODS services. DMC-ODS services are provided by county DMC-ODS plans and include the following: outpatient services; intensive outpatient services; partial hospitalization; residential treatment; withdrawal management; Opioid (narcotic) Treatment Program; additional Medication Assisted Treatment; recovery services; case management; and physician consultation.

• • 1. Non-Specialty Mental Health Services (NSMHS). Medi-Cal managed care plans cover a set of mental health benefits that DHCS used to refer to as “mild to moderate” mental health services, but are now called NSMHS. These include mental health evaluation and treatment, including individual, group, and family psychotherapy; psychological and neuropsychological testing; outpatient services for the purposes of monitoring drug therapy; psychiatric consultation; and, outpatient laboratory, drugs, supplies, and supplements, excluding separately billable drugs claimed by outpatient pharmacy providers via Medi-Cal Rx.
  1. CalAIM behavioral health proposals. In October 2019, DHCS released a broad, sweeping, multi-year initiative aimed at improving the health outcomes of beneficiaries in Medi-Cal, known as CalAIM. CalAIM implementation was originally scheduled to begin in January 2021, but was delayed due the impact of the COVID-19 public health emergency. The behavioral health system reforms under CalAIM include, among other proposals, standardizing screening tools, reforming documentation requirements and standards, and changing reimbursement methodologies and medical claiming codes. AB 133 (Committee on Budget), Chapter 143, Statutes of 2021, implements various components of the CalAIM initiative, including those providing authority for DHCS to develop and implement documentation standards.
     1. Screening and transition tools. On December 22, 2022, DHCS released Behavioral Health Information Notice (BHIN) No: 22-065 on standardized, statewide Adult and Youth Screening and Transition of Care Tools to guide referrals of adult and youth beneficiaries to the appropriate Medi-Cal mental health delivery system and ensure that beneficiaries requiring transition between delivery systems receive timely, coordinated care. Effective January 1, 2023, the BHIN requires MHPs to implement both the standardized Screening and Transition of Care Tools for Medi-Cal mental health services.
     2. Clinical documentation requirements. On April 22, 2022, DHCS released BHIN No: 22-019 which established, effective July 1, 2022, new chart documentation requirements for SMHS, DMC, and DMC-ODS services. The BHIN intends to streamline and standardize clinical documentation requirements across Medi-Cal SMHS, DMC, and DMC-ODS services to align with medical provider requirements, improve efficiency, and decrease provider burnout. DHCS states that existing requirements for provider documentation are confusing and may lead to provider burden and risk of payment disallowance during audits. DHCS states these updated documentation requirements better align with Centers for Medicare and Medicaid Services’ national coding standards and physical health care documentation practices.

According to DHCS, the new criteria were developed based on significant feedback from stakeholders, including county behavioral health directors, consumer advocates, labor organizations representing county behavioral health workers, and mental health and substance use disorder treatment providers.

The BHIN states DHCS will monitor plans and counties for compliance with the new documentation standards, and deviations from the standards will require corrective action plans. DHCS also indicates recoupment will be focused on fraud, waste, and abuse. The BHIN addresses a number of items, including standardized assessment requirements; SMHS, DMC, and DMC-ODS problem list and progress notes; treatment and care planning requirements; and telehealth consent.

DHCS states counties are required to implement the documentation requirements established in BHIN 2022-019, effective July 1, 2022. According to DHCS, implementation includes updating policies and procedures, as well as supporting materials for triennial (SMHS) or annual (DMC/DMC-ODS) reviews to ensure compliance. DHCS also requires that counties communicate these updates to providers as necessary.

As part of CalAIM, DHCS is also transitioning the local government financing mechanism for SMHS reimbursement from a “certified public expenditure” methodology whereby costs must be certified, to one based on an intergovernmental transfer, as well as pursuing further administrative integration between mental health and substance use systems. Both of these efforts are also expected to reduce state and county administrative burden.

• 1. November 30, 2022 Coalition Letter. In late 2022, a coalition of behavioral health stakeholders, including County Behavioral Health Directors of California (CBHDA), the California Association of Social Rehabilitation Agencies (CASRA), and the three cosponsors of this bill, wrote to DHCS to share concerns with the collective efforts to reform specialty behavioral health documentation reform under CalAIM. The letter acknowledges the documentation reform efforts that culminated in the April 2022 BHIN, but communicates a shared understanding there is significant work left to do to realize the vision of documentation reform under CalAIM. The coalition indicated it had been working together to develop an inventory of additional federal and state policies impacting specialty behavioral health documentation practices, and corresponding recommendations for state guidance that would support more effective implementation of CalAIM reforms. The coalition indicated it anticipated sharing those recommendations as well in the weeks ahead and reiterated its willingness to partner on these efforts with DHCS and each other.
  2. Ongoing work. DHCS has acknowledged that although the BHIN 22-019 issued in April 2022 was intended to reduce documentation burden, it did not address all the issues in the community that lead to excessive documentation burden. Accordingly, DHCS is actively soliciting stakeholder input on revisions to the BHIN that will further assist providers and county MHP and DMC-ODS plans to reduce documentation burden. Based on this additional analysis and in consultation with stakeholders, DHCS expects to release an updated notice in September 2023 that will supersede the BHIN and take effect in 2024. The revised BHIN will seek to address challenges that prevented the April 2022 BHIN from having its intended effect of reducing paperwork, and provide further clarity about DHCS requirements. This increased clarity should, in turn, reduce the tendency for counties averse to fiscal risk of recoupments based on DHCS audits, from requesting excessive documentation from contracted providers.

1. SUPPORT. A coalition of health care providers supports this bill, generally expressing acknowledgement of DHCS’s efforts in this area, but also frustration with the pace of reform. Providers emphasize the day-to-day toll behavioral health documentation has on the ability of individual providers to see more patients and the negative effect it has on morale. For instance, Seneca Family of Agencies (Seneca) indicates that just the intake packet required for an initial appointment with a child or adolescent in need of mental health services can exceed 30 pages. Seneca asserts California is suffering from a behavioral health provider shortage, and we simply cannot afford to have the providers California does have spending half of their time filling out forms and navigating different requirements across counties instead of providing clinical services. California Health+ Advocates (CH+A), representing community clinics, estimate that paperwork for patients consumes 40-50% of their time to complete, which leaves them with even less time to provide health care services. CH+A indicates community health centers that contract with counties to provide specialty mental health and substance use disorder services to children, adults, and older adults in the Medi-Cal program bear an enormous paperwork burden, which is a significant driver of provider burnout and attrition.
2. CONCERN. CBHDA has shared a letter of concern. According to CBHDA, significant work has been accomplished and remains underway through CalAIM, including efforts to streamline documentation requirements and better align county behavioral health documentation standards with other healthcare delivery systems. CBHDA indicates DHCS implemented standardized screening and transition tools effective January 1, 2023, streamlined documentation requirements effective July 1, 2022, and is currently in the process of developing changes to clinical audit practices to move away from provider recoupments tied to documentation and instead focus on quality and program integrity. CBHDA notes that this bill does not acknowledge the significant collaboration currently underway between counties, provider associations, and DHCS in joint efforts to continue to advance documentation relief. CBHDA believes that because of progress made to date and the ongoing partnership with providers and DHCS, the effort to impose new standardization requirements is premature. Finally, CBHDA is concerned that efforts to mandate specific forms for all clinical processes, such as assessments, would have the unintended consequence of recreating documentation standards that are unique to county behavioral health which will continue to put providers on an unleveled playing field with other health care delivery systems. In addition, clinical practice changes over time, and counties need the ability to adapt to best clinical practice without having to go through the state.
3. PREVIOUS LEGISLATION.
   1. SB 293 (Limon) of 2021 was similar to this bill. It would have required DHCS, with respect to specialty mental health services provided under the EPSDT) to develop standard forms relating to medical necessity criteria, mandatory screening and transition of care tools, and documentation requirements; allowed DHCS to develop and maintain a list of DHCS-approved nonstandard forms; allowed forms on the nonstandard forms list to be used by county MHP contractors, in addition to the standard forms, to determine eligibility and reimbursement for specialty mental health services; required DHCS to require that a contractor or provider use the standard forms. SB 293 was referred to the Assembly Committee on Appropriations and not heard at the request of the author.
   2. AB 133 implements various components of the CalAIM initiative, including those providing authority for DHCS to develop and implement documentation standards.
   3. AB 763 (Gray) of 2019 contained many provisions similar to this bill. AB 763 was held on the Senate Appropriations suspense file.
4. AMENDMENTS. It appears varying county interpretation of DHCS requirements, as well as variation in county risk tolerance for potential audit-related recoupments of funds, continues to drive variation in documentation required of providers. DHCS, meanwhile, is working to clarify and standardize requirements for data elements it considers critical to document, and is adopting a quality improvement framework for audit protocols and recoupments that are focused on fraud, waste, and abuse rather than focusing on less clinically meaningful clerical errors. DHCS and behavioral health stakeholders, including this bill’s sponsors, appear to be working in good faith to identify additional barriers and forge solutions that work for all stakeholders in the system, all of whom have legitimate needs and constraints.

Although such large changes in state and local bureaucracies cannot happen overnight, the tantalizing prospect of freeing up California’s public behavioral health clinicians from low-value paperwork, thereby allowing them to provide additional behavioral services, creates a strong state interest in ensuring a continued focus on rapid progress in this space. It is unclear if this bill’s ambitious vision of standardizing everything within the next couple of years with zero variation by county is realistic or even is the right vision. However, a statutory expectation of a higher level of standardization may be necessary to create the focus needed to meet the “moonshot” of successful behavioral health documentation reform. To the extent the paperwork burden can be successfully reduced while maintaining program integrity, it could increase behavioral health access for Medi-Cal beneficiaries as if the state had trained and deployed many new behavioral health clinicians.

Following conversations between the Committee, author, and sponsor, and based on Committee concerns about the new bureaucratic burden of requiring DHCS to approve any non-standard forms and unintended consequences of prematurely prohibiting any documentation that is beyond the standard forms, author has agreed to amend this bill to:

• 1. Revert to existing law in the current-law section referencing documentation reform, and clarify the new section added by the bill governs documentation reform requirements as of January 1, 2024;
  2. Strike the requirements related to mandatory screening and transition of care tools, which are already developed and in use;
  3. Remove the requirement for DHCS to develop and maintain a list of DHCS-approved nonstandard forms;
  4. Remove the prohibition on using any other forms related to intake, assessment, treatment planning, eligibility determination, or reimbursement; and,
  5. In place of the prohibition in d) above, clarifies that DHCS maintains the discretion to restrict the imposition of additional documentation requirements beyond those requirements included on standard forms, including, but not limited to, restrictions developed in consultation with representatives of Medi-Cal behavioral health delivery systems on what Medi-Cal behavioral health delivery systems impose on their contract providers, consistent with Medi-Cal managed care plans and taking into account the need to ensure quality and program integrity and to address equity and disparities. (This language specifying the allowable restrictions is carried-over from current law, as enacted in AB 133, to also apply to this new set of provisions in this bill.)
  6. Makes other minor, clarifying and conforming changes.

These amendments intend to balance the needs of stakeholders by maintaining the requirement to use standard forms for capturing the minimum data elements DHCS defines as necessary, but maintaining flexibility at this time for requiring additional information if needed. If standard forms with minimum data elements are developed and deployed, this should allow for a distillation of what, if any, additional information is required beyond these forms, and allow counties to more naturally shed unnecessary or excessive requirements. Amendments will also remove the references to mandatory screening and transition of care tools, as these have already been implemented and are in use, thereby focusing the bill on the critical issue of clinical documentation reform, including documentation of medical necessity criteria, and make related clarifying and conforming changes.

REGISTERED SUPPORT / OPPOSITION:

Support

Association of Community Human Service Agencies
CA Association of Alcohol and Drug Executives, INC
California Access Coalition
California Alliance of Child and Family Services
California Assisted Living Association
California Association of Social Rehabilitation Agencies
California Children's Hospital Assn
California Council of Community Behavioral Health Agencies (CBHA)
California Health+advocates, Subsidiary of The California Primary Care Association
Choc Children's (Children's Hospital of Orange County)
Pacific Clinics
Seneca Family of Agencies
Sycamores
Westcoast Children's Clinic

Opposition

None on file.

Analysis Prepared by: Lisa Murawski / HEALTH / (916) 319-2097