BILL ANALYSIS Ó ----------------------------------------------------------------- |SENATE RULES COMMITTEE | SB 1466| |Office of Senate Floor Analyses | | |(916) 651-1520 Fax: (916) | | |327-4478 | | ----------------------------------------------------------------- UNFINISHED BUSINESS Bill No: SB 1466 Author: Mitchell (D) Amended: 8/15/16 Vote: 21 SENATE HEALTH COMMITTEE: 9-0, 4/6/16 AYES: Hernandez, Nguyen, Hall, Mitchell, Monning, Nielsen, Pan, Roth, Wolk SENATE HUMAN SERVICES COMMITTEE: 5-0, 4/12/16 AYES: McGuire, Berryhill, Hancock, Liu, Nguyen SENATE APPROPRIATIONS COMMITTEE: 7-0, 5/27/16 AYES: Lara, Bates, Beall, Hill, McGuire, Mendoza, Nielsen SENATE FLOOR: 39-0, 6/2/16 AYES: Allen, Anderson, Bates, Beall, Berryhill, Block, Cannella, De León, Fuller, Gaines, Galgiani, Glazer, Hall, Hancock, Hernandez, Hertzberg, Hill, Hueso, Huff, Jackson, Lara, Leno, Leyva, Liu, McGuire, Mendoza, Mitchell, Monning, Moorlach, Morrell, Nguyen, Nielsen, Pan, Pavley, Roth, Stone, Vidak, Wieckowski, Wolk NO VOTE RECORDED: Runner ASSEMBLY FLOOR: 79-0, 8/23/16 - See last page for vote SUBJECT: Early and Periodic Screening, Diagnosis, and Treatment Program: trauma screening SOURCE: Californians for Safety and Justice Youth Law Center DIGEST: This bill requires screening services provided under the Early and Periodic Screening, Diagnosis, and Treatment SB 1466 Page 2 Program (EPSDT) to include screening for trauma, as defined. Assembly Amendments delete the requirement that a child who is removed from the custody or care of his or her parent or legal guardian to be assessed by the county mental health plan for specialty mental health services, and modify the definition of "trauma" in this bill. ANALYSIS: Existing law: 1)Establishes the Medi-Cal program, administered by the Department of Health Care Services (DHCS), under which qualified low-income individuals receive health care services. 2)Establishes a schedule of benefits under the Medi-Cal program, which includes EPSDT for any individual under 21 years of age, consistent with federal Medicaid requirements. Defines, through regulation, "screening services" for purposes of EPSDT to mean: a) An initial, periodic, or additional health assessment of a Medi-Cal eligible individual under 21 years of age provided in accordance with the requirements of the Child Health and Disability Prevention (CHDP) program; b) A health assessment, examination, or evaluation of a Medi-Cal eligible individual under 21 years of age by a licensed health care professional acting within his or her scope of practice, at intervals other than the CHDP intervals, to determine the existence of physical or mental illnesses or conditions; or c) Any other encounter with a licensed health care professional that results in the determination of the existence of a suspected illness or condition or a change or complication in a condition for a Medi-Cal eligible person under 21 years of age. 3)Requires mental health plans to provide specialty mental health services to eligible Medi-Cal beneficiaries, including SB 1466 Page 3 both adults and children. Includes EPSDT within the scope of specialty mental health services for eligible Medi-Cal beneficiaries under the age of 21 pursuant to federal Medicaid law. 4)Requires DHCS, in collaboration with the California Health and Human Services Agency, and in consultation with the Mental Health Services Oversight and Accountability Commission, to create a plan for a performance outcome system for EPSDT mental health services provided to eligible Medi-Cal beneficiaries under the age of 21 This bill: 1)Requires, consistent with federal law, screening services provided under the EPSDT benefit include screening for trauma consistent with the protocols DHCS develops under this bill. 2)Defines "trauma," as used in this section, means the result of an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or threatening and that has lasting adverse effects on the individual's functioning and physical, social, emotional, or spiritual well-being. 3)Requires DHCS, in consultation with the Department of Social Services (DSS), behavioral health experts, child welfare experts, and stakeholders, to adopt, employ, and develop, as appropriate, tools and protocols for the screening of children for trauma, consistent with existing law and this bill. 4)Permits DHCS to implement, interpret, or make specific this bill by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions, without taking SB 1466 Page 4 regulatory action. Comments 1)Author's statement. According to the author, adverse childhood experiences (ACEs) are potentially traumatic events that can have negative, lasting effects on health and well-being. These experiences range from physical, emotional, or sexual abuse to parental divorce or the incarceration of a parent or guardian. A growing body of research has sought to quantify the prevalence of adverse childhood experiences and illuminate their connection with negative behavioral and health outcomes, such as obesity, alcoholism, and depression, later in life. Children in foster care have suffered from abuse, neglect or exploitation, and have suffered secondary trauma as a result of being removed from their parents. Research clearly shows that nearly all children associated with Child Welfare systems have an underlying condition of complex trauma as a result of an adverse childhood experience. At a minimum this underlying condition contributes to the poor outcomes - social, educational and health - for foster children. This bill requires that existing screenings under EPSDT to include a trauma screen. Additionally, this bill includes child abuse and neglect and removal from the home by a child welfare agency as evidence of trauma. 2)EPSDT. The EPSDT benefit provides comprehensive screening, diagnostic, treatment, and preventive health care services for children under age 21 who are enrolled in Medi-Cal, and is key to ensuring that children who are eligible for EPSDT services receive appropriate preventive, dental, mental health, developmental, and specialty services. Federal Medicaid law defines the EPSDT benefit to include a comprehensive array of preventive, diagnostic, and treatment services for low-income children under age 21. States are required to provide coverage of any services listed in a section of the federal Medicaid Act to children who are eligible for EPSDT services when the services are determined to be medically necessary to correct SB 1466 Page 5 or ameliorate any physical or behavioral conditions. The EPSDT benefit is more robust than the Medi-Cal benefit package provided to adults and is designed to ensure that eligible children receive early detection and preventive care in addition to medically necessary treatment services, so that health problems are averted or diagnosed and treated as early as possible. Medi-Cal managed care plans are required to cover and ensure the provision of screening, preventive, and medically necessary diagnostic and treatment services for individuals under the age of 21 (including EPSDT), except certain services are "carved out" of the plan. For individuals enrolled in Medi-Cal managed care, the Medi-Cal managed care is responsible for "mild to moderate" mental health coverage, while more severe mental health conditions are "carved out" and are the responsibility of the county specialty mental health plan (MHP). 3)Specialty mental health "carve out." The Medi-Cal Specialty Mental Health Services Program is "carved-out" of the broader Medi-Cal program and is administered by DHCS under a federal waiver approved by the Centers for Medicare and Medicaid Services (CMS). DHCS contracts with an MHP in each county to provide or arrange for the provision of Medi-Cal specialty mental health services. All MHPs are county mental health departments. Specialty mental health services are a Medi-Cal entitlement services for adults and children that meet medical necessity criteria, which consist of having a specific covered diagnosis, functional impairment, and meeting intervention criteria. MHPs must certify that they incurred a cost before seeking federal reimbursement through claims to the State. MHPs are responsible for the non-federal share of Medi-Cal specialty mental health services. Mental health services for Medi-Cal beneficiaries who do not meet the criteria for specialty mental health services are provided under the broader Medi-Cal program either through managed care plans (by primary care providers within their scope of practice) or fee-for-service (for children exempt from mandatory enrollment in Medi-Cal managed care). Children's specialty mental health services are provided under the federal requirements of EPSDT benefit, which is available to full-scope beneficiaries under SB 1466 Page 6 age 21. FISCAL EFFECT: Appropriation: No Fiscal Com.:YesLocal: No According to the Assembly Appropriations Committee: Staff assumes the state would be responsible for any nonfederal share of costs under this bill based on the requirements of Article XIII, Section 36 of the California Constitution (Proposition 30), which states new legislation that increases costs already borne by a local agency for programs mandated for 2011 Realignment shall apply to local agencies only to the extent the state provides annual funding for the cost increase. EPSDT specialty mental health services were included in 2011 Realignment. 1)Costs, likely in the millions annually for additional screening and assessment services provided to Medi-Cal-eligible children, including foster children (GF/federal). 2)Depending how screening is operationalized and the take-up of services, state costs for additional specialty mental health services for children who screen positive and receive specialty mental health services could be significant. For every thousand children who receive specialty mental health services, the state would incur about $6 million in costs annually. Costs associated with a significantly higher referral rate to specialty mental health services could cost in tens or hundreds of millions of dollars (GF/federal). The state could also experience unknown additional cost pressure for provision of additional mental health services for mild to moderate diagnoses through Medi-Cal managed care plans (GF/federal). 3)To the extent increased provision of mental health services to SB 1466 Page 7 Medi-Cal-eligible children results in improved social, emotional and health outcomes, the state could experience some unknown reductions in Medi-Cal costs over the long term, associated with reductions in higher-cost behavioral health treatment services such as psychiatric hospitalizations (GF/federal). 4)DHCS and DSS will incur minor staff costs to consult with stakeholders and provide guidance to operationalize the required trauma screening (GF/federal). SUPPORT: (Verified8/19/16) Californians for Safety and Justice (co-source) Youth Law Center (co-source) Advokids Alliance for Children's Rights California Alliance of Child and Family Services California Pan-Ethnic Health Network Children Now County Welfare Directors Association of California Fight Crime Invest in Kids California Futures Without Violence National Health Law Program San Luis Obispo County Department of Social Services Western Center on Law and Poverty Youth Law Center OPPOSITION: (Verified8/19/16) Department of Finance SB 1466 Page 8 ARGUMENTS IN SUPPORT: Californians for Safety and Justice (CSJ) writes in support that this bill ensures that medical professionals conducting already mandated health screenings look for signs of trauma to ensure that children who have suffered trauma receive the care they need - care they are legally entitled to receive. In light of the overwhelming evidence confirming the traumatic nature of child abuse and neglect and the secondary trauma of removal from one's home - this measure unambiguously establishes that foster children have suffered trauma and should be assessed for appropriate EPSDT services. CSJ states the State has the legal and moral obligation to act as the parent of all children in the child welfare system, and this bill is consistent with long-standing policies that ensure children in the child welfare system receive the best possible care that will help them thrive as adults. The San Luis Obispo County Department of Social Services (SLOCDSS) writes in support that it serves, in conjunction with its partners in the County Probation Department, over 300 foster children who have experienced abuse or neglect that spans the spectrum of severity. SLOCDSS states it has encountered difficulties in ensuring that these children receive the therapeutic services they need, as mental health providers debate with one another over the relative severity of the trauma these children have endured. Too often, these children-especially those who suffered secondary trauma as a result of being removed from their caregivers-are shuffled back and forth between unresponsive systems of care, are denied the therapy they need to heal from the impacts of trauma and ultimately suffer the cumulative effects of untreated trauma as they transition to adulthood. ARGUMENTS IN OPPOSITION: The Department of Finance writes in opposition to the previous version of this bill, arguing this bill would result in significant General Fund costs not included in the 2016 Budget Act, and this bill may duplicate some existing data efforts. Currently, federal Medicaid regulations require states to perform external quality reviews of county Medi-Cal Specialty Mental Health Services annually. It is unclear if the foster youth segment would not already be included in the EQRO's overall review of county mental health SB 1466 Page 9 plans. ASSEMBLY FLOOR: 79-0, 8/23/16 AYES: Achadjian, Alejo, Travis Allen, Arambula, Atkins, Baker, Bigelow, Bloom, Bonilla, Bonta, Brough, Brown, Burke, Calderon, Campos, Chang, Chau, Chávez, Chiu, Chu, Cooley, Cooper, Dababneh, Dahle, Daly, Dodd, Eggman, Frazier, Beth Gaines, Gallagher, Cristina Garcia, Eduardo Garcia, Gatto, Gipson, Gomez, Gonzalez, Gordon, Grove, Hadley, Harper, Roger Hernández, Holden, Irwin, Jones, Jones-Sawyer, Kim, Lackey, Levine, Linder, Lopez, Low, Maienschein, Mathis, Mayes, McCarty, Medina, Melendez, Mullin, Nazarian, Obernolte, O'Donnell, Olsen, Patterson, Quirk, Ridley-Thomas, Rodriguez, Salas, Santiago, Steinorth, Mark Stone, Thurmond, Ting, Wagner, Waldron, Weber, Wilk, Williams, Wood, Rendon NO VOTE RECORDED: Gray Prepared by:Scott Bain / HEALTH / (916) 651-4111 8/23/16 19:54:39 **** END ****