Overview of California’s Public Mental Health System Family Voices of California 14 th Annual Health Summit March 14, 2016 Diane E. Van Maren, MPA and Masters in Special Ed Policy Consultant

Delivery Systems for Public Mental Health Services Covered California: – Qualified individuals and small businesses purchase subsidized health insurance as authorized under the federal Affordable Care Act. – Mental health treatment services are required in the essential health benefits package which is purchased through Covered California. Medi-Cal Program: – Managed Care Plans provide comprehensive health care services, and certain mild to moderate-level mental health services. – County Behavioral Health Plans are the sole provider of specialty mental health services, and Mental Health Services Act (Prop 63) services. Special Education: – Federal and State law provide access to a free and appropriate public education, including related services necessary to benefit from special education. Mental health services are covered under the related services component. Regional Centers: – Contingent upon eligibility and individualized needs, mental health services are obtained from the Medi-Cal Program (Managed Care Plan and/or County Behavioral Health Plans), the family’s insurance, or are provided or purchased by the Regional Center.

Medi-Cal Managed Care Plans and Mental Health Medi-Cal Managed Care Plans manage the Enrollee’s mental and physical health care, which includes but is not limited to, the coordination of all medically necessary, contractually required Medi-Cal covered services, including mental health services, both within and outside the Managed Care Plans network. SB X1 1 (Hernandez and Steinberg), Statutes of 2013, added new mental health benefits effective as of January 1, 2014 for all Medi-Cal beneficiaries. New benefits serve to provide early intervention for mild to moderate needs and include: – Individual and Group mental health evaluation and treatment (psychotherapy); – Psychological testing, when indicated, to evaluate a mental health condition; – Outpatient services for monitoring medication therapy; – Outpatient laboratory, medications, supplies and supplements; and – Psychiatric consultation

Medi-Cal Managed Care Plans and Mental Health Medi-Cal Managed Care Plans must: – Ensure mental health screening of all Enrollees by a network Primary Care Physician. – Provide services to Enrollee by a network Primary Care Physician (within their scope of practice). – Refer the Enrollee to a mental health provider within the Managed Care Plan’s network for a mental health assessment, when applicable. – Provide early intervention for mild to moderate needs (previous slide). Enter into a comprehensive Memorandum of Understanding (MOU) with County Behavioral Health Plans for Specialty Mental Health services. Use a mutually agreed upon assessment tool (in MOU with the County Behavioral Health Plan) to assess Enrollee’s needs.

County Behavioral Health Plans Specialty Mental Health Services - Structure 1915 (b) Waiver ( through June 30, 2020 ): -Functions independently from Medi-Cal Managed Care Program through Waiver. -Requires a contract between the State (DHCS) and each County. -Requires MOU and coordination of treatment between each County and each Medi-Cal Managed Care Plan. -Includes the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Program. -Utilizes County Realignment Funds, and when applicable Mental Health Services Act Funds, as the non-federal share to obtain federal reimbursement. County Behavioral Health Plan Responsibilities: -Assure 24-hour, seven day/week access to emergency, hospital and post- stabilization care for covered psychiatric conditions for Medi-Cal Enrollees. -Establish and certify network delivery systems utilizing County-owned and operated services or contract with private entities. -Authorize all Specialty Mental Health services and negotiate most rates for services.

Specialty Mental Health Services Overview of Eligibility Medi-Cal entitlement services for adults and children that meet specified medical necessity criteria, including: – Having a specific covered diagnosis (one of 18 specific diagnoses in the DSM). – Experiencing severe functional impairment with primary activities of daily living; or a reasonable probability of significant deterioration in an important area of life without treatment; or a reasonable probability a child will not progress developmentally as appropriate. – Meeting intervention criteria (i.e., the service is expected to significantly improve mental health condition). Receipt of Specialty Mental Health Services requires enrollment in a County Behavioral Health Plan.

Specialty Mental Health Services Broader Eligibility for Children/Adolescents Medi-Cal Enrollees under the age of 21 are eligible for Early and Periodic Screening, Diagnosis and Treatment (EPSDT) services as provided by Medi-Cal under the 1915 (b) Waiver, and required by federal and State law. EPSDT services must be provided by County Behavioral Health Plans when the Enrollee is not responsive to physical health care treatment and their condition can be ameliorated or corrected by Specialty Mental Health Services (CA Code of Regulations, Section , Title 9). Many Enrollees under the age of 21 with mental health needs that may be considered moderate, meet medical necessity criteria to access Specialty Mental Health Services provided by County Behavioral Health Plans. EPSDT services do not need to cure a condition or restore an Enrollee to a previous functional level. “No Wrong Door” – Medi-Cal Managed Care and County Behavioral Health must coordinate services. EPSDT services ensure Enrollees receive early detection and preventive care in addition to medically necessary services.

Specialty Mental Health Services All Services** Screening, Assessment, and Diagnosis Day Treatment Counseling and Psychotherapy Day Rehabilitation Medication SupportAdult Residential Treatment Services Targeted Case Management Therapy and Other Mental Health Services Crisis Intervention, Crisis Stabilization, Crisis Residential Psychiatric Nursing Facility Services Acute Inpatient Hospitalization Psychiatrist Services Rehabilitative Mental Health Services Katie A. Settlement Services **Services are offered in traditional settings, such as mental health clinics, hospitals and long-term care facilities, as well as in less- traditional settings including wellness centers, individuals’ homes, schools, and homeless shelters. Intensive Therapeutic Behavioral Services, Intensive Care Coordination, Intensive Home Based Services, Therapeutic Foster Care and all necessary services to correct or ameliorate defects, physical and mental illnesses, and conditions discovered by screening services EPSDT Services

Overview of State Monitoring for Mental Health Services Department of Managed Health Care (DMHC) – Oversees 90 percent of California’s commercial health care marketplace, including health maintenance organizations (HMOs). This includes all aspects of a plan’s operation to ensure compliance with CA law (such as mental health parity), including Evidence of Coverage, contracts with doctors and hospitals, provider networks, and complaint and grievance systems. – Assesses the following areas: Quality Management, Grievances and Appeals, Access and Availability of Services, Utilization Management, and Continuity of Care. – Conducts onsite routine medical surveys every three years, including mental health provider network reviews. – Has Interagency Agreement with DHCS to review mental health provider networks for Medi-Cal Managed Care entities (Knox-Keene licensed, and Health Plan of San Mateo).

Overview of State Monitoring for Mental Health Services Department of Health Care Services – Oversees the entire Medi-Cal Program, including all aspects of the Medi- Cal Managed Care Program, and the Specialty Mental Health Program operated by County Behavioral Health Plans. – Requires all Medi-Cal Managed Care Plans to submit mental health provider networks. – Contracts with Medi-Cal Managed Care Plans, and with County Behavioral Health Plans for the provisions of California’s Medi-Cal services. Regularly monitors compliance through various reviews of program and fiscal information. – Issues regulatory guidance as needed. – Tracks and monitors all MOUs between Medi-Cal Managed Care Plans and County Behavioral Health Plans. – Implementing a “Performance Outcomes System” for EPSDT Services to improve outcomes, provide transparency and inform fiscal decisions.

Overview of Proposition 63 of 2004: The Mental Health Services Act Background – Dramatically increased funding through a 1 percent tax on personal incomes in excess of $1 million. – Projected to provide about $1.4 billion in and over $1.8 billion in – Expanded a broad continuum of prevention, early intervention and direct service needs to supplement existing funding sources. – Created the Mental Health Services Oversight and Accountability Commission (OAC) to provide primary administrative oversight of this Act. – Counties develop three-year MHSA service plans, with annual updates, with local stakeholders (public meetings) as required by State law and regulations. – DHCS also provides oversight as directed in State law.

Proposition 63 – Mental Health Services Act Key Components – Prevention and Early Intervention Both universal and selective approaches, including population-based approaches and people identified as being high-risk, are used to address prevention and early intervention needs. Key outreach and education projects include: (1) Stigma and discrimination reduction; (2) Suicide Prevention; and (3) Student Mental Health. – Community Services and Supports At least 80 percent of all MHSA revenues are expended for services to individuals with severe mental illness. These services are focused on recovery and resilience and include Full Service Partnerships (for Adults and Children), client and family services, crisis intervention, peer support, and promising clinical practices.

School-Based Mental Health Services Federal and State law provide access to a free and appropriate public education, including related services necessary to benefit from special education. Mental health services are covered under the related services component. (Federal Individuals with Disabilities Education Act (IDEA)). As of 2011, mental health services provided to special education students are provided through the Department of Education as required in AB 114. Special Education Local Plan Areas (SELPAs) are responsible for conducting student mental health assessments, recommending mental health services required for the student to benefit from their education, and for providing those services to the students. County Mental Health Plans maintain responsibility for EPSDT services for these students when medical necessity criteria and related aspects are met.

Funding Public Mental Health Federal Medicaid Reimbursement County Realignment Funds 1991 County Realignment Funds 2011 Mental Health Services Act Funds (Proposition 63 of 2004) State General Fund Proposition 98/General Fund Federal Grant Funds for Special Education