Bill Text: CA AB1175 | 2019-2020 | Regular Session | Amended

NOTE: There are more recent revisions of this legislation. Read Latest Draft

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Bill Title: Medi-Cal: mental health services.

Spectrum: Partisan Bill (Democrat 1-0)

Status: (Vetoed) 2020-01-21 - Consideration of Governor's veto stricken from file. [AB1175 Detail]

Download: California-2019-AB1175-Amended.html

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Amended  IN  Assembly  April 23, 2019

Amended  IN  Assembly  April 02, 2019

Amended  IN  Assembly  April 01, 2019

Amended  IN  Assembly  March 18, 2019

CALIFORNIA LEGISLATURE— 2019–2020 REGULAR SESSION

Assembly Bill

No. 1175

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Introduced by Assembly Member Wood

February 21, 2019

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An act to amend Sections 14197.05 14707.7 and 14715 of, and to add Sections 14197.06 and 14715.5 to, the Welfare and Institutions Code, relating to Medi-Cal.

LEGISLATIVE COUNSEL'S DIGEST

AB 1175, as amended, Wood. Medi-Cal: mental health services.

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 specialty mental health services and nonspecialty mental health services. The Medi-Cal program is, in part, governed and funded by federal Medicaid program provisions.

Existing law requires the department to implement managed mental health care for Medi-Cal beneficiaries through contracts with county mental health plans. Under existing law, the county mental health plans are responsible for providing specialty mental health services to enrollees, and Medi-Cal managed care health plans deliver nonspecialty mental health services to enrollees. Existing law requires county mental health plans and Medi-Cal managed care health plans to be governed by various guidelines, including network adequacy standards and a requirement that an external quality review organization (EQRO) annually review these plans and plan data, such as the number of Medi-Cal beneficiaries in foster care who receive mental health services each year and network adequacy standards. plans. Existing law requires the department to consult with stakeholders, including subject matter experts who represent providers, to inform the updates to the performance outcomes reports for specialty mental health services. Existing law requires the department to ensure that contracts for county mental health plans and the Medi-Cal managed care health plans include a process for screening, referral, and coordination with necessary services, and to require a county mental health plan that provides Medi-Cal specialty mental health services to enter into a memorandum of understanding (MOU) with a Medi-Cal managed care health plan that provides Medi-Cal health services to some of the same Medi-Cal recipients served by the county mental health plan. Existing regulations provide for a dispute resolution process to be used to resolve matters between a Medi-Cal managed care health plan and a county mental plan.

This bill would require the EQRO to collect additional data, including performance data for each Medi-Cal managed care health plan and county mental health plan, to inform strategies to improve access to mental health services. department, as part of its consultation with stakeholders concerning updates to the performance outcomes reports for specialty mental health services, to include additional data in these reports, including the Healthcare Effectiveness Data and Information Set measures. The bill would require the department, by January 1, 2021, and annually thereafter, to publish on its internet website a performance outcome report that addresses specified information, including language capacity and utilization by service type. The bill would require the department to require the EQRO to report, by specified dates, various information concerning the county mental health plan and the Medi-Cal managed care health plan, such as the average expenditure per individual provided mental health services and provider usage of electronic health record systems. The bill would require the department to consult with and inform stakeholders, including subject matter experts who represent providers, on the development of the performance outcome system and performance outcomes systems report.

This bill would require the department to require that the MOU include additional components, including a referral protocol between the county mental health plan and the Medi-Cal managed care health plan that tracks the number of referrals for service from one plan to the other plan. The bill would require the department to annually evaluate the implementation of the MOU and related protocol and policies, and to report to the Legislature on specified matters, including the findings of the review and identifying the timeframes for these plans to achieve compliance with these provisions by January 1, 2021. The bill would require a county mental health plan and Medi-Cal managed care health plan that are unable to resolve a dispute to timely submit a request for resolution to the department, and to ensure that there is no delay in the provision of medically necessary services pending the resolution of the dispute. The bill would require the department to issue a written decision to the plans within 30 calendar days from receipt of the request.

Digest Key

Vote: MAJORITY   Appropriation: NO   Fiscal Committee: YES   Local Program: NO  

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Bill Text

The people of the State of California do enact as follows:

SECTION 1.Section 14197.05 of the Welfare and Institutions Code is amended to read:

14197.05.

(a)As part of the federally required external quality review organization (EQRO) review of Medi-Cal managed care health plans in the annual detailed technical report required by Section 438.364 of Title 42 of the Code of Federal Regulations, effective for contract periods commencing on or after July 1, 2018, the EQRO designated by the department shall compile the data described in subdivision (b), by plan and by county, for the purpose of informing the status of implementation of the requirements of Section 14197.

(b)(1)The information compiled by the EQRO shall include all of the following:

(A)Number of requests for alternative access standards in the plan service area for time and distance, categorized by provider types, including specialists, and by adult and pediatric.

(B)Number of allowable exceptions for the appointment time standard, if known, categorized by provider types, including specialists, and by adult and pediatric.

(C)Distance and driving time between the nearest network provider and ZIP Code of the enrollee furthest from that provider for requests for alternative access standards.

(D)Approximate number of beneficiaries impacted by alternative access standards or allowable exceptions.

(E)Percentage of providers in the plan service area, by provider and specialty type, that are under a contract with a Medi-Cal managed care health plan.

(F)The number of requests for alternative access standards approved or denied by ZIP Code and provider and specialty type, and the reasons for the approval or denial of the request for alternative access standards.

(G)The process of ensuring out-of-network access.

(H)Descriptions of contracting efforts and explanation for why a contract was not executed.

(I)Timeframe for approval or denial of a request for alternative access standards by the department.

(J)Consumer complaints, if any.

(2)The information described in paragraph (1) shall be presented in a chart format to enable comparison among counties, provider types, and plans.

(c)The EQRO shall develop a methodology to assess information that will help inform the experience of individuals placed in a skilled nursing facility or intermediate care facility and the distance that they are placed from their place of residence. The EQRO shall report the results from the use of this methodology in the EQRO annual Medi-Cal managed care health plan technical report.

(d)The department shall comply with the requirements of subsection (c) of Section 438.364 of Title 42 of the Code of Federal Regulations in making the information described in this section publicly available.

(e)It is the intent of the Legislature to provide data to inform strategies to improve access to mental health services.

(1)The EQRO shall annually collect performance and comparison data for each Medi-Cal managed care health plan and county mental health plan that enables comparison of data relating to access to mental health services rendered by each entity, the use of electronic health records and electronic health record systems, and expenditures on mental health services.

(2)By January 1, 2021, and annually thereafter, the department shall publish on its internet website a performance outcome report for Medi-Cal specialty mental health services. The performance outcome report shall include the measures that are published in the county mental health plans’ performance outcome systems reports, in addition to measures on nonspecialty mental health services that are developed pursuant to paragraph (3). The department’s performance outcome report shall set forth an easily understandable summary of quality, access, timeliness, and translation and interpretation capabilities regarding the performance of each Medi-Cal managed care health plan and county mental health plan.

(3)Commencing no later than January 15, 2020, and as needed thereafter, the department shall consult with and inform stakeholders, including subject matter experts who represent providers, consumer advocates, consumers, family members, counties, Medi-Cal managed care health plans, county mental health plans, and the Legislature, on the development of the performance outcome system and performance outcomes systems reports, as described in Sections 14707.5 and 14707.7, and the data collected on matters identified in subdivision (b) of Section 14715 and the Special Terms and Conditions of the Medi-Cal Specialty Mental Health Services Waiver, as approved pursuant to Section 1915(b) of the federal Social Security Act (42 U.S.C. Sec. 1396n(b)). The stakeholder consultation shall continuously inform stakeholder participants on the development of performance outcome measures for the county mental health plans and Medi-Cal managed care health plans.

(4)(A)For purposes of further developing the performance outcomes reports for specialty mental health services and nonspecialty mental health services, the EQRO shall, at a minimum, consider all of the following:

(i)High-quality, culturally and linguistically competent, and accessible specialty mental health services and nonspecialty mental health services for eligible beneficiaries, consistent with federal law.

(ii)Strategies to reduce suicide rates, and populations with low treatment prevalence rates.

(iii)The Healthcare Effectiveness Data and Information Set measures and Consumer Assessment of Healthcare Providers and Systems measures, as reported by Medi-Cal managed care health plans, stratified by individuals that are diagnosed with severe mental illness.

(B)The performance outcomes reports for specialty and nonspecialty mental health services shall consider the Special Terms and Conditions of the Medi-Cal Specialty Mental Health Services Waiver in 2015, as approved pursuant to Section 1915(b) of the federal Social Security Act (42 U.S.C. Sec. 1396n(b)) and the Medicaid Managed Care Quality Rating System.

(C)In order to evaluate the county mental health plan and Medi-Cal managed care health plan performance, at a minimum, the performance outcomes reports for specialty and nonspecialty mental health services shall be stratified by both the statewide, county, and plan levels in the following areas:

(i)Access, including timely access to services, such as the waiting time for an assessment and for a first appointment.

(ii)Language capacity and language access.

(iii)Quality, including outcomes and patient experience.

(iv)Utilization by service type and penetration.

(v)Grievance and appeals.

(D)(i)The data specified in subparagraph (C) shall be stratified by age, sex, gender identity, race, ethnicity, primary language, sexual orientation, and any other data elements for which there is peer-reviewed evidence to assess performance outcomes related to mental health disparities.

(ii)The department shall not report any demographic data described in subparagraph (C) or this subparagraph that would permit identification of individuals.

(5)Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement, interpret, or make specific this subdivision by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions, without taking regulatory action.

SEC. 2.SECTION 1.

 Section 14197.06 is added to the Welfare and Institutions Code, to read:

14197.06.

 On and before January 1, 2021, and two years thereafter, the department shall require the federally required external quality review organization to report on all of the following:

(a) For Medi-Cal managed care health plans and county mental health plans, the average expenditure per plan member that received mental health services, identified by the type of mental health service and in the aggregate.

(b) For county mental health plans, the number and percentage of both of the following:

(1) Mental health care providers that are contracted with or employed by the county.

(2) Mental health care providers who have one or more contracts for mental health services with one or more Medi-Cal managed care health plans in the county.

(c) For Medi-Cal managed care health plans, the number and percentage of contracting mental health care providers in each county who have a contract with the county mental health plan for specialty mental health services.

(d) For county mental health plans, the number and percentage of mental health care providers that are contracted with or employed by the county who use any of the following:

(1) An electronic health record system.

(2) An electronic health record system that is interoperable with one or more county mental health plans’ electronic health record system.

(3) An electronic health record system that is interoperable with one or more Medi-Cal managed health care plans’ electronic health record systems.

(4) An electronic health record system that it is interoperable with one or more Medi-Cal managed health care plans and county mental health plans, and is interoperable with both entities.

(e) For Medi-Cal managed care health plans, the number and percentage of contracting mental health care providers who use any of the following:

(1) An electronic health record system.

(2) An electronic health record system that is interoperable with a county mental health plan’s electronic health record system.

(3) An electronic health record system that is interoperable with the Medi-Cal managed care health plan.

(4) An electronic health record system that it is interoperable with both the Medi-Cal managed care health plan and the county mental health plan.

SEC. 2.

 Section 14707.7 of the Welfare and Institutions Code is amended to read:

14707.7.

 (a) It is the intent of the Legislature to build upon performance outcomes system reports the department has developed pursuant to Section 14707.5 and the Special Terms and Conditions of the Medi-Cal Specialty Mental Health Services Waiver, as approved pursuant to Section 1915(b) of the federal Social Security Act (42 U.S.C. Sec. 1396n(b)), in order to provide data to inform strategies to increase access to mental health services and to reduce mental health disparities.

(b) (1) Commencing no later than January 15, 2018, and as needed thereafter, the department shall consult with stakeholders, including, but not limited to, subject-matter subject matter experts who represent providers, consumer advocates, consumers, family members, counties, and the Legislature, to inform the updates to the performance outcomes reports for specialty mental health that the department developed pursuant to Section 14707.5 and the Special Terms and Conditions of the Medi-Cal Specialty Mental Health Services Waiver. The stakeholder consultation shall continuously inform the development of performance outcome and disparities reduction measures.

(2) In building upon the performance outcomes reports for specialty mental health services, the department shall also consider both all of the following objectives, among others:

(A) High-quality, culturally and linguistically competent, and accessible specialty mental health services for all eligible beneficiaries, consistent with federal law.

(B) Strategies to reduce mental health disparities.

(C) Strategies to reduce suicide rates, and to reduce the amount of populations with low treatment prevalence rates.

(3) The performance outcomes reports for specialty mental health services shall also consider the Special Terms and Conditions of the Medi-Cal Specialty Mental Health Services Waiver, as approved pursuant to Section 1915(b) of the federal Social Security Act (42 U.S.C. Sec. 1396n(b)) and the Medicaid Managed Care Quality Rating System.

(4) In order to identify mental health disparities, at a minimum, the performance outcomes reports for specialty mental health services shall be produced using existing data collected by the state, stratified by both the statewide and county levels in the following areas:

(A) Access, such as timely access to services, including waiting time to assessment and waiting time to first appointment.

(B) Language capacity and language access.

(C)Quality.

(C) Quality, including outcomes and patient experience.

(D) Utilization by service type and penetration.

(E) Grievance and appeals.

(5) (A) Data required pursuant to paragraph (4) shall be stratified by age, sex, gender identity, race, ethnicity, primary language, sexual orientation, and any other data elements for which there is peer-reviewed evidence to assess performance outcomes related to mental health disparities.

(B) The department shall not report any demographic data under paragraph (4) or this paragraph that would permit identification of individuals.

(6) (A) The department shall publish the performance outcomes reports based on available data for specialty mental health services described in this section on the department’s Internet Web site internet website by December 31, 2018. The department shall also provide the performance outcomes reports to the Legislature by December 31, 2018.

(B) Commencing January 1, 2019, and annually thereafter, the department shall update the performance outcomes reports for specialty mental health and shall post the updated reports on the department’s Internet Web site. internet website.

(7) Commencing January 1, 2019, the department shall consult, as needed, with the stakeholders specified in paragraph (1) to do both of the following:

(A) Incorporate additional components into the performance outcomes reports, stratified by statewide, county, and plan levels, including, but not limited to, components both of the following:

(i) Components concerning the reduction of mental health disparities, such as timely access to services, language access, and quality and utilization measures, relating to mental health services obtained through Medi-Cal managed care plans.

(ii) The Healthcare Effectiveness Data and Information Set measures and Consumer Assessment of Healthcare Providers and Systems measures, as reported by Medi-Cal managed care health plans, that are stratified by individuals who are diagnosed with mental illness.

(B) Make recommendations for statewide quality improvement and efforts to reduce mental health disparities based on information reported in the performance outcomes reports.

(8) Upon completion of the activities specified in paragraph (7), the department shall consult with stakeholders on an as-needed basis.

(9) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department may implement, interpret, or make specific this subdivision by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions, without taking regulatory action.

SEC. 3.

 Section 14715 of the Welfare and Institutions Code is amended to read:

14715.

 (a) (1) The department shall require a county mental health plan that provides Medi-Cal specialty mental health services to enter into a memorandum of understanding with any Medi-Cal managed care plan that provides Medi-Cal health services to some of the same Medi-Cal recipients served by the county mental health plan. The memorandum of understanding shall comply with applicable regulations, including Section 1810.370 of Title 9 of the California Code of Regulations.

(2) For purposes of this section, a “Medi-Cal managed care health plan” means any prepaid health plan or Medi-Cal managed care health plan contracting with the department to provide services to enrolled Medi-Cal beneficiaries under Chapter 7 (commencing with Section 14000) or Chapter 8 (commencing with Section 14200), or Part 4 (commencing with Section 101525) of Division 101 of the Health and Safety Code.

(b) The department shall require the memorandum of understanding to include all of the following:

(1) A process and entity to be designated by the county mental health plan to receive notice of adverse benefit determinations related to requests for mental health services from the Medi-Cal managed care health plan, and to provide any additional information requested in the notice in accordance with Section 438.210(d) of Title 42 of the Code of Federal Regulations, and as necessary for a medical necessity determination.

(2) A requirement that the county mental health plan respond by the close of the business day following the day the notice is received.

(3) A referral protocol between the county mental health plan and the Medi-Cal managed care health plan that tracks all of the following:

(A) The number of referrals for service from one plan to the other plan.

(B) The mean and median time from initial contact to date of service following a transfer from one plan to the other plan.

(C) The number of requests for service that result in the enrollee receiving the requested service within 10 business days.

(4) A referral protocol between the county mental health plan and the Medi-Cal managed care health plan that refers the enrollee to another plan if it is determined that the enrollee seeks mental health services that are the responsibility of another plan.

(5) (A) A process through which a Medi-Cal enrollee receiving nonspecialty mental health services from a county mental health plan provider may continue to receive nonspecialty mental health services from that same mental health care provider if the enrollee has an ongoing relationship with the mental health care provider and the mental health care provider is willing to accept the Medi-Cal managed care health plan’s rate for the service offered, or the applicable county mental health plan rate, whichever is higher. The Medi-Cal managed care health plan shall also determine that the mental health care provider meets applicable professional standards and has no disqualifying quality of care issues. The Medi-Cal managed care health plan shall inform the enrollee of this option whenever the enrollee has previously received specialty mental health services, and is subsequently referred to the Medi-Cal managed care health plan for nonspecialty mental health services.

(B) A process through which an enrollee receiving mental health services from a mental health care provider that participates in a Medi-Cal managed care health plan’s network may continue to receive specialty mental health services from that same mental health care provider if the enrollee has an ongoing relationship with the mental health care provider and the mental health care provider is willing to accept the Medi-Cal managed care health plan’s rate for the service offered, or the applicable county mental health plan rate, whichever is higher. The Medi-Cal managed care health plan shall also determine that the mental health care provider meets applicable professional standards and has no disqualifying quality of care issues. The Medi-Cal managed care plan shall inform the enrollee of this option whenever the enrollee has previously received nonspecialty mental health services, and is subsequently referred to the Medi-Cal managed care health plan for specialty mental health services.

(6) Care coordination protocols between county mental health plans and Medi-Cal managed care health plans that address all of the following:

(A) Care coordination requirements, as addressed in all-county letters, plan letters, plan or provider bulletins, or similar instructions that are issued by the department, including all plan letter 18-015, dated September 19, 2018, and its attachments, and MHSUDS Information Notice No. 16-061, dated December 9, 2016.

(B) Coordination of care for transportation services, including nonmedical transportation, as specified in subdivision (ad) of Section 14132.

(C) Protocols to ensure that enrollees with mental health conditions who also receive services through the Drug Medi-Cal Treatment Program, also known as Drug Medi-Cal, or the Drug Medi-Cal organized delivery system, as authorized under the California Medi-Cal 2020 Demonstration, Number 11-W-00193/9, and as approved by the federal Centers for Medicare and Medicaid Services and described in the Special Terms and Conditions, have access to appropriate and coordinated services.

(7) A process to review implementation of the memorandum of understanding and related policies and protocols. This process shall, at a minimum, occur on an annual basis.

(c) (1) The department shall annually evaluate the implementation of the memoranda of understanding and related protocol and policies for compliance with this section. This review process shall consider policies and practices from county mental health plans and Medi-Cal managed care health plans, and grievances and appeals related to coordination of care between the plans.

(2) The department shall submit a joint report to Legislature summarizing the findings of this review, describing any corrective action that is required from the county mental health plans or the Medi-Cal managed care health plans, and identifying the timeframes for these plans to achieve compliance with the requirements of this section by January 1, 2021.

(3) The requirement for submitting a report imposed under paragraph (2) shall be inoperative four years from the date that the report is due, pursuant to Section 10231.5 of the Government Code.

(4) A report to be submitted pursuant to paragraph (3) shall be submitted in compliance with Section 9795 of the Government Code.

(d) The department may sanction a county mental health plan pursuant to subdivision (e) of Section 14712 for failure to comply with this section.

(e) This section applies to contracts entered into, amended, modified, extended, or renewed on or after January 1, 2021.

SEC. 4.

 Section 14715.5 is added to the Welfare and Institutions Code, immediately following 14715, to read:

14715.5.

 (a) (1) If a county mental health plan and a Medi-Cal managed care health plan have a dispute, as described in Section 1850.505 of Title 9 of the California Code of Regulations, and are unable to reach a resolution within 15 business days from the initiation of the dispute resolution process, both the county mental health plan and the Medi-Cal managed care health plan shall submit a request for resolution to the department.

(2) The department shall, within 30 calendar days from the receipt of the request, issue a written decision to the county mental health plan and the Medi-Cal managed care plan.

(b) A dispute between the county mental health plan and the Medi-Cal managed care health plan shall not delay the provision of medically necessary services by the Medi-Cal managed care health plan or the county mental health plan. Pending resolution of the dispute, both plans shall comply with Section 1850.525 of Title 9 of the California Code of Regulations.