Transcript Mental Health and Substance Use Disorder Policy

CIMH LEADERSHIP INSTITUTE
Patricia Ryan, Executive Director
California Mental Health Directors Association
Tom Renfree, Executive Director
County Alcohol and Drug Program Administrators Association
of California
December 6, 2012
Major Historical Mental Health
Fiscal/Policy Milestones
 1969: Community Mental Health Services Act,
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Deinstitutionalization, Short/Doyle Act
1991: Realignment 1991
1993: Medi-Cal Rehabilitation Option
1995-97: Medi-Cal Specialty Mental Health
Consolidation
2004: Prop. 63 – Mental Health Services Act
3
Community Mental Health Services
Act/Deinstitutionalization
(1969)
 The California Community Mental Health
Services Act 1969 was a national model of
mental health legislation that
“deinstitutionalized” mental health services,
serving people with mental disabilities in the
community rather than in state hospitals.
4
Short-Doyle Act
(1969)
 The Short-Doyle Act was the funding mechanism
intended to build the community mental health
system. Legislative intent language called for
funding to shift from state hospitals to
community programs.
 However, the state failed to distribute the full
savings achieved through the closures of state
hospitals to the community mental health system.
5
No Entitlement for Mental Health
Services
 Unlike services to persons with developmental
disabilities, the mental health system in
California was never conceived as an
“entitlement.”
 Mental health services were to be provided “to
the extent resources are available.”
 This essential difference built rationing of
services into the framework of mental health
service delivery…
6
Community Mental Health
System in Crisis
1970-1990
 Beginning with an inadequate funding base,
state allocations to counties were severely
diminished due to inflation throughout the
1970s and 80s.
 In 1990, California faced a $15 billion state
budget shortfall which would certainly have
resulted in even more drastic cuts to mental
health.
 Community mental health programs were
already near collapse and overwhelmed with
unmet need. This crisis propelled the
enactment of “Realignment.”
7
Realignment
1991
 “Realignment” was enacted in 1991 with passage of the
Bronzan-McCorquodale Act.
 It represented a major shift of authority from the state to
counties for mental health programs.
 Realignment 1991 created a new dedicated revenue source
for counties.
 Instead of community mental health being funded by the
State General Fund (and thus subject to the annual state
budget process), new “Realigned” revenues would flow
directly to counties.
8
1991 Realignment
 “1991 Realignment” refers to the realigning of the funding
and responsibility for mental health services, social
services and public health services
 It represented a major shift of authority from state to
counties for mental health programs
 Three revenue sources funded 1991 Realignment
 ½ Cent of State Sales Tax
 State Vehicle License Fees
 State Vehicle License Fee Collections
9
Realignment Funds Distributed by
Formula
 Annually, Realignment
revenues were1 distributed to
counties on a monthly basis
until each county received
funds equal to the previous
year’s total.
 Funds received above that amount
were placed into growth accounts:
Sales Tax and VLF.
 Realignment “growth” funds were
distributed annually, and the
first claim on the Sales Tax
Growth Account went to
caseload-driven social services
entitlement programs (IHSS
and child welfare).
 Any remaining growth from the
Sales Tax Account and all VLF
growth were then distributed
according to a formula developed
in statute.
10
Mental Health Programs
Realigned from the State to
Counties
 All community-based mental health services
 State hospital services for civil commitments
 Mental health services for those in “Institutions for
Mental Disease (IMDs),” which provide long-term
psychiatric nursing facility care
11
Benefits of 1991 Realignment
 A stable funding source for programs, which made a
long-term investment in mental health infrastructure
financially practical.
 The ability to use funds to reduce high-cost restrictive
placements, and to serve clients appropriately in the
community.
 Greater fiscal flexibility, discretion and control,
including the ability to “roll-over” funds from one year
to the next, enabling long-term planning and multi-year
funding of projects.
 Emphasis on a clear mission and defined target
populations.
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But Realignment Formula Flawed
– Insufficient Growth for Mental
Health
 Under Realignment 1991, mental health
received no Sales Tax growth from FY 2005/06
through FY 2010-11.
 In Fiscal Years 2007/08, 2008/09 and 2009/10,
mental health did not even make the prior year’s
base.
 FY 2009/10 and FY 2010/11, Mental Health
Sales Tax revenues approximated the original
baseline amounts from FY 1991/92.
 FY 2010/11 VLF revenues were approximately the
same as FY 2003/04 amounts.
13
Realignment Growth for MH:
Fiscal Year 2000/01 to 2010/11
Realignment Funding for Mental Health
15.0%
10.0%
2003-04
2001-02
2004-05 2005-06
2002-03
5.0%
2006-07
2010-11
0.0%
2007-08
-5.0%
`
2009-10
-10.0%
2008-09
Fiscal Year
-15.0%
% Growth abov e Previous
FY
2000-01
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Medi-Cal Mental Health Services
Understanding the changes in California’s
Specialty Mental Health Medi-Cal program
since Realignment, and the interaction of MediCal revenues with Realignment, is critical to
analyzing the current structure and status of
public mental health services in California…
15
Medi-Cal Mental Health Services
History in California
 The Fee-for-Service “clinic option” Medi-Cal program
originally consisted of “physical” health care benefits,
with mental health treatment making up only a small
part of the program.
 Mental health services were limited to treatment
provided by physicians (psychiatrists), psychologists,
hospitals, and nursing facilities, and were reimbursed
through the Fee-For-Service Medi-Cal system
(FFS/MC).
16
Medi-Cal Mental Health Services
 Short-Doyle/Medi-Cal (SD/MC) started as a pilot project
in 1971, and counties were able to obtain FFP to match
their own funding to provide certain mental health
services to Medi-Cal eligible individuals.
 The SD/MC program offered a broader range of mental
health services than those provided by the original FFS
Medi-Cal program.
17
Medi-Cal Rehabilitation Option
1993
 A CA Medicaid State Plan Amendment in 1993
added more services under the federal
Medicaid “Rehab Option” to the scope of
benefits, including:
 Community based (non-clinic) services
 Expanded service provider types
 Additional service types
 Expanded acute care model to include long term
community care model
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Medi-Cal EPSDT
1995
 Early and Periodic Screening, Diagnosis and
Treatment (EPSDT) represents an expansion of
services resulting from a successful class action
lawsuit against the state.
 The state’s settlement agreement resulted in
increased state responsibility for funding for
Medi-Cal specialty mental health services for full
scope Medi-Cal beneficiaries under age 21.
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Medi-Cal Specialty Mental Health
Consolidation
1995-1998
 From 1995 through 1998, the state consolidated Fee-
for- Service and Short-Doyle programs into one
“carved out” specialty mental health managed care
program, under a Medicaid 1915(b) “Freedom of
Choice” waiver.
 Counties were given the “right of first refusal” for
taking on this new responsibility of managing
specialty mental health care.
 Under this system, all Medi-Cal beneficiaries were
required to access their specialty mental health
services through the county Mental Health Plan
(MHP).
20
Medi-Cal Consolidation
 General mental health care needs for Medi-Cal
beneficiaries remain under the responsibility of
non-specialty fee-for-service providers and Medi-
Cal Managed Care plans.
 DHCS fee-for-service maintains responsibility for
all pharmaceutical costs for specialty mental
health MHP beneficiaries.
21
Medi-Cal Consolidation
 Upon consolidation, the state DHCS transferred the
funds it had been spending under the FFS system for
inpatient psychiatric and outpatient physician and
psychologist services to county Mental Health Plans
(MHPs).
 It was assumed (by counties) that MHPs would
receive additional funds yearly beyond the base
allocation for increases in Medi-Cal beneficiary
caseloads, and for COLAs.
 Any costs beyond that allocation were to come
from county 1991 Realignment revenues.
22
Medi-Cal Consolidation
 In other words, the risk for this entitlement
program shifted from the state to the
counties…
23
California’s Current Medi-Cal Specialty
Mental Health System
 Under the provisions of our Medicaid Title 42, Section
1915(b) “freedom of choice” waiver, California’s
county MHPs are considered prepaid inpatient
health plans.
 California’s MHPs are responsible for assuring 24
hour, seven day/week access to emergency, hospital
and post-stabilization care for the covered psychiatric
conditions for Medi-Cal beneficiaries.
California’s Medi-Cal Mental Health System
In addition, California has two approved state plan
amendments (SPA) that increase the scope of
outpatient, crisis and residential and inpatient mental
health coverage provided to Medi-Cal beneficiaries
when medically necessary, by the MHP.
California’s Approved State Plan Amendments:
 Targeted case management for persons with mental
illness.
 Mental health services available under the
Rehabilitation Option, broadening the range of
personnel and locations that were available to provide
services to eligible beneficiaries.
California’s Medi-Cal Mental Health System
 Both federal and state code and regulation specify that there is
to be a contract between the state and the MHP/PIHP specifying
the conditions under which the managed care program will
operate.
 The regulations and contract also specify requirements for the
coordination of health and mental health treatment between
the county and the state contracted health plans, including that
an MOU be in place between the county and each health plan
specifying the process for timely referral and treatment.
Federal Financial Participation
Critical to Counties
 Federal Medicaid dollars (FFP)
currently constitute the largest revenue
source for county mental health
programs.
27
Community Mental Health
Services Funding
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Mental Health Services Act (Prop. 63)
2004
 The MHSA (Prop. 63) created a 1% tax on income in excess of $1 million to
expand mental health services
 Approximately 1/10 of one percent of tax payers are impacted by tax
 Two primary sources of deposits into State MHS Fund
 1.76% of all monthly personal income tax (PIT) payments (Cash
Transfers)
 Not just millionaires
 Annual Adjustment based on actual tax returns
 Settlement between monthly PIT payments and actual tax returns
 Funds now distributed to counties monthly based on unspent and
unreserved monies in State MHS Fund at end of prior month
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MHSA: What Is it?
 Purpose is to reduce the long-term adverse impact of
untreated mental illness
 Intent is to expand mental health services
 Recovery/wellness
 Stakeholder involvement
 Focus on un-served and underserved
 Focus on effective services and cost-effective
expenditures
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MHSA Is Community-Driven
“The most important change that the MHSA brought
forward is to bring the voice of the person
receiving services and the families – across
ethnicity – to the center of the conversation rather
than at the margins of the conversation.” (Dr. Marvin J.
Southard, Los Angeles County Mental Health Director)
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Mental Health Services Act
MHSA Estimated Revenues
a/
(Cash Basis-Millions of Dollars)
Fiscal Year
Actual
Estimated
10/11
11/12
12/13
Cash Transfers
$905.0
$906.0
$981.0 $1,030.5 $1,082.0
Annual Adjustment
$225.0
($64.5)
$157.0
$173.0
$200.0
$1.3
$1.4
$1.0
Interest
Total
$9.7
$1,139.7
$2.4
13/14
14/15
$843.9 $1,139.3 $1,204.9 $1,283.0
a/ FY12/13 Governor's May Revised Budget cash transfers and interest through FY12/13 and
annual adjustment through 13/14.
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California’s Public Substance Use Disorder System
 In California, the public system of care for the prevention
and treatment of SUD is overseen by a single state agency
(which until July of 2013 is the State Department of Alcohol
& Drug Programs), but is administered by counties, which
either provide services directly or (in most cases) contract
with private providers for services.
 Public treatment of SUD has been predominantly provided
in separate specialty services programs, some of which are
based on social-model recovery (i.e. 12-step), and others
which offer medication-assisted treatment (i.e. methadone
maintenance).
California’s Public Substance Use Disorder System
 SUD treatment is typically provided by staff members who are
state-certified but not professionally licensed.
 Traditional sources of funding for public SUD services:
 Federal Substance Abuse Prevention & Treatment Block
Grant.
 FFP for Drug Medi-Cal
 State General Fund (now Realignment funding) for:
 Drug Medi-Cal Match
 Perinatal Services
 Drug Court Treatment Programs
 Drug Medi-Cal (D/MC) was originally a set of benefits within
Short-Doyle Medi-Cal. The two systems separated in the late
seventies, but still today are linked in the billing process at the
state level.
California’s Public Substance Use Disorder System
 At the state level in California, Drug Medi-Cal is a fee-for-service Medi-Cal
specialty carve out. Services reimbursed by D/MC must be medically
necessary and provided by or under the direction of a physician. Specific
benefits are the following:
 Narcotic Treatment Program (NTP) – Outpatient treatment primary




utilizing methadone
Outpatient treatment utilizing the long-acting narcotic antagonist
Naltrexone
Outpatient Drug Free – Mostly group counseling and some limited
individual counseling
Day Care Rehabilitative – Intensive outpatient treatment, including group
and individual counseling, eligibility for which is limited to pregnant and
postpartum women and, as an EPSDT benefit, to children under 21.
Perinatal Residential – Residential treatment provided to pregnant and
postpartum women in facilities of 16 beds of less, not including beds
occupied by children. (Room & board must be paid for by revenue other
than D/MC.)
Substance Use Disorder Services
Funding (2011)
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Federal Medicaid Rules
Section 1902 of the SSA specifies the basic Medicaid
requirements. With few exceptions, the following rules must
hold for the Drug Medi-Cal program administration:
 Comparability of Services
 Services to be comparable for eligible individuals – equal
in amount, scope, duration for all beneficiaries in a
covered group; services to categorically needy cannot be
less in amount, scope, duration than those provided to
medically needy groups.
Federal Medicaid Rules
 Statewideness:
 Benefits offered to any individual must be available
throughout the state.
 Choice of Providers:
 An individual may obtain Drug Medi-Cal services from any
institution, agency, pharmacy, person, or organization that is
qualified to perform the services (i.e. D/MC-certified).
 In California, if a certified D/MC provider is not given a
contract by a specified county, that provider is guaranteed a
direct contract with the state. DHCS can access the county’s
realignment funds in the BH subaccount to finance the direct
contract.
Sobky v. Smoley
A Class action lawsuit filed in 1992 (Sobky v. Smoley) found
the state in violation of provisions of federal Medicaid law
relating to statewideness, comparability of services, and
reasonable promptness. The lawsuit was concerned
primarily with the availability of narcotic treatment services,
but the principles of federal law apply to Medi-Cal benefits
generally.
Other SUD Issues

Treatment of SUD has largely evolved outside of the
mainstream healthcare system, and has been
predominantly provided in separate specialty services
programs, only some of which offer medication-assisted
treatment.

Because substance abuse as a disease has been viewed with
suspicion and disapproval, funding streams that have been
developed for other systems have not been developed for
SUD services.

The CA SUD treatment system has benefits that are so
limited that they do not allow practitioners to provide best
practices or evidence-based services, and the
reimbursement rates are so low that it is often difficult to
find providers.
Other SUD Issues
 More than three-quarters of the funding for SUD treatment
services comes from public sources, compared to less than half
for all other health care.
 Nationwide, state general fund spending for SUD treatment
declined 3.8% between FY 2008 and FY 2009, and an additional
7.3% in FY 2010. In California, state funding for SUD services has
been reduced by over 40% over the past 5 years.
 Only about 40% of adults report that their SUD treatment was
paid for by insurance, including Medicaid. About one-third
either pay out of pocket or receive services free; the rest rely on
other sources of payment.
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Recent Mental Health/Substance Use
Policy Milestones
 2008: Federal Mental Health Parity (The Paul
Wellstone/Pete Domenici Mental Health Parity and
Addiction Equity Act) Passes
 2009: The Federal Affordable Care Act Passes
 2010: CA Receives Federal Approve for its 1115: A “Bridge to
Health Reform” Demonstration Waiver
 2011: Realignment 2011/Public Safety Realignment
Federal Mental Health Parity
2008
 MH & SU services must be provided at
parity with general healthcare services,
including in these areas:
 Coverage restrictions (copayments, deductibles,
etc.)
 Lifetime limits/costs
 Treatment limits (number of visits/days covered)
 Parity applies to:
 Large Employers
 Medicaid Managed Care Plans
 Health Insurance Exchanges for Individual and
Small Group Policies
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Federal Affordable Care Act (ACA)
2009
 Employers with 50+ employees will be fined if they don’t
offer health insurance. Small companies that offer
coverage can receive tax credits.
 Medicaid expansion in 2014 will be 100% federally funded
to cover single adults up to 133 % of federal poverty
 $14,404 individual income, $29,326 family of four
income.
 An estimated 16 million new people nationally, at least
one-fifth of whom are likely to have mental illness
and/or substance use disorder service needs.
 The Congressional Budget Office estimates almost onequarter of Americans who lack health insurance today
will be covered under Medicaid over the next 10 years.
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ACA: Essential Health Benefits
for the Individual and Small Group Markets
 California’s Governor Brown recently signed legislation
requiring an individual or small group health care service plan
contract or health insurance policy that is issued, amended or
renewed in California on or after January 1, 2014 to at
minimum include coverage for essential health benefits.
 This coverage requirement applies to individual and small
group plans/policies offered to consumers and small
businesses both inside and outside of the California Health
Benefit Exchange.
 The legislation selects a Kaiser small group product as
California’s reference (“benchmark”) plan.
Mental Health Benefits in the CA Benchmark Plan
 According to the Evidence of Coverage (EOC) for the
identified benchmark plan, coverage should include services
and benefits for a broad range of mental health conditions,
utilizing the mental disorder definition as supplied by the
DSM-IV-TR.
 According to the EOC, mental health services are covered
“…only when the services are for the diagnosis or treatment
of mental disorders. A mental disorder is a mental health
condition identified as a mental disorder in the DSM-IV-TR
that results in clinically significant distress or impairment of
mental, emotional, or behavioral functioning.”
 Coverage is not limited to a specific list of conditions or
diagnoses.
Mental Health Benefits in the CA
Benchmark Plan
 Outpatient Mental Health Services:
 Individual and group mental health evaluation and treatment
 Psychological testing when necessary to evaluate a mental
disorder
 Outpatient services for the purpose of monitoring drug therapy
 Inpatient & Intensive Psychiatric Treatment:
 Inpatient psychiatric hospitalization
 Short-term hospital-based intensive outpatient care (partial
hospitalization)
 Short-term multidisciplinary treatment in an intensive outpatient
psychiatric treatment program
 Short-term treatment in a crisis residential program in a licensed
psychiatric treatment facility with 24 hour/day monitoring by
clinical staff for stabilization of an acute psychiatric crisis
 Psychiatric observation for an acute psychiatric crisis
Substance Use Disorder Benefits
in the CA Benchmark Plan
 Inpatient Detoxification : Hospitalization for medical management of
withdrawal symptoms, including room and board, physician services,
drugs, dependency recover services, education and counseling
 Outpatient Chemical Dependency Care:
 Day treatment programs
 Intensive outpatient treatment programs
 Individual and group chemical dependency counseling
 Medical treatment for withdrawal symptoms
 Methadone maintenance treatment for pregnant members during
pregnancy and for 2 months after delivery at a licensed treatment
center approved by the Medical Group. *Methadone maintenance
treatment is NOT covered in any other circumstances
 Transitional Residential Recovery Services: Chemical dependency
treatment in a nonmedical transitional residential recovery setting
approved in writing by the Medical Group that provides counseling and
support services in a structured environment.
Parity & The Benchmark Benefits
 CMHDA and CADPAAC successfully advocated that language
be added to the legislation to clarify that any individual or
small group plan or policy issued, amended, or renewed on or
after January 1, 2014 must comply with the Paul Wellstone
and Pete Domenici Mental Health Parity and Addiction
Equity Act of 2008 and all corresponding rules, regulations
and guidance.
 Inclusion of this reference to federal parity law was
particularly important in order to ensure plan/policy
compliance with both quantitative and non-quantitative
limitations – the latter of which may not be easily discernable
in the benchmark EOC.
 Some questions still remain regarding coverage of certain
substance use disorder treatments, such as methadone
maintenance treatment ,which is excluded from coverage in
the benchmark EOC.
Impacts of Parity/ACA
 The Affordable Care Act (ACA) expands the Parity
requirements to all private health insurance plans, to
Medicaid, and to plans under the state Health Exchanges.
Opportunities under Parity:
 Less cost shifting from the private to the public sector.
 Increased payment from commercial insurance.
 Addiction and MH treatment programs and workforce
who learn to leverage parity for their organizations will
go to the front of the line.
California’s 1115(b) Waiver:
A Bridge to Health Reform
 California has received approval for a new 5-year
Medicaid waiver (2010-2015) as a “bridge to
federal reform.”
 If savings are achieved and milestones met, it
could bring as much as $10 billion in new federal
funds.
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1115(b) Waiver
Low Income Health Program (LIHP)
 County option to participate
 Counties provide match to expand coverage to
individuals up to 133% of federal poverty before 2014
 Receive 50% federal matching dollars
 Counties may set their own eligibility levels up to 133%
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1115(b) Waiver
Low Income Health Program (LIHP)
1.
Medicaid Coverage Expansion (MCE)
•
•
•
•
•
2.
Up to 133% FPL
Mental Health Minimum Benefit Required
Substance Use Disorder Services NOT Required
FFP not capped
May be CPE or capitated
Health Care Coverage Initiative (HCCI)
•
•
•
•
134% to 200% FPL
Mental Health Minimum Benefit Not Required
FFP is capped – county will get an allocation
Financed through Inter-Governmental Transfer (IGT)
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LIHP Core Benefits
 The LIHP offers two sets of core benefits – one portion
for the MCE portion and one for the HCCI portion
 Among the MCE core benefits are minimum mental
health services that must be offered to MCE-eligible
enrollees
 According to the Special Terms and Conditions of the
waiver, “the state must offer a minimum evidencebased benefits package for mental health services under
the Demonstration to promote services in communitybased settings with an emphasis on prevention and
early intervention.”
 While each LIHP may choose to include additional
benefits (as approved by CMS) to the core benefit
offering, such as expanded mental health services
and/or substance use disorder treatment, SUD services
are NOT included as a required core MCE benefit.
Minimum MH Benefits
in 1115(b) Waiver
 For MCE enrollees (under 133% of FPL), each participating county
must provide the following minimum package of mental health
benefits:
 Up to 10 days/year acute inpatient hospitalization in an acute care
hospital, psychiatric hospital, or psychiatric health facility
 Psychiatric pharmaceuticals
 Up to 12 outpatient encounters/year, including assessment,
individual/group therapy, crisis intervention, medication support
and assessment. If a medically necessary need to extend treatment
to an enrollee exists, the plan can optionally expand the service(s)
 Substance Use Services are Optional in MCEs
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Where is Health Care Headed?


More integration of care
More focus on primary care:
‣ Patient-centered medical homes
‣ Federally Qualified Health Centers

More accountability (pay for outcomes)

Bundled payments (Accountable Care Organizations)

Electronic health records, health information exchanges
The Importance of Integrated Care
“Almost all the new service models unleashed by the
Accountable Care Act – from Medicaid Health Homes
to Accountable Care Organizations to patientcentered Medical Homes – cannot succeed without
integrating behavioral and general medical care. The
theme of “integration” is popping up everywhere.
Yet the mainstream is not prepared. They need our
help.”
- Michael F. Hogan, PhD, Commissioner
New York State Office of Mental Health
Discussion Questions/Health Care
Reform
 How will HCR, Parity and the 1115 Waiver impact our capacity
as providers of mental health and substance use service
providers?
 How will administration, contracting, and reimbursement of
services change through the 1115 waiver and HCR?
 How will MH/SU advocates ensure that sufficient resources,
providers and progressive models of service remain available
for the populations we serve?
 How well will we be able to work with health plans and
primary care in coordinating care for those with serious
MH/SUD disorders?
 How will counties position themselves to be the best in serving
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those with serious MH/SU disorders?
Public Safety Realignment
2011
 Pressured by continuing deficits, Governor Brown
proposed realigning many public safety and health
and human services programs from the state to
counties.
 He wanted to move responsibility for these services
so that they could be more efficiently managed and
provided at a level that was “closer to the people.”
 The plan was to create a new, dedicated,
constitutionally protected revenue source for
counties that was approved by voters by ballot
initiative.
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Programs Realigned to Counties
 Court Security
 Local Public Safety




Subventions
Local Jurisdiction of
Lower‐level Offenders
and Parole Violators
Adult Parole
Foster Care, Child
Welfare Services,
Adoptions Assistance
Program, Child Abuse
Prevention
Adult Protective Services
 Community Mental
Health
 EPSDT
 MH Managed Care
 1991 MH Realignment
 Substance Use TX
 Drug Medi‐Cal
 Women and Children’s
Residential Treatment
Services
 Drug Court
 Non-Drug Medi‐Cal
Substance Abuse Treatment
Services
Goals
 Protect California’s essential public services
 Create a government structure that meets public needs in






the most effective and efficient manner
Have government focus its resources on core functions
Assign program and fiscal responsibility to the level of
government that can best provide the service
Have interconnected services provided at a single level of
government
Provide dedicated revenues to fund these programs
Provide as much flexibility as possible to the level of
government providing the service
Reduce duplication and minimize overhead costs
64
Account Structure
State Level:
 Creates two new accounts: Support Services & Law Enforcement
 Within the two new accounts, creates separate subaccounts. The
Support Services Account would contain the Protective Services
Subaccount and the Behavioral Health Subaccount.
 The Protective Services Subaccount includes:
1. Foster Care
2. Child Welfare Services
3. Adoptions
4. Adoptions Assistance
5. Child Abuse Prevention, Intervention & Treatment
6. Adult Protective Services
Account Structure: Behavioral
Health Subaccount
The Behavioral Health Subaccount includes:
 1. Medi-Cal Specialty Mental Health (including EPSDT




and Managed Care)
2. Drug Medi-Cal
3. Perinatal Drug Services
4. Non-Drug Medi-Cal Services
5. Drug Courts
Account Structure
County Level:
 Two corresponding accounts would be created at the county
level: Support Services and Law Enforcement.
 The local Support Services Account would contain the two
subaccounts: Protective Services and Behavioral Health, with
the same programs under each as delineated on the state level.
 There would be no separate growth accounts at the county level.
 Counties would (theoretically) have maximum flexibility
to spend funds on any program within the Protective
Services Subaccount and within the Behavioral Health
Subaccount.
Growth Allocations Change Over Time
Support Services Growth Subaccount Allocations
2012-13
2013-14
2014-15
Protective
Services
Behavioral Health
82%
62%
45%
13%
33%
50%
‘91 Mental Health
5%
5%
5%
Note: The percentages in 2014-15 assumes $200 million child
welfare restoration is met. Once restoration is met, these
would be the ongoing proportions for growth funds.
Base
• Establish a base year in statute (which will differ by
program/account)
• Current year base + current year growth = new base
• When revenues are not sufficient to fund the base,
there would be an automatic restoration of base from
the next year’s growth
Growth
State Level
 Growth funds would be the amount of realignment revenues above the
amount needed to fund each account’s prior year base.
 Growth funds would be distributed to each account on a proportionate
basis (approximately 65% for Supportive Services and 35% for Law
Enforcement).
 Separate growth accounts would be established at the state level, one
for VLF growth and one of sales tax growth.
 The Sales Tax Growth Account would include two subaccounts: the
Support Services Growth Account and the Law Enforcement Services
Growth Account.
 The VLF Growth Account would be wholly attributable to the Public
Safety Subventions Account.
Growth
County Level
• Counties would (theoretically) have the discretion to
distribute growth funds to any program within each
subaccount on the HHS side.
2011 Realignment: Key Issues
 Up to 10% transferability between Protective Services
and Behavioral Health
 One year only, does not become permanent funding source
 Board of Supervisors hearing
 Documentation forwarded to SCO, SCO forwards to
Legislature
 No transferability between Law Enforcement Services
Account and Support Services Account
 Board may establish Support Services Reserve
 Max. 5% total funds allocated to Subaccounts in prior year
 Board of Supervisors hearing
 Documentation forwarded to SCO, SCO forwards to
Legislature
Realignment 2011 and
Medi-Cal Specialty Mental Health
 Counties must fund Medi-Cal Specialty Mental Health
Services, including Early and Periodic Screening,
Diagnosis and Treatment (EPSDT), from moneys
received from:
 The 2011 Behavioral Health Subaccount and the
Behavioral Health Growth Special Account
 The 1991 Realignment Mental Health Subaccount
 MHSA funds, to the extent permissible under the Act
Realignment 2011 and
Drug Medi-Cal
 Under the 2011 Realignment legislation in California, the
state retains the responsibility for the certification and
monitoring of D/MC programs, and will continue to set
rates, while counties assume the responsibility and
financial risk for administering and funding D/MC services
at the local level.
 As an entitlement program D/MC cannot be capped and,
operating on a fee-for-service basis, does not have the
administrative and clinical controls on utilization that local
Mental Health plans have.
 Financing D/MC caseload growth becomes a local
responsibility under Realignment, but the specific
mechanisms for accommodating and funding caseload
growth are not defined.
Realignment and Drug Medi-Cal
Maintenance of Effort:
 The purpose of the Substance Abuse Prevention and
Treatment Block Grant MOE is to ensure Federal
SAPTBG funds are used to supplement, not supplant
state funding.
 The SAPTBG MOE has implications for the county’s
Behavioral Health realignment subaccount, as it limits
somewhat the county’s flexibility with regard to the
use of those subaccount funds.
Other MH/SU Realignment
2011 Issues
 If county is failing or at risk of failing to perform
the functions of a Behavioral Health Subaccount
program to the extent federal funds are at risk:
 If DHCS makes this determination, it notifies State
Controller, Department of Finance, and the county
 Determine amount needed from the subaccount to
perform the function
 Controller deposits county’s allocation attributable to
program into the “County Intervention Support Services
Subaccount” (for access by DHCS for the program).
DHCS determines when this may cease.
Criminal Justice Realignment
 Statewide $489.9 million base available in FY 2012-13
for two components:
 Local custody, alternative custody, and alternative
supervision services for new adult offenders that are
either non-violent, non-serious, or non-sex offenders
 Post-release community supervision for adults paroled
out of state prison (excluding violent, serious, 3rd strike,
high risk sex offenders)
Community Planning Process for
Criminal Justice Realignment
 AB 109 and AB 117 require each county’s Community
Corrections Partnership (CCP) to recommend to the
Board of Supervisors an implementation plan
 Led by Chief Probation Officer
 CCP must include the county mental health director
 CCP Executive Committee, which votes to approve the
plan, must include either the county mental health,
substance use, or social services director.
 Meetings are subject to the Brown Act’s posting and
open meeting requirements.
Prop. 30:
Constitutional Protections
2012
 Includes Constitutional Protections for Counties
 State must provide funds for new laws (after 9/30/12) or
new regulations, executive orders, administrative
directives (after 10/9/11) that increase costs of local
services mandated by 2011 Realignment legislation.
 Unless the state provides funding, state cannot submit
federal plans/waivers/SPAs that increase local costs.
 State provides 50% needed funds for changes to federal
statutes/regulations or federal judicial or administrative
proceedings.
Opportunities for Behavioral Health
Under 2011 Realignment
 Opportunities to maximize available FFP under the new Medicaid
expansion, using Realignment 2011 funds (including enrolling AB 109
parolees)
 Opportunities to improve care for those with co-occurring MH/SU
disorders
 Opportunities to improve public safety and reduce recidivism
 Opportunity to work with all health/human services departments to
identify cost-effective ways to serve the same clients
 Opportunities (over the long term) to ensure growth for behavioral
health services, rather than protect against State General Fund cuts
Challenges for Behavioral Health Under
2011 Public Safety Realignment
 Ensuring that sufficient resources, providers and
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
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progressive models of service remain available for the
populations that we serve
Impact of Katie A settlement
Impact of transfer of Healthy Families children to EPSDT
Managing a behavioral health subaccount that combines a
managed Medi-Cal program (Specialty Mental Health)
with an unmanaged Medi-Cal program (Drug Medi-Cal)
Delayed growth for BH Subaccount because of $200 million
growth to Child Welfare
Determining MH/SU Subaccount Distribution Formulas
November 17, 2011
Challenges for Behavioral Health Under
2011 Public Safety Realignment
 Lack of a “freedom of choice” waiver for Drug Medi-
Cal
 Ability to effectively manage Drug Medi-Cal utilization
and quality without waiver, selective contracting
November 17, 2011
Discussion Questions:
Realignment 2011
 Now that the state’s role has significantly diminished, and




counties’ has increased, how do counties collectively manage
both intra-county issues (such as funding distributions) and
external relations: state, stakeholders, CSAC, etc.?
How can counties ensure that they have sufficient funds to
meet Medi-Cal entitlement obligations for EPSDT, Medi-Cal
Managed Care, and Drug Medi-Cal with so many other
realigned programs competing for funding?
How can counties effectively manage the behavioral health
subaccount with no current ability to manage the Drug MediCal program?
How can the LIHP programs be used to leverage federal funds
for parolees returning to our communities?
Other questions for local MH/AOD leaders?
83
Our/Your Future: How can you provide
leadership in these major policy areas?
 Realignment 2011, including full risk for Medi-Cal
behavioral health services
 Federal Health Care Reform
 Federal Mental Health Parity
 Community Corrections – continued shift from state to
counties
It is clear that counties will need to be the leaders,
with the full engagement of stakeholders in their
communities, in the development of behavioral
health policy in California.
Are you ready??
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Contact Information
Patricia Ryan, Executive Director
California Mental Health Directors Association
(916) 556-3477, ext. 108
[email protected]
Tom Renfree, Executive Director
County Alcohol and Drug Program Administrators
Association of California
(916) 441-1850
[email protected]