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Receive an overview of changes impacting Solano County Behavioral Health related to new mandates and statewide directives for the delivery of services
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Published Notice Required? Yes ___ No _X_
Public Hearing Required? Yes ___ No _X_
DEPARTMENTAL RECOMMENDATION:
The Department of Health and Human Services recommends that the Board of Supervisors receive an overview of changes impacting Solano County Behavioral Health related to new mandates and statewide directives for the delivery of services.
SUMMARY:
The State of California initiated a plan for policy changes to redesign the state mental health and substance use system, collectively known as the behavioral health system. As part of this effort, the Department of Health Care Services (DHCS) entered into updated federal waivers in how services are reimbursed and initiated the California Advancing and Innovating Medi-Cal (CalAIM) to shift the Medi-Cal program including population-based initiatives focused on children, foster youth, and those who are unhoused or justice-involved. Concurrently, various new laws have emerged in alignment with these changes. Proposition 1, which was passed by voters in March 2024, makes substantial changes to the existing Mental Health Services Act (MHSA). Additional new laws that will have significant impacts on Behavioral Health include the Care Act and the Lanterman-Petris-Short (LPS) Act, which govern the involuntary detention, treatment, and conservatorship of people with behavioral health conditions; and both Acts expand eligibility and increase requirements of treatment for new populations. These and many other directives have created significant workload implications for counties, specifically to behavioral health departments, with little to no funding accompanying these mandates.
FINANCIAL IMPACT:
Solano County and the Behavioral Health Division have new mandates that are either unfunded, partially funded, or initially funded but have no ongoing operational funding. Mandates in place since January 2022 which have funds associated, either through grants or allocations, were included in the Health and Social Services’ FY2023/24 Midyear Report submittal. As additional funds become known, H&SS will update the budget and provide the Board with updates. Future appropriations and estimated revenues remain unknown.
The costs of preparing the agenda item are nominal and absorbed by the Department’s FY2023/24 Working Budget.
DISCUSSION:
The Department of Health Care Services (DHCS) contracts with California’s 56 Mental Health Plans (MHPs) for the provision of Medi-Cal Specialty Mental Health Services (SMHS) and for the Drug Medi-Cal Organized Delivery System (DMC-ODS) Plan for Substance Use Disorder (SUD) services. The State Plan, which governs how counties administer their Mental Health Plans, contains all information necessary for the Centers for Medicare and Medicaid Services (CMS) to determine if the State can receive Federal Financial Participation (FFP).
Behavioral Health is responsible for SMHS under the MHP contract which operates as a Prepaid Inpatient Health Plan (a limited benefit package) as a “zero dollar” contract, because there is technically no maximum amount of services that can be delivered, as long as the MHP has the funds for local match that are necessary to draw down federal dollars. For Solano County Behavioral Health, this includes administrative oversight for SMHS that includes Medi-Cal compliance, quality assurance, program improvement, community planning, data and record keeping and other responsibilities. Behavioral Health also offers clinical program oversight and service delivery through county-operated services and contractors. SMHS are defined as services that are moderate to high intensity - children, youth and adults with the greatest need and often complex co-occurring conditions. Operation of the County Mental Health Plan under Solano County’s contract obligates the County to the requirements and scope of specialty mental health services that the County must either provide or arrange for on behalf of eligible Medi-Cal beneficiaries of Solano County. Services are delivered in accordance with the County’s Implementation Plan for a wide variety of service types that may be offered based upon individualized medical necessity to beneficiaries (and as resources are available to indigent residents) including outpatient treatment, intensive case management, therapy, crisis services, etc. The MHP is not reimbursed for high-cost inpatient hospital or institutional services for facilities with over 16 beds known as Institutions for Mental Disease (IMDs).
Behavioral Health also provides services for SUD under the DMC-ODS regional model. Administratively, the division’s oversight for SUD functions through a contract with Partnership HealthPlan for managing the provider network, Drug Medi-Cal compliance, and service delivery via contractors. For SUD, Behavioral Health supports those who do not have Medi-Cal as well as those who need both SUD and SMHS services at the same time. Under the Drug Medi-Cal Organized Delivery System (DMC-ODS) services include all State Plan services and expanded federal reimbursement for multiple levels of residential treatment, early intervention services, two levels of intensive outpatient services, case management, medication assisted treatment, withdrawal management, and others. Additionally, DMC-ODS is a federally required managed care plan.
New Mandates and/or Changes added to Solano Behavioral Health since 2022
CalAIM:
CalAIM is a multi-year initiative to redesign the state mental health and substance use system, collectively known as the behavioral health system. The initiative was launched in 2022 and implementation will continue through 2027. CalAIM launched behavioral health payment reform (a systemwide change in the billing of behavioral health services) across the Medi-Cal program along with population-based initiatives focused on children, foster youth, and those who are unhoused or justice-involved.
Changes to policies and practices include:
• Clarifications to the criteria for Specialty Mental Health Services (SMHS).
• Improvements to the Drug Medi-Cal Organized Delivery System (DMC-ODS) policy.
• Establishing criteria to be used in determining appropriate level of care for covered SUD treatment services.
• Updates to behavioral health documentation requirements to include the use of an active and ongoing problem list, progress notes, and other documentation within the clinical record reflecting the care given, and in alignment with the appropriate billing codes.
• No Wrong Door policy to ensure members receive mental health services regardless of the delivery system where they seek care (via county behavioral health, Medi-Cal managed care plan (MCP), or the fee-for-service delivery system).
• Standardized screening and transition tools to determine the most appropriate Medi-Cal mental health delivery system for individuals currently not receiving mental health services or for individuals seeking mental health services.
• Behavioral health payment reform, which is currently in progress. Payment reform transitions counties from cost-based reimbursement to fee-for-service reimbursement funded via intergovernmental transfers. As part of payment reform, SMHS and SUD services transitioned from Healthcare Common Procedure Coding System (HCPCS) Level II coding to Level I coding, known as Current Procedural Terminology (CPT) coding, when possible.
• Behavioral health administrative integration of specialty mental health and SUD treatment services. This is separate from the CalAIM full integration plan that integrates physical, behavioral, and oral health care into comprehensive managed care plans.
CalAIM’s population-based initiatives and new benefits will require Behavioral Health to administratively implement:
• Children and youth behavioral health initiatives that add services such as early intervention, school-linked fee schedule (reimbursable services at the schools), Family First Prevention Services Act (FFPSA) with Child Welfare Services, system of care requirements, and First Episode Psychosis requirements.
• Mobile crisis benefits to include qualifying community-based mobile crisis intervention services as a Medi-Cal benefit. This requirement includes access to coordinated crisis care 24-hours a day, 7-days a week, 365-days per year.
• Justice Involved Initiative will require eligible individuals who are incarcerated the ability to enroll in Medi-Cal 90 days before their release and access billable services in the jails; Providing Access and Transforming Health (PATH) Justice-Involved Capacity Building Program will provide funding to support implementation of pre-release Medi-Cal application and suspension processes and requires collaboration with the Sheriff’s Office, H&SS’ Employment and Eligibility Division, and the Department of Information Technology.
• Expansion of behavioral health peer support specialists, including a new billable rate and certification of specialists.
• Evidence based practice and service requirements with Behavioral Health Community-Based Organized Networks of Equitable Care and Treatment (BH-CONNECT), part of the Section 1115 Demonstration Waiver.
• Implementation of Assertive Community Treatment (ACT), supported employment, First Episode Psychosis, enhanced care management, institutions for mental disease waiver, community supports, contingency management (option), and community health workers (option).
• Requirements to develop, operate and support services within housing of all types and level of need including housing supports, Behavioral Health Continuum Infrastructure Program grants ($2.2 billion), Proposition 1’s $6.2 billion housing bond, new No Place Like Home funding rounds, Community Care Expansion (CCE), Data Exchange, BHSA Housing Category (30%), and Behavioral Health Bridge Housing additional funding rounds.
Kaiser Carve In:
• Kaiser is working collaboratively with Solano and Sacramento counties to develop a joint plan that includes methods for identifying members, screening and assessment needed, service types, documentation exchange, staffing/contracts needed, etc. There will be a phased in transition, the planning period has started and continues through June 2024 and the phased in transition of clients will begin July 1, 2024 and conclude December 31, 2024.
• The total number transitioning from Kaiser to the county is still being finalized; however, the initial annual estimate indicates a total of 650 individuals which include approximately 390 adults and 178 child/youth for Full Service Partnership and intensive outpatient levels, and approximately 69 adults/children in subacute/residential placements. Although these estimates are lower than the original estimate of 2,091, the most significant impact to funding will be those in inpatient care who are largely not known until they enter crisis. However, clients receiving inpatient or residential care, admitted prior to July 1, 2024 by Kaiser will remain the responsibility of Kaiser to avoid disruption to the client until January 2025.
Other New Legislation:
Lanterman-Petris-Short (LPS) Act and Crisis Continuum:
• SB 43 updated the Lanterman-Petris-Short (LPS) Act, which governs involuntary detention, treatment, and conservatorship of people with behavioral health conditions. SB 43, signed by Governor Newsom in October 2023, broadens eligibility for conservatorship to include people who are unable to provide for their personal safety or necessary medical care due to severe substance use disorder or serious mental illnesses. Solano County approved a one year deferral of implementation of this Act.
• AB 2275 defines the time frame for involuntary commitments under the LPS Act.
• AB 2242 amends the LPS Act to allow counties to pay for the provision of mental health services under the LPS Act using MHSA funding.
• AB 988 established the “9-8-8” emergency response call system for Californians experiencing a mental health crisis. This system is being expanded at the federal and state level.
• SB 184 (Chapter 47, Statutes of 2022) established a growth cap for individuals committed as Incompetent to Stand Trial (IST) on felony charges and admitted to a Department of State Hospitals for treatment. Counties who exceed the growth cap are financially penalized.
CARE Court:
• SB 1338 - Community Assistance, Recovery, and Empowerment (CARE) Court Program will be launched in December 2024. CARE court is a civil court process that provides participants with services and supports through Individualized CARE plans which can initially be structured to last up to 12 months but can be extended for an additional 12 months as necessary. Behavioral Health will provide outreach, engagement, care planning and treatment. If a person cannot successfully complete a CARE plan, the Court may utilize existing authority under the LPS Act to ensure the participants safety (begin conservatorship process which will impact the Public Guardian and County Counsel.
If local governments do not meet their specified responsibilities under the court-ordered CARE plans, the Court will have the ability to order sanctions and, in extreme cases, appoint an agent to ensure services are provided.
Opioid Settlement Funds:
• Opioid settlement allocations must be expended on opioid remediation that includes high impact abatement activities delineated by DHCS. Priorities for use of the funds are referred to as High Impact Abatement Activities (HIAA) to expand SUD services, address disparities, focus on diversion, youth prevention and Naloxone distribution.
Proposition 1, approved by voters in March 2024, with implementation on July 1, 2026:
• Contains two major components: (1) changes the Mental Health Services Act (MHSA) to the Behavioral Health Services Act (BHSA) and on how funding from the Act can be used; and (2) approves a $6.4 billion bond to build (a) more places for mental health care and drug or alcohol treatment, and (b) more housing for people with mental health, drug, or alcohol challenges.
• Prop 1 makes no changes to the amount of revenue collected through the tax, but the funding will be used differently. It also redistributes the allocation of BHSA revenues from counties to the state from 5% to 10% to be used for workforce initiatives and prevention.
• Prop 1 significantly changes the categories under which counties must allocate BHSA dollars. Most significantly, BHSA creates a new requirement that one third (30%) of funds allocated in each county (with some possible exceptions for rural counties) must be spent on housing.
Impacts on the County and Behavioral Health
Undoubtedly, these changes and mandates significantly impact Behavioral Health administration and staff. H&SS, Behavioral Health Division, oversees behavioral health managed care operations and clinical direct services. These changes add workload to the administrative team and operations side, while some impact clinical services or the need to expand services.
Since August 2023, for comparison, Solano Behavioral Health has had a 30% increase in the number of contracts supported. Half of those are service contracts that require significant oversight, monitoring, assurance, and utilization management to ensure outcomes and adhere to funding caps. County-operated services and these service contracts currently take up an enormous amount of scrutiny and clinical support, even without adding the necessary changes that will come from CalAIM or Proposition 1.
Administratively, these mandates require full integration of services requiring data exchanges/health information sharing (impact to the Department of Information Technology (DoIT)), increased fiscal oversight with an eye towards capitation (H&SS Fiscal), flexibility in shifting contracts from cost-reimbursement to fee for service and flexibility in contracting, placements and other (H&SS contracts), and programmatic and procedural development with agencies for specific initiatives. The goal will be to ensure that Behavioral Health, as an SMHS and DMC-ODS plan, achieves value-based care (“we get what we pay for”) and population health management targets, requiring more clinical, fiscal, and administrative oversight.
Ultimately, the mandates will shift in how Behavioral Health organizes and administers specialty mental health and substance use disorder services. The goal is to better align the financing of behavioral health with that of physical health, offer financial flexibility and revenue generation to innovate, improve quality of care, shift to value-based/incentive payment arrangements, improve access to care, i.e., “no wrong door" approach, and ensure data-driven decision making. New payment reform rates are expected to help providers hire and support clients and increase revenue for system reinvestment. New sustainability metrics and performance monitoring are expected to maximize revenue and optimize outcomes.
Within Behavioral Health, these changes require significant administrative obligations for services and contracts through additional oversight and comprehensive analytics tools. More clinical provider engagement will be necessary to meet standards and obligations. Significant support will be needed from the H&SS fiscal team to support projections and claims processes; from DoIT to support data interoperability, health information exchange, and tools; from County Counsel and other partners to quickly determine changes; and partnerships and commitments across other agencies will be needed on shared mandates.
ALTERNATIVES:
The Board may choose to not receive this overview of new mandates and statewide directives impacting Solano County Behavioral Health and the delivery of behavioral health services; however, this is not recommended as these changes and mandates have a significant impact on the County, various departments and in particular the H&SS’ Behavioral Health Division, whereby many carry warnings of corrective action plans, sanctions, and penalties for delays and non-compliance.
OTHER AGENCY INVOLVEMENT:
Health and Social Services, Behavioral Health Division, is working closely where initiatives impact the Courts, Sheriff’s Office, Jails, Probation, Department of Information Technology, Public Guardian, County Counsel, and others.
CAO RECOMMENDATION:
APPROVE DEPARTMENTAL RECOMMENDATION