Transcript Slide 1

1991 Bronzan – McQorkuodale Act CA
Welfare & Institution Code 5600
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AKA Realignment
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Passed in response to continuing mental health
budget uncertainties
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Reorganized the funding and focus of public
mental health servicer
Funding Provisions
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Created a dedicated Revenue stream outside of the
general budget process that was funded by an
increase in state sales tax and vehicle license fees
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Trust funds set up for mental health, public health
and social services in each county
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Expectation was that economic growth would help
revenue keep up with inflation. Established a
formula for determining how revenue growth would
be divided up.
Funding Provisions (Continued)
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Provided more flexibility for counties in how
money could be spent as well as provisions
that encouraged longer term planning (no
“use it or lose it”)
Allowed local Board of Supervisors to O.K.
the reallocation of no more than 10% among
the 3 trust funds
Required a “maintenance of effort” for county
contribution
Performance Contract with DMH
(WIC 5650)
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Replaced the Annual County Short Doyle
Plan with a contract that specified, among
other assurances, that;
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The county would provide services to persons
receiving involuntary treatment
The county shall comply with all provisions and
requirements in law pertaining to patients’ rights
The county comply with other state and federal
laws, report specific data, meet all the various
requirements and rules necessary for MediCal,
reimbursement etc.
Performance Contract with DMH
(Continued)
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The local Mental Health Board has reviewed and
approved procedures ensuring citizen and
professional participation at all stages of the
planning process
Program Reform
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Mandated the provision of client centered and
culturally competent services in an integrated
system of care targeted to seriously and
persistently mentally ill children, adults, and
older adults
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Created “performance outcome measures” to
gauge the effectiveness of such services.
Program Reform (Continued)
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Implemented in statute the California State
Master Plan (AB 904)
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Services were to be provided “to the extent
resources are available.”
Target Population - Adults with serious and
persistent mental disorders
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“Persons with the existence of a mental
disorder which is severe in degree and
persistent in duration which may cause
behavioral functions which interferes
substantially with the primary activities of
daily living, and which may result in an
inability to maintain stable adjustment and
independent functions without treatment,
support, and rehabilitation for a long or
indefinite period of time”
Target Population (Continued)
The person shall
 Have a DSM identifiable diagnosis - - other than
substance abuse disorder or developmental disorder
or an acquired traumatic brain injury..
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And, as a result of the mental disorder has
substantial functional impairments or symptoms, or
a psychiatric history demonstrating that without
treatment there is an immanent risk of
decomposition to having substantial impairment or
symptoms
Target Population (Continued)
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And – As a result of a functional impairment
and circumstances the person likely to
become so disabled as to require public
assistance, services or entitlements
Target Population – Seriously Emotionally
Disturbed Children or Adolescents
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A minor under 18 with psychiatric diagnosis,
other than primary substance abuse disorder
or developmental disorder, which results in
behavior inappropriate to the child’s age
according to expected developmental norms.
Members of this target population shall meet
one or more of the following criteria;
Target Population – Seriously Emotionally
Disturbed Children or Adolescents
(Continued)
1) As a result of the mental disorder has
substantial impairment in at least two of the
following areas
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Self Care
School functions
Family relationships
Ability to function in the community
Target Population – Seriously Emotionally
Disturbed Children or Adolescents
(Continued)
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And either of the following;
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A) the child is at risk of removal from home or has
already been removed from the home
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B) The mental disorder and impairments have
been present for more than six months or are
likely to continue for more than a year without
treatment
Target Population – Seriously Emotionally
Disturbed Children or Adolescents
(Continued)
2) The child displays one of the following:
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Psychotic features
Risk of suicide
Risk of violence due to mental disorder
3) The Child meets special education
eligibility requirement as specified
Consolidation of Medi-Cal Fee-for-Service
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Combined Medi-Cal Fee-for Service System and the
county Short-Doyle Medi-Cal System
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Counties given their portion of the state match for
the Federal Financial Participation (FFP)
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Counties offered right of first refusal to become the
local Mental Health Plan
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Agreed to met the mandated guidelines for
participation
Consolidation of Medi-Cal Fee-for-Service
(Continued)
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The local MHP became providers of both
psychiatric inpatient services as well as for
specialty mental health services. Specialty
Mental Health Services are services for
people with mental illness or emotional
problems that a regular doctor cannot treat.
1) Title 9 CCR, 1810.100 et seq
Local Mental Health Plans are responsible
for
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Informing and educating Medi-Cal recipients about
the availability and methods of accessing specialty
mental health services
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Providing written information and forms in various
languages, as well as services in language of
choice, and that interpreter services are available at
no charge to the recipient.
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Screening and assessing Medi-Cal recipients to
determine if meet “Medical Necessity” for receiving
services
Local Mental Plans are Responsible for
(Continued)
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Maintain an appeal and a grievance process
that meets regulatory requirements
Medical Necessity for Non-hospital
Speciality Mental Health Services:
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Medi-Cal beneficiary must meet all the
following criteria:
1) Must have a covered diagnosis
Medical Necessity for Non-Hospital
Specialty Mental Health Services (Continued)
2) Must have at least one of the following
impairments as a result of the qualified
diagnosis (es)
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A significant impairment in an important area of
life functioning
A probability of significant deterioration in an
important area of life functioning
Children also qualify if there is a probability the
child will not progress developmentally as
developmentally appropriate (child is a person
under 21 years old).
Medical Necessity for non-hospital Specialty
Mental Health Services (Continued)
3) And must have each of the intervention
criteria below
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Focus of the proposed intervention addresses the
condition identified in # 2
Expectation that proposed intervention will
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Significantly diminish the impairment Or
Prevent significant deterioration in an important area of
life functioning Or
Allow a child to progress developmentally as individually
appropriate
Medical Necessity for non-hospital
Specialty Mental Health Services
(Continued)
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And the condition would not be responsive to
physical healthcare-based treatment
Services “Required” Entitlement
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Mental Health Services:
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Including mental health treatment services
provided by licensed clinicians as well as
rehabilitation or recovering services that assist
persons with developing coping skills for daily
living. May be provided in clinic or community,
individuality or in a group
Services “Required” Entitlement
(Continued)
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Medication Support Services
Targeted Case Management
Crisis Intervention and Crisis Stabilization
Adult Residential Treatment Services
Day Treatment Intensive
Day Rehabilitation
Psychiatric Health Facility
Psychiatric Inpatient Hospital Services
Grievance System
A Grievance is an expression of unhappiness
about anything regarding specialty mental
health services (and isn’t an issue covered by
the Appeal and Fair Hearing processes.
Grievance System (Continued)
Grievances:
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May be filed at anytime
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May be filed orally or in writing, if filed orally it does
NOT have to be followed up in writing
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May authorize someone to act on his/her behalf
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Grievance forms and self-addressed envelopes
must be available at all provider sites
Grievance System (Continued)
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Decision makers must be qualified to make a
decision (if clinical) and not involved in any
previous level of review or decision-making
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A written confirmation that grievance has
been received shall be sent to the
beneficiary. Grievance shall be entered into
“Grievance Log” that is reviewed by state
Grievance System (Continued)
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A decision regarding the grievance must be
made with in 60 days, with a possible two
week extension
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The beneficiary is notified in writing as to the
decision
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A Notice of Action is sent to the beneficiary if
the timeline is not met
Appeal Process
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An appeal is a request to review a decision
made by the Mental Health Plan or your
provider about your specialty mental health
services. Generally will be about a denial or
change of service
Standard Appeal
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Must be written and signed
Services may continue if the appeal is within 10
days of a notice of action (if received)
Appeal Process (Continued)
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Have reasonable opportunity to review records
and information and present evidence in writing or
in person.
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May take up to 45 days to review
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Receive written notice that the appeal is being
reviewed, that you have a right to a State Fair
Hearing following the Appeal Process, as well as
the notice of the decision.
Appeal Process (Continued)
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Expedited Appeal
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May be requested if waiting for 45 days will
jeopardize life, health or ability to maintain or
regain maximum function.
If does not qualify for expedited process will be
notified within 2 days orally and in writing. May file
a grievance
If expedited process is granted will resolve with 3
working days, though a 14-day extension is
possible
Notice of Action
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May receive a notice of Action if:
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Upon assessment, person does not qualify for
specialty mental health services
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MHP changes the type or frequency of services
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MHP terminates specialty mental health services
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MHP does not meet required timeline in the
grievance or appeal process
Notice of Action (Continued)
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Are generally triggered by the authorization
process so many clients getting services
directly from the county will not receive
Notice of Action.
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There are lots of reasons why people may
not get a N.O.A.
The Client Plan – or Service plan or care
plan
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The Annual Plan upon which all individual’s
services are based
Goals, objectives and interventions identified
by client and staff
Must be signed by the client
For reimbursement all service notes must
match goals and interventions
Can be amended during course of year
Medi-Cal Administrative Activities
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Claiming for activities associated with the
administrative
Activities include outreach, training, planning,
quality assurance, quality improvement
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Reimbursements rates differ depending upon
whether all Medi-Cal clients or only some
Reimbursements rates differ whether or not
provider is licensed (SPMP-skilled professional
medical provider)
Other Populations Receiving Services
Early and Periodic Screening Diagnosis and
Treatment Services - - Medi-Cal funded
services for children, youth and adolescents
up to 21. Includes Therapeutic Behavioral
Services
Cal-Works – Medi-Cal beneficiaries enrolled in
the Cal-works program through (TANF)
Provides services to overcome mental health
barriers to work.
Other Populations Receiving Services
(Continued)
AB3632 – Mental Health services that enable
children/youth to benefit from their public education
ConRep Services – State funded program that
provides treatment services and supervision to
certain persons on forensic status
Local Forensic Services – may provide mental health
services in local jails, and detention facilities – may
be funded by Mental Health or criminal justice.
AB 2034 Program-services to homeless target
population clients who are not “open” to the system.
Rationing Care - Strategies
Clinical ____ Balance ____ Fiscal
risk
risk
=
Amount & type of services
Rationing Care – Strategies (Continued)
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Limiting access of non-target population
clients and redirecting to other systems – like
federally qualified health clinics (FQHCs)
Limiting access to uninsured clients – though
have a mechanism to get them on benefits
ASAP
Shift Medi-Cal recipients to physical health
care system – no longer meet “medical
necessity”.
Current Trends
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Cost of providing services increases
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Lack of growth in realignment
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MHSA funds new “full partnership” and
outreach services can’t be used to supplant
existing services
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Increase in Medi-Cal population means more
core funding diverted to those services
Current Trends (Continued)
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Los Angeles County – $125 million in MHSA funds $70 million short-fall in core mental health budget
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Santa Clara County - $19 million in MHSA funds for
07-08 - $17 million cut from core mental health
budget
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Fresno County - $8.6 million in MHSA funds - $8
million cut in core Mental health budget
*Budget information from LA Times “New Funds, enduring ills” by
Gold & Romney 9/16/07
Approaching a Two-Tiered System
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“Full-partnership” services from MHSA
funded programs
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Fewer & fewer services available to other
target-population clients
 Other
Topics?
 Questions?
Thank You