Realignment 2011

Growth AllocationOctober 16, 2015

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GOAL FOR TODAY

IDENTIFY RELEVANT FACTORS USED TO DETERMINE THE ALLOCATION

METHODOLOGY FOR DISTRIBUTING GROWTH FUNDS

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HISTORY

1957 – State legislature enacts the Short-Doyle Act

By the end of this year, there was a total of 14 state hospitals with a population of 36,319

1966 – Medi-Cal is created: Title XIX of the Social Security Act authorized the Federal Government to reimburse states for the costs • The Act requires states to share in the costs of Medicaid

expenditures and permits state and local governments to participate in financing the non-federal share of the Medicaid expenditures

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HISTORY

1968 – The Lanterman-Petris-Short Act changes the law by establishing standards and legal procedures for involuntary hospitalization

1969 – The California Community Mental Health Services Act “deinstitutionalized” mental health services to the community rather than state hospitals

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HISTORY

1971 – Traditional Medi-Cal benefits expand to include Short-Doyle community mental health services which allowed counties to obtain federal funds to match their own funding. Short Doyle/Medi-Cal System (SD/MC) offered a broader range of mental health services

1972 and 1973 – Governor Reagan vetoed provisions to use savings from state hospitals closures to fund community mental health programs

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HISTORY

1974 – Legislature requires all counties to have mental health programs

1984 – AB 3632 (McGuire) assigns county mental health departments the responsibility to provide special education students with mental health services

1987 – AB 377 (Cathie Wright) passed to fund the Children’s System of Care model in California (based on the Ventura County Pilot)

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1991 LANDSCAPE

• State budget shortfall• Historically, there was no dedicated funding

stream for mental health• Programs were funded on a year to year basis

subject to the appropriation by the Legislature• Result was that funding was unpredictable which

made it difficult to plan

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1991 REALIGNMENT

1991 – Bronzan-Wright-McCorquodale Realignment Act of 1991

• Shifts authority from state to counties for mental health programs

• Three revenue sources fund Realignment ½ cent of State Sales taxState Vehicle License FeesState Vehicle License Fee Collections

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1991 REALIGNMENT

• Realignment revenues are collected by the State and distributed to counties on a monthly basis as funds are collected until each county receives funds equal to previous year’s total

• Revenues above that amount are placed into growth accounts and distributed according to a formula, as set forth in statute

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1991 REALIGNMENT

To the extent resources are available, mental health funds should be to serve the target populations:

1. Seriously emotionally disturbed children or adolescents: Minors under the age of 18 who have a DSM diagnosis other than substance use or developmental disorder which results in behavior inappropriate to the child’s age and shall meet one or more of the following:

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1991 REALIGNMENT

Self-care School functioning Family relationships, OR Ability to function in the community

AND either of the following occur

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1991 REALIGNMENT

The child is at risk of removal from the home or has already been removed

Impairments have been present for more than 6 months or are likely to continue for more than a year without treatment

OR the child displays psychotic features, risk of suicide or violence

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1991 REALIGNMENT

2. Adults with DSM diagnosis other than a substance use disorder or developmental disorder or Traumatic Brain Injury (TBI) Adult has substantial functional impairments in

independent living, social relationships, vocational skills or physical condition

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1991 REALIGNMENTTarget population adult individuals to be served (to the extent resources are available) include: Homeless persons who are mentally ill Person needing state hospital, acute inpatient

care, etc. Person arrested or convicted of crimes Person with first episode of mental illness with

psychotic features Veterans in need of mental health services

Reference: WIC 5600.3

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1991 REALIGNMENT

Services to be provided to children and adults (to the extent resources are available):• Pre-crisis and crisis• Comprehensive Evaluation and Assessment• Individual Service Plan• Medication Education and Management• Case Management• Twenty-Four Hour Treatment

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1991 REALIGNMENT

• Rehabilitation and Support Services• Vocational Rehabilitation• Residential Services• Services for Homeless Persons• Group ServicesReference: WIC 5600.4

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HISTORY

1993 – California adopts the Medicaid Rehabilitation Option to expand community mental health services (State Plan Amendment)

1995 – Medi-Cal Managed Care is implementedCalifornia institutes Medicaid Early and

Periodic Screening, Diagnosis and Treatment (EPSDT)

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EPSDT

• As part of the lawsuit (T.L. v Belshé), the state agreed to provide State General Fund to counties as the match for these expanded services

• Counties assumed responsibility for providing these services which included all of the specialty mental health services

• MHP’s to provide the SMHS to children with SED who meet medical necessity criteria

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1915(b) WAIVER1995 – Waiver approved which consolidated the Psychiatric Inpatient Hospital services provided through the Fee for Service System and the SD/MC. County mental health departments became responsible for both FFS and SD/MC psychiatric hospital systems for the first time.• All Medi-Cal beneficiaries must receive their specialty mental health

services through the county: The 1915(b) Medicaid waiver waives “freedom of choice” for the beneficiary

• This resulted in the risk for this entitlement program shifting from

the state to the counties

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HISTORY

• From 1995 through 1998, the state consolidated FFS and SD/MC programs into one “carved out” specialty mental health managed care program via a phase-in waiver process • Consolidation allowed for more flexibility in the use of

state funding by the counties and enabled more integrated and coordinated care

• Local governments must certify that the expenditures are eligible for FFP (Federal Financial Participation)

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HISTORY

1999 – Assembly Bill 34 (Steinberg) is passed for pilot programs in 3 counties for homeless mentally ill adults

2000 – Assembly Bill 2034 (Steinberg) expands the homeless mentally ill adults program

2000 – Assembly Bill 88 (Thomson) requires health plans to provide “parity” coverage for adults with specified mental illnesses and for SED children

2004 – Voters approve the Mental Health Services Act (Proposition 63)

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HISTORY

2008 – The US Mental Health Parity and Addiction Equity Act of 2008 requires group health insurance plans to offer coverage for mental illness and SUD

2010 – The Patient Protection and Affordable Care Act (ACA): Managed Care Plans to provide services to mild to moderate mental illness

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2011 REALIGNMENT

2011 – Realignment 2011

Motivating Factors:• $26 billion budget gap and expiring taxes• Federal 3 Judge Panel on prison

overcrowding• Move government closer to the people

where the services are delivered23

2011 REALIGNMENT

• Build on previous success of state-county realignment

• Realignment funding is constitutionally protected

• Funded with 1.0625 cent sales tax until 2017, state constitutionally obligated to pay equivalent thereafter

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2011 REALIGMENTOctober 1, 2011- Assembly Bill 109 – began “Public Safety” Realignment

2012 - Assembly Bill 114 (Carter) transfers responsibility for educationally related mental health services (formerly AB 3632) to county education agencies (LEAs)

November, 2012 - Constitutional Amendment - Proposition 30

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2011 REALIGNMENT• Also realigned

– Drug Medi-Cal – Women’s and Children Residential Treatment

Services and – Drug Court

• A Realignment Behavioral Health Subaccount was created, funded through sales tax revenue distributed to the counties

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DRUG MEDI-CAL REALIGNMENT

• Substance Use Disorder (SUD) Services remain the same as outlined before EXCEPT for those counties that opt-in to the recently approved Drug Medi-Cal Organized Delivery System (DMC-ODS) 1115 Demonstration Waiver

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2011 REALIGNMENT

There are no separate accounts for the realigned programs within the Behavioral Health Subaccount – all BH realigned programs must be funded through this subaccount

Realignment “superstructure” language – Created separate accounts between the

Support Services (Health and Human Services) and Law Enforcement Service Accounts

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2011 REALIGNMENT

• Any Medi-Cal beneficiary (adults and children) who meets medical necessary criteria is entitled to receive SMHS– DSM Diagnosis (with some exceptions)– Significant impairment or probability of

significant deterioration in an important area of life

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2011 REALIGNMENT

The Early and Periodic Screening, Diagnosis and Treatment (EPSDT) benefit provides comprehensive and preventive health care services for children under 21 years of age who are enrolled in Medi-Cal– access to all necessary services to “correct

or ameliorate defects, physical and mental illnesses and conditions discovered by the screening services”

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1915(b) WAIVER

Services covered under the waiver and SPA:– Outpatient (Assessment, plan development, individual

or group therapy, collateral)– Targeted Case Management– Medication Support– Day Treatment Intensive and Rehabilitative– Crisis Intervention– Crisis Stabilization– Psychiatric Hospitalization

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ADDITIONAL SERVICESFor children and youth:• Therapeutic Behavioral Services (Emily Q v

Bonta)• Intensive Care Coordination and Intensive Home

Based Services (Katie A v Bonta)• Therapeutic Foster Care – In process (Katie A v

Bonta)

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1915(b) Waiver

Applies to PIHP – Prepaid Inpatient Health Plan (PIHPs) – which means

(1) Provides medical services to enrollees under contract with the State agency;

(2) Provides, arranges for, or otherwise has responsibility for the provision of any inpatient hospital services; and

(3) Does not have a comprehensive risk contract

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1915(b) WAIVER

Waives sections of 1902 Social Security Act:– State wideness– Comparability

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2011 REALIGNMENTSection 30029.07 of Government Code regarding the Behavioral Health Subaccount:

The funds shall be allocated pursuant to schedules provided by the Department of Finance created in accordance with any criteria contained in this section and in consultation with appropriate state departments and the California State Association of Counties

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2011 REALIGNMENT

Funds distributed from the Behavioral Health Subaccount must be used to provide

Medi-Cal specialty mental health services and DMC and other drug services per Section 30025(f)(16)(B)

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2011 REALIGNMENT

Base not set yet due to changing landscape and no historical data:• Affordable Care Act• Katie A Implementation• Healthy Families Transition

(December, 2012)• Drug Medi-Cal

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2011 REALIGNMENTSince 2011 Realignment, factors applied to growth:• First call on growth is to entitlement programs to cover

prior year Medi-Cal claims • True-up of the counties over their BH Subaccount prior

year amounts• Provide a minimum of $100,000 to counties that have

not participated in DMC (FY 13/14)• Remaining 13/14 growth was distributed based on the

number of Medi-Cal beneficiaries in each county after fully funding

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GOAL FOR TODAY

IDENTIFY RELEVANT FACTORS USED TO DETERMINE THE ALLOCATION

METHODOLOGY FOR DISTRIBUTING GROWTH FUNDS

Keep in mind: Growth is variable and Counties need predictability for planning

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Please direct comments or questions to:

MHSUDStakeholderInput@dhcs.ca.gov

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