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AB-1470 Medi-Cal: behavioral health services: documentation standards.(2023-2024)



Current Version: 08/19/24 - Enrolled

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AB1470:v95#DOCUMENT

Enrolled  August 19, 2024
Passed  IN  Senate  September 12, 2023
Passed  IN  Assembly  August 15, 2024
Amended  IN  Senate  July 03, 2023
Amended  IN  Assembly  April 27, 2023
Amended  IN  Assembly  March 23, 2023

CALIFORNIA LEGISLATURE— 2023–2024 REGULAR SESSION

Assembly Bill
No. 1470

Introduced by Assembly Member Quirk-Silva

February 17, 2023

An act to amend Section 14184.402 of, and to add Section 14184.406 to, the Welfare and Institutions Code, relating to Medi-Cal.


LEGISLATIVE COUNSEL'S DIGEST


AB 1470, Quirk-Silva. Medi-Cal: behavioral health services: documentation standards.
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 behavioral health services. The Medi-Cal program is, in part, governed and funded by federal Medicaid program provisions. Existing law establishes the California Advancing and Innovating Medi-Cal (CalAIM) initiative, subject to receipt of any necessary federal approvals and the availability of federal financial participation, in order to, among other things, improve quality outcomes and reduce health disparities.
The bill, as part of CalAIM, and with respect to behavioral health services provided under the Medi-Cal program, would require the department to standardize data elements relating to documentation requirements, including, but not limited to, medically necessary criteria, and would require the department to develop standard forms containing information necessary to properly adjudicate claims pursuant to CalAIM Terms and Conditions. The bill would require the department to consult with representatives of specified associations and programs for purposes of implementing these provisions.
The bill would require the department to conduct, on or before July 1, 2025, regional trainings for personnel and provider networks of applicable entities, including county mental health plans, Medi-Cal managed care plans, and entities within the fee-for-service delivery system, on proper completion of the standard forms. The bill would require each applicable entity to distribute the training material and standard forms to its provider networks, and to commence, no later than July 1, 2025, using the standard forms. The bill would require providers of applicable entities to use those forms, as specified. The bill would authorize the department to restrict the imposition of additional documentation requirements beyond those included on standard forms, as specified.
The bill would require the department to conduct an analysis on the status of utilization of the standard forms by applicable entities, and on the status of the trainings and training material, in order to determine the effectiveness of implementation of the above-described provisions. The bill would require the department to prepare a report containing findings from the analysis no later than July 1, 2026, and a followup report no later than July 1, 2028, and to submit each report to the Legislature and post it on the department’s internet website.
Vote: MAJORITY   Appropriation: NO   Fiscal Committee: YES   Local Program: NO  

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


SECTION 1.

 (a) The Legislature finds and declares all of the following:
(1) Behavioral health providers under the Medi-Cal program report that completing paperwork requires many hours of training to properly complete, and this administrative task is a major driver of provider burnout and attrition.
(2) Moreover, the paperwork required by each county significantly varies, which means that individuals who are employed at facilities that serve populations from multiple counties must navigate many different sets of forms, and they spend even more time being trained to properly complete the paperwork.
(3) The result is that providers have less time to serve clients with behavioral health issues, and these clients are more likely to need crisis services or hospital emergency care because other community-based interventions are unavailable.
(4) California is suffering from a behavioral health provider shortage, and the state cannot afford to have its providers spend half of their time completing forms instead of providing clinical services to clients.
(b) Therefore, it is the intent of the Legislature to dramatically reduce and standardize the paperwork burden for providers of behavioral health services under the Medi-Cal program to encourage providers to serve more beneficiaries in the Medi-Cal program, to ensure eligibility and reimbursement determinations are made consistently across all counties, to provide clear guidance to counties and providers of these services about requirements imposed by federal law, and to minimize the risk of negative audit findings and retroactive disallowances that threaten county budgets.

SEC. 2.

 Section 14184.402 of the Welfare and Institutions Code is amended to read:

14184.402.
 (a) Notwithstanding any other law, including, but not limited to, the applicable provisions of Chapter 11 (commencing with Section 1810.100) of Division 1 of Title 9, and Chapter 3 (commencing with Section 51000) of Subdivision 1 of Division 3 of Title 22, of the California Code of Regulations, commencing no sooner than January 1, 2022, all medically necessary determinations for covered specialty mental health services and substance use disorder services provided by a Medi-Cal behavioral health delivery system shall be made in accordance with Section 14059.5, except as provided in this section and any written instructions issued by the department pursuant to subdivision (i) until such time that regulations are promulgated or amended.
(b) (1) Subject to subdivision (f) of Section 14184.102, the following nonspecialty mental health services shall be covered by a Medi-Cal managed care plan, or available through the Medi-Cal fee-for-service delivery system for beneficiaries not enrolled in a Medi-Cal managed care plan or for services that are carved out from a Medi-Cal managed care plan’s comprehensive risk contract:
(A) Individual and group mental health evaluation and treatment, including psychotherapy, family therapy, and dyadic services.
(B) Psychological testing, when clinically indicated to evaluate a mental health condition.
(C) Outpatient services for the purposes of monitoring drug therapy.
(D) Psychiatric consultation.
(E) Outpatient laboratory, drugs, supplies, and supplements.
(2) Covered nonspecialty mental health services for adult beneficiaries with mild-to-moderate distress or mild-to-moderate impairment of mental, emotional, or behavioral functioning resulting from mental health disorders, as defined by the current edition of the Diagnostic and Statistical Manual of Mental Disorders, shall be provided by a Medi-Cal managed care plan or through the Medi-Cal fee-for-service delivery system. A Medi-Cal managed care plan shall provide medically necessary nonspecialty mental health services to enrolled beneficiaries under 21 years of age as required pursuant to Section 1396d(r) of Title 42 of the United States Code. A Medi-Cal managed care plan shall also be responsible for providing covered nonspecialty mental health services to enrolled beneficiaries with potential mental health disorders not yet diagnosed.
(c) For enrolled beneficiaries 21 years of age or older, a county mental health plan shall provide covered specialty mental health services for beneficiaries who meet both of the following criteria:
(1) The beneficiary has one or both of the following:
(A) Significant impairment, where impairment is defined as distress, disability, or dysfunction in social, occupational, or other important activities.
(B) A reasonable probability of significant deterioration in an important area of life functioning.
(2) The beneficiary’s condition as described in paragraph (1) is due to either of the following:
(A) A diagnosed mental health disorder, according to the criteria of the current editions of the Diagnostic and Statistical Manual of Mental Disorders and the International Statistical Classification of Diseases and Related Health Problems.
(B) A suspected mental disorder that has not yet been diagnosed.
(d) For enrolled beneficiaries under 21 years of age, a county mental health plan shall provide all medically necessary specialty mental health services required pursuant to Section 1396d(r) of Title 42 of the United States Code. Covered specialty mental health services shall be provided to enrolled beneficiaries who meet either of the following criteria:
(1) The beneficiary has a condition placing them at high risk for a mental health disorder due to experiencing trauma evidenced by scoring in the high-risk range under a trauma screening tool approved by the department, involvement in the child welfare system, juvenile justice involvement, or experiencing homelessness.
(2) The beneficiary meets both of the following requirements:
(A) The beneficiary has at least one of the following:
(i) A significant impairment.
(ii) A reasonable probability of significant deterioration in an important area of life functioning.
(iii) A reasonable probability of not progressing developmentally as appropriate.
(iv) A need for specialty mental health services, regardless of presence of impairment, that are not included within the mental health benefits that a Medi-Cal managed care plan is required to provide.
(B) The beneficiary’s condition as described in subparagraph (A) is due to one of the following:
(i) A diagnosed mental health disorder, according to the criteria of the current editions of the Diagnostic and Statistical Manual of Mental Disorders and the International Statistical Classification of Diseases and Related Health Problems.
(ii) A suspected mental health disorder that has not yet been diagnosed.
(iii) Significant trauma placing the beneficiary at risk of a future mental health condition, based on the assessment of a licensed mental health professional.
(e) (1) Covered services provided under a county Drug Medi-Cal Treatment Program or a Drug Medi-Cal organized delivery system shall use criteria adopted by the American Society of Addiction Medicine to determine the appropriate level of care for substance use disorder treatment services.
(2) Covered services provided under a county Drug Medi-Cal Treatment Program or a Drug Medi-Cal organized delivery system shall include all medically necessary substance use disorder services for an individual under 21 years of age as required pursuant to Section 1396d(r) of Title 42 of the United States Code.
(3) A full assessment utilizing the criteria adopted by the American Society of Addiction Medicine shall not be required for a beneficiary to begin receiving services through a Drug Medi-Cal Treatment Program or a Drug Medi-Cal organized delivery system.
(f) (1) This section and Section 14059.5 shall not be construed to exclude coverage for, or reimbursement of, a clinically appropriate and covered mental health or substance use disorder prevention, screening, assessment, treatment, or recovery service under any of the following circumstances:
(A) Services were provided prior to determining a diagnosis.
(B) The prevention, screening, assessment, treatment, or recovery service was not included in an individual treatment plan.
(C) The treated Medi-Cal beneficiary has a co-occurring mental health condition and substance use disorder.
(D) For a provider who provides specialty mental health services to a Medi-Cal beneficiary under a contract between the department and a county mental health plan when that beneficiary concurrently receives nonspecialty mental health services from a Medi-Cal managed care plan or under the Medi-Cal fee-for-service delivery system, if those services are coordinated between the specialty and nonspecialty delivery systems and those services are not duplicative.
(E) For a provider who provides nonspecialty mental health services to a Medi-Cal beneficiary pursuant to a comprehensive risk contract with a Medi-Cal managed care plan or under the Medi-Cal fee-for-service delivery system when that beneficiary concurrently receives specialty mental health services from a county mental health plan, if those services are coordinated between the nonspecialty and specialty delivery systems and those services are not duplicative.
(2) This section and Section 14059.5 shall not be construed to exclude clinically appropriate and covered mental health or substance use disorder services during the assessment process.
(g) A dispute between a county mental health plan and a Medi-Cal managed care plan shall not delay the provision of medically necessary services by the county mental health plan or the Medi-Cal managed care plan.
(h) (1) The department shall develop, in consultation with county behavioral health directors, consumer advocates, labor organizations representing county behavioral health workers, mental health and substance use disorder treatment providers, and Medi-Cal managed care plans, standardized screening tools to guide a referral to a Medi-Cal behavioral health delivery system. The department shall develop a standardized screening tool for Medi-Cal beneficiaries who are under 21 years of age and a separate standardized screening tool for those who are 21 years of age or older. The department may require the use of these standardized screening tools by Medi-Cal behavioral health delivery systems and Medi-Cal managed care plans.
(2) The department shall develop, in consultation with county behavioral health directors, consumer advocates, labor organizations representing county behavioral health workers, mental health and substance use disorder treatment providers, and Medi-Cal managed care plans, standardized statewide transition tools to ensure that Medi-Cal beneficiaries requiring transition between delivery systems receive timely coordinated care. The department shall develop a standardized statewide transition tool for Medi-Cal beneficiaries who are under 21 years of age and a separate standardized statewide transition tool for those who are 21 years of age or older. The department may require the use of these standardized statewide transition tools.
(3) The department shall develop, in consultation with county behavioral health directors, consumer advocates, labor organizations representing county behavioral health workers, and mental health and substance use disorder treatment providers, documentation standards and changes to the department’s clinical auditing standards. The department may require the use of these documentation standards by Medi-Cal behavioral health delivery systems, including, but not limited to, restrictions developed in consultation with representatives of Medi-Cal behavioral health delivery systems on what Medi-Cal behavioral health delivery systems impose on their contract providers, consistent with Medi-Cal managed care plans and taking into account the need to ensure quality and program integrity and to address equity and disparities. Effective January 1, 2024, clinical documentation standards for use in Medi-Cal behavioral health delivery systems shall be developed in accordance with Section 14184.406.
(i) (1) Notwithstanding Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code, the department, without taking any further regulatory action, shall implement, interpret, and make specific this section and the associated CalAIM Terms and Conditions by means of all-county letters, plan letters, information notices, or similar instructions, until regulations are promulgated or amended in accordance with paragraph (2).
(2) Notwithstanding subdivision (d) of Section 14184.102, the department shall promulgate or amend regulations, as necessary, to implement, interpret, and make specific this section and the associated CalAIM Terms and Conditions in accordance with the requirements of Chapter 3.5 (commencing with Section 11340) of Part 1 of Division 3 of Title 2 of the Government Code by July 1, 2024.

SEC. 3.

 Section 14184.406 is added to the Welfare and Institutions Code, to read:

14184.406.
 (a) (1) With respect to behavioral health services provided under the Medi-Cal program, including specialty mental health services, nonspecialty mental health services, and substance use disorder services, the department shall standardize data elements relating to documentation requirements, including, but not limited to, medically necessary criteria. The department shall develop standard forms containing information necessary to properly adjudicate claims in a manner that is consistent with the implementation of this article, including subdivision (h) of Section 14184.402, as approved by the federal Centers for Medicare and Medicaid Services, pursuant to the CalAIM Terms and Conditions. The standard forms shall include forms for the intake of, assessment of, and the treatment planning for, Medi-Cal beneficiaries who are eligible for those services.
(2) For purposes of implementing this section, the department shall consult with representatives from all of the following:
(A) The County Behavioral Health Directors Association of California.
(B) The California State Association of Counties.
(C) The County Welfare Directors Association of California.
(D) Behavioral health programs in at least one small, medium, and large county.
(E) Associations that represent children’s hospitals, foster youth, parents and caregivers, community-based children’s behavioral health providers, children’s health legal advocates, providers of adult and older adult care, and providers of substance use disorder treatment.
(3) If a provider within an applicable entity serves an eligible Medi-Cal beneficiary, the department shall require that provider to use the standard forms in a manner that is consistent with the CalAIM initiative, as approved by the federal Centers for Medicare and Medicaid Services, pursuant to the CalAIM Terms and Conditions, and pursuant to the timeline described in subdivision (c).
(4) The department shall ensure that all forms developed pursuant to this section comply with the federal Medicaid program law and regulations, the CalAIM Terms and Conditions, and applicable state and federal privacy laws that govern medical information, including the Confidentiality of Medical Information Act (Part 2.6 (commencing with Section 56) of Division 1 of the Civil Code) and the federal Health Insurance Portability and Accountability Act of 1996.
(b) (1) On or before July 1, 2025, the department shall conduct regional trainings for the personnel and provider networks of applicable entities on proper completion of the standard forms, as described in paragraph (1) of subdivision (a), to ensure that those individuals receive adequate training to appropriately complete these forms.
(2) (A) Training material developed pursuant to paragraph (1) shall be made available to any applicable entities, as determined appropriate by the department, for use in local trainings.
(B) Each applicable entity shall distribute the training material, as specified in paragraph (1), and standard forms, as described in paragraph (1) of subdivision (a), to the entity’s provider networks.
(c) (1) Each applicable entity and a provider network of that entity shall utilize the standard forms developed by the department, as described in paragraph (1) of subdivision (a), for performing the intake of, assessment of, and treatment planning for, Medi-Cal beneficiaries who are eligible for behavioral health services under the Medi-Cal program.
(2) No later than July 1, 2025, each applicable entity shall commence using the standard forms described in paragraph (1).
(3) The department may restrict the imposition of additional documentation requirements beyond those requirements included on standard forms, including, but not limited to, restrictions developed in consultation with representatives of Medi-Cal behavioral health delivery systems on what Medi-Cal behavioral health delivery systems impose on their contract providers, consistent with Medi-Cal managed care plans and taking into account the need to ensure quality and program integrity and to address equity and disparities.
(d) (1) The department shall conduct an analysis on the status of utilization of the standard forms by applicable entities, as described in subdivision (c), and on the status of the trainings and training material described in subdivision (b), in order to determine the effectiveness of implementation of this section.
(2) The department shall prepare a report containing findings from the analysis described in paragraph (1) no later than July 1, 2026, and a followup report no later than July 1, 2028. The department shall submit each report to the Legislature, in accordance with Section 9795 of the Government Code, and shall post the report on the department’s internet website.
(e) For purposes of this section, the following definitions apply:
(1) “Applicable entity” means a Medi-Cal behavioral health delivery system, a Medi-Cal managed care plan, or an entity within the fee-for-service delivery system, if it provides behavioral health services under the Medi-Cal program.
(2) “Medi-Cal behavioral health delivery system” has the same meaning as set forth in Section 14184.101.
(3) For purposes of county populations, the following definitions apply:
(A) “Small county” means a county with a population of fewer than 300,000 people.
(B) “Medium county” means a county with a population of 300,000 to 700,000 people, inclusive.
(C) “Large county” means a county with a population of greater than 700,000 people.