Medi-Cal: behavioral health treatment: stakeholder feedback., the official text

An act to add Section 14132.561 to the Welfare and Institutions Code, relating to Medi-Cal.

LEGISLATIVE COUNSEL'S DIGEST

Existing law provides for the Medi-Cal program, which is administered by the State Department of Health Care Services, under which qualified low-income individuals receive health care services. The Medi-Cal program is, in part, governed and funded by federal Medicaid Program provisions. Under existing law, to the extent required by the federal government and effective no sooner than required by the federal government, behavioral health treatment (BHT) is a covered service under the Medi-Cal program for individuals under 21 years of age.
This bill would require the department, on or before July 1, 2027, to ensure that certain individuals providing BHT services under Medi-Cal undergo background checks. The bill would require the department to convene a stakeholder workgroup made up of BHT providers, managed care plans, and consumers with autism, among others, to review the implementation of BHT services in Medi-Cal and to advise the department on, among other topics, clinical guidelines for the provision of BHT services, treatment plan requirements, requirements for the provision of center-based services compared to services provided elsewhere, and supervision of unlicensed and uncertified professionals, as specified. The bill would require the department, on or before January 1, 2028, to release and maintain clear clinical guidance for the provision of the BHT benefit, as specified. The bill would require the department, on or before January 1, 2029, to report to the legislature on the utilization of the BHT benefit, a synopsis of changes made as a result of the stakeholder workgroup, and recommendations for actions necessary to ensure Medi-Cal reimbursement practices align with federal Medicaid program integrity requirements.

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

SECTION 1.
Section 14132.561 is added to the Welfare and Institutions Code, to read:
14132.561.
(a) For the purposes of this section, “behavioral health treatment” or “BHT” has the same meaning as in Section 14132.56.
(b) On or before July 1, 2027, the department shall ensure that any provider of BHT services paid for by the Medi-Cal program conducts a state and national criminal background check on its employees who interact with patients, according to departmental guidance.
(c) The department shall convene a stakeholder workgroup in the first quarter of the 2027 calendar year. The workgroup shall include all of the following:
(1) BHT providers, which may include representatives of trade associations and licensing or certifying bodies, in addition to providers.
(2) Providers of other services to children with autism, including, but not limited to, speech and hearing specialists, occupational therapists, psychiatrists, and vision specialists.
(3) Managed care plans.
(4) Consumers with autism.
(5) Consumer advocates for organizations led by individuals with autism and organizations serving families of autistic children.
(6) The department may consult with the Department of Managed Health Care or invite that department to the workgroup, for the purposes of coordination with the commercial market.
(d) The stakeholder workgroup shall review the implementation of BHT services in Medi-Cal, including applied behavior analysis and other evidence-based interventions. The workgroup shall advise the department on all of the following:
(1) Clinical guidelines for the provision of BHT services, including independent clinician assessment for treatment and reauthorization requirements.
(2) Treatment plan requirements, including the number of hours in a treatment plan, documentation of an individual’s needs, and how treatment outcomes specific to the individual and the effectiveness of treatment are reviewed.
(3) Requirements for the provision of center-based services compared to services provided in the home, school, or otherwise in the child’s natural environment to ensure only services that qualify as BHT services are billed.
(4) Supervision of unlicensed and uncertified professionals, including the number of hours of supervision required, location of the supervisor, and number of unlicensed professionals a licensed or board-certified professional may supervise. Consideration shall also be given to how such supervision is monitored.
(5) Standardization of Medi-Cal managed care plan documentation requirements, including credentialing.
(6) Best practices in prioritizing quality care in contracting with BHT services providers.
(7) Feasability of requiring fingerprint-based criminal background checks of BHT service providers.
(e) The stakeholder workgroup shall meet no less than quarterly in the 2027 and 2028 calendar years. Workgroup meetings shall be open to the public and allow for public participation via comment or in writing.
(f) On or before January 1, 2028, the department shall release and maintain clear clinical guidance for the provision of the BHT benefit described in Section 14132.56. The guidance shall be consistent with federal recommendations on BHT services and Early and Periodic Screening, Diagnostic, and Treatment services for individuals under 21 years of age and shall include any modifications based on input from the stakeholder workgroup.
(g) On or before January 1, 2029, the department shall report to the Legislature and publish on its internet website, an analysis of the utilization of BHT services in California since 2014, a synopsis of changes made as a result of the stakeholder workgroup, and recommendations for statutory, regulatory, or administrative actions necessary to ensure Medi-Cal reimbursement practices align with federal Medicaid program integrity requirements. In creating this report, the department shall consider all of the following:
(1) Whether BHT services reimbursed under the Medi-Cal program meet federal Medicaid requirements governing rehabilitative services and Early and Periodic Screening, Diagnostic, and Treatment services.
(2) Whether the department and Medi-Cal managed care plans utilize uniform, publicly accessible, evidence-based clinical standards for determining medical necessity and treatment intensity.
(3) Whether reimbursed services include documented functional impairments, measurable treatment goals, and periodic assessment of clinical progress sufficient to demonstrate that services constitute therapeutic interventions covered under the Medicaid program.
(4) Whether the supervision standards for BHT services are equivalent to or greater than the supervision, observation, documentation, and clinical oversight requirements imposed on comparable health services in other allied health professions regulated under the Business and Professions Code.
(5) Whether any statutory changes are needed to require a fingerprint-based background check on BHT service providers.
(h) (1) The requirement for submitting a report imposed under subdivision (g) is inoperative on January 1, 2033, pursuant to Section 10231.5 of the Government Code.
(2) A report to be submitted pursuant to subdivision (g) shall be submitted in compliance with Section 9795 of the Government Code.
(i) 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, or make specific this section by means of all-county letters, plan letters, plan or provider bulletins, or similar instructions.