MENTAL HEALTH SERVICES

Clayton Chau, MD, PhDRegional Executive Medical Director,

Institute for Mental Health & Wellness, Providence St Joseph Health

Southern CA Region

Associate Clinical Professor of Psychiatry, UCI Medical School

Clayton.Chau@stjoe.org

In any given year, about 5%-7% of adults and 5%-9% of children have a serious mental illness (22-23% diagnosable MI, 6% addiction)

MIs are the leading cause of disability in the U.S. and Canada for ages 15-44

1 in 5 adults have a mental health condition. That’s over 40 million Americans, more than the populations of New York and Florida combined

Rates of youth depression increase to 12.5% in 2015 from 8.5% in 2011

Even with severe depression, 80% youth are left with no or insufficient treatment

56% of American adults with a mental illness DID NOT receive treatment; and, only a third of those received treatments received adequate treatments

Mental health conditions have risen up to the most costly and disabling condition in the US since 2013 compared to the second behind heart diseases in 2009.

FACTS

U.S. health care spending grew 5.8% in 2015, reaching $3.2 trillion or $9,990 per person. As a share of the nation's Gross Domestic Product, health spending accounted for 17.8%.

However, only 7.6% was spent on mental health and substance use disorders

The faster growth experienced in 2014 was primarily due to the major coverage expansions under the Affordable Care Act, particularly for Medicaid and private health insurance

Hospital Care (32% share): Spending for hospital care increased 5.6% to $1 trillion in 2015 compared to 4.6% growth in 2014. The faster growth in 2015 was influenced by the continued growth of non-price factors, such as the use and intensity of services

Physician and Clinical Services (20% share): Spending on physician and clinical services increased 6.3% in 2015 to $634.9 billion from 4.8% growth in 2014.

Other Professional Services (3% share): Spending for other professional services reached $87.7 billion in 2015, an increase of 5.9%, which is an acceleration from of 5.1% in 2014. Spending in this category includes establishments of independent health practitioners (except physicians and dentists) that primarily provide services such as physical therapy, optometry, podiatry, or chiropractic medicine

Dental Services (4% share): Spending for dental services increased 4.2% in 2015 to $117.5 billion, faster than in 2014 when growth was 2.4%

Other Health, Residential, and Personal Care Services (5% share): Spending for other health, residential, and personal care services grew 7.8% in 2015 to $163.3 billion after increasing 5% in 2014. This category includes expenditures for medical services that are generally delivered by providers in non-traditional settings such as schools, community centers, and the workplace; as well as by ambulance providers and residential mental health and substance abuse facilities

Home Health Care (3% share): Spending growth for freestanding home health care agencies accelerated in 2015, increasing 6.3% to $88.8 billion following growth of 4.5% in 2014. The faster growth in 2014 was attributable to increased spending by the two largest payers of home health, Medicare, with growth of 2.6%, and Medicaid, with growth of 6%. Combined, both payers of home health care represented 76% of total home health spending

Nursing Care Facilities and Continuing Care Retirement Communities (5% share): Spending for freestanding nursing care facilities and continuing care retirement communities increased 2.7% in 2015 to $156.8 billion, an acceleration from growth of 2.3% in 2014. The faster growth in 2015 was due to the increased spending in Medicare of 5.6% vs 2.5% in 2014

Prescription Drugs (10% share): Retail prescription drug spending decelerated in 2015, growing 9% to $324.6 billion compared to the 12.4% growth in 2014. The growth in 2015 is attributed to the increased spending on new medicines, price growth for existing brand name drugs, increased spending on generics, and fewer expensive blockbuster drugs going off-patent

Durable Medical Equipment (2% share): Retail spending for durable medical equipment reached $48.5 billion in 2015 and increased 3.9%, slightly faster than the 3.5% growth in 2014. This includes items such as contact lenses, eyeglasses and hearing aids

Other Non-durable Medical Products (2% share): Retail spending for other non-durable medical products, such as over-the-counter medicines, medical instruments, and surgical dressings, grew 3.7% to $59 billion in 2015.

Medicare (20% share): Medicare spending grew 4.5% to $646.2 billion in 2015, a slight deceleration from 4.8% growth in 2014. This slightly slower growth in 2015 was largely attributable to slower growth in Medicare enrollment.

Medicaid (17% share): Total Medicaid spending slowed slightly to 9.7% in 2015, but continued the strong growth that began in 2014 at 11.6%. State and local Medicaid expenditures only grew 4.9% while federal Medicaid expenditures increased 12.6% in 2015. The increased spending by the federal government was largely driven by the newly eligible enrollees under the ACA, which were fully financed by the federal government

Private Health Insurance (33% share): Total private health insurance expenditures increased 7.2% to $1.1 trillion in 2015, faster than the 5.8% growth in 2014. The acceleration in 2015 was driven by increased enrollment and strong growth in benefit spending.

Out-of-Pocket (11% share): Out-of-pocket spending grew 2.6% in 2015 to $338.1 billion which was slightly faster than annual growth of 1.4% in 2014. The increase in 2015 was influenced by the expansion of insurance coverage and the corresponding drop in the number of individuals without health insurance

1700’s – Family’s, poor houses, jails

1840’s – First wave of public hospital development

1880’s – Second wave of state hospital development shifts cost and responsibility to state level

1920 & 1930’s – Departure of syphilitics and epileptics

Post World War II – Mental illness begin to depart to community

1950’s – Arrival of effective antipsychotics and antidepressants; state hospitals develop outpatient medication clinics; arrival of child guidance movement; Eisenhower’s Commission on Mental Illness and Health (1955)

1960’s – Medicaid/medicare shift many cost to the Fed; persons with dementia (and many MI) depart to nursing homes; growth of general and private acute inpatient; growth of outpatient; Community Mental Health Center (CMHC) movement and Fed grants

1970’s – Institute for Mental Disease (IMD) exclusion exemptions; commitment limited to dangerousness; harsher drug laws increased number of MI in jail and prisons; First Presidential Report on Mental Health

1980’s – IMD exclusion exemption for facilities of less than 16 beds; Fed block grants CMHC funds to state; states retarget CMHCs to SMI; states take advantage of DSH (disproportional shared hospitals) to shift costs to Fed

1990’s – Medicaid waivers allow states to increase fed share of funding; behavioral managed care causes loss of private sector inpatient

2000 – Second Presidential Commission on Mental Health (2002)

Creation of NIMH: 1946

Eisenhower Commission on Mental Illness and Health: 1955

Action for MH Deinstutionalization

CMHC Construction Act of 1963 (Community Mental Health Act)

Bush President’s New Freedom Commission on Mental Health: 2002

Fragmentation and gaps in care for children

Fragmentation and gaps in care for adults with serious mental illnesses

High unemployment and disability for people with serious mental illnesses (MI)

Lack of care for older adults with MI

Lack of national priority for mental health and suicide prevention

The National Mental Health Act of 1946 created the NIMH (National Institute of Mental Health) and increased appropriations for therapy and research

Deinstitutionalization which began in the late 1950s was ushered in by President JFK as the result from the Action for Mental Health Report in 1961

Community Mental Health Centers Act in 1963 started the construction of community mental health centers

One unfortunate result is the numerous homeless, mental ill people (33%, range from 15-70%) who would once have lived in state institutions but are now left to the understaffed, financially limited, and often grossly inadequate public health services

Barriers: Civil Commitment laws and the right to (refuse) treatment

Address mental health with the same urgency as physical health

Align relevant Federal programs (ie housing, training, quality employment) to improve access and accountability for mental health services

Create a Comprehensive State Mental Health Plan

www.mentalhealthcommission.gov/reports/FinalReport

2008 - MH and SA Parity Act

2009 – Economic Crisis

2009 – HIT Act

2010 – Health Care Reform

Severely curtails ability of Insurance plans to use segmentation and avoidance of risk as a business strategy

Severely curtails limited forms of coverage Standardizes Benefit packages Standardizes and improves affordability of

coverage Standardizes information and formatting for

billing Improves transparency and comparability of

coverage Expands parity of coverage for Mental illness and

Substance abuse

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Data Driven Care

Population Management

Integration of Behavioral Healthcare and general Healthcare

Increase use of Preventive care

Increase access to Primary care

Health Information Technology interoperability stds

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Bundled Payments

Global Payments

Pay for Performance

Accountable Care Organizations (ACOs)

Reduces Hospital Payments

Increases Primary Care and Preventive care payments

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$6.3 Billion bill, signed into law on Dec 13, 2016; with 3 arms: Discovery – $4.8 B to NIH to research genetic, lifestyle and environmental diseases,

to support Joe Biden’s “Cancer Moonshot” initiative to speed research for a cure, and to invest more funds in the Brain Research through Advancing Innovative Neurotechnologies (BRAIN) initiative to investigate diseases like Alzheimer’s

Development – advancing new therapies for patients through many avenues

Modernizing clinical trials and involving patients in the regulatory review process

Streamlining regulations

Providing more clarity and consistency for developers of health software and medical apps

Incentivizing drug development for childhood diseases

Allowing the FDA to use flexible measures when reviewing breakthrough technologies

Delivery – making sure that anything gained in the Discovery and Development branches is available to patients when they want and need it

Incorporated the Helping Families in Mental Health Crisis Act, first introduced by then Congressman Tim Murphy (R-Pa), to improve mental health system of care, improve parity and address the opioid epidemic

Authorized by the 21st Century Cures Act

Seeks to enhance coordination across federal agencies to improve service access and delivery of care for adults with Severe Mental Illnesses (SMIs) and children with Severe Emotional Disorders (SEDs)

Its charge:◦ Report on advances in research on SMI and SED related to prevention, diagnosis,

intervention, treatment and recovery, and access to services and supports;

◦ Evaluate the effect federal programs related to SMI and SED have on public health, including outcomes across a number of important dimensions; and

◦ Make specific recommendations for actions that federal departments can take to better coordinate the administration of mental health services for adults with SMIs and children with SEDs

Psychiatric hospitals: VA, state and county, and private

Psychiatric units of private hospitals

Residential treatment centers for emotionally disturbed children

Federally funded community mental health centers

Independent psychiatric outpatient clinics

Private practice psychiatrists (5%) Private practice psychologists and therapists

(LCSWs and MFTs)

Approximately 75% of privately insured receive mental health services under some form of manage care

Medi-Cal and Medicare transferred services to HMOs

Cost control by tightening criteria defining medical necessity for mental health services

Discounted fees or case rates or capitation

Mental Health Parity Act of 1996

◦ Federal law addressing annual/aggregate lifetime dollar limits

Mental Health Parity Act of 1999

◦ California law requiring private insurers to cover treatment of specific severe mental illnesses under the same terms and conditions applied to treatments of other illnesses

Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act (MHPAEA) of 2008

◦ Expands the scope of MH parity requirements at the federal level and includes SUD

With the MHPAEA, Congress eliminated discriminatory co-payments in Medicare

Up until 07/08 medicare beneficiaries pay 20 percent of the government-approved amount for most doctors' services but 50 percent for outpatient mental health services

With this new law, the co-payment for mental health care has gradually reduced to 20 percent over six years

Signed into law by President Barack Obama in March 2010, the ACA is projected to extend insurance coverage to more than 30 million Americans through 2019

On September 23, 2010, a number of key provisions kicked in. Insurers, for example, are no longer able to rescind an individual's coverage if he or she becomes ill. Neither are they able to deny coverage to children with preexisting conditions. And young adults are now able to stay on their parents' plan until age 26 years

In the first 3 months of 2016, 27.3 million (8.6%) persons of all ages were uninsured at the time of interview—1.3 million fewer persons than in 2015 and 21.3 million fewer persons than in 2010.

In the first 3 months of 2016, among adults aged 18–64, 11.9% were uninsured at the time of interview, 19.5% had public coverage, and 70.2% had private health insurance coverage.

In the first 3 months of 2016, among children aged 0–17 years, 5.0% were uninsured, 42.1% had public coverage, and 54.9% had private coverage.

In 2012, the Supreme Court gave states the right to opt out of the expansion

The biggest winners from the law include people between the ages of 18 and 34, African Americans, Hispanics, and people who live in rural areas

The share of the California population ages 18 to 64 enrolled in Medi-Cal rose 52%

Kaiser Family Foundation estimated that 4.7 million previously uninsured Californians now have health care coverage as of March 2016. The Commonwealth Fund recently estimated that California’s uninsured rate has dropped from 22 percent to 8 percent

Allows states to expand Medicaid to new populations◦ Example: Low-income adults with no dependent

children◦ Federal government picks up 100% of costs for first

three years; reduced to 90% by 2020

Individual Mandate◦ Penalty for being uninsured — $695 per adult; max of

$2,085 per family

Provides subsidies (tax credits) to purchase coverage through health benefits exchange

◦ 138% to 400% of the Federal Poverty Level (FPL)

• Medicaid is called Medi-Cal in California

• About 11.9 million covered currently in CaliforniaChildren under 5 with family income up to 133% FPL

Children 6–18 with family income up to 100% FPL

Parents with income up to 106% FPL

• Approximately 4.7 million have been newly eligible

Mandatory: Existing aid categories up to 138% FPL (includes 5% income disregard)

Optional: Adults under 65 without dependent children

Legal Status Program Eligibility

Lawful Permanent Residents (LPR) who have resided in U.S. for at least 5 years

•Full-scope Medi-Cal with federal match•Subsidies to purchase coverage in the exchange

LPRs < 5 years •Subsidies to purchase coverage in the exchange

Legal immigrant children and pregnant women in 5-year waiting period

•Full-scope Medi-Cal

Permanent Residents Under Cover of Law (PRUCOL)

•Full-scope Medi-Cal without a federal match

Undocumented immigrants •Full scope Medi-Cal for individuals 19 or younger started on May 1, 2016•Ineligible to purchase coverage through exchanges, even if entirely with their own money

Guaranteed Issue: Plans are required to cover anyone who applies, regardless of health history or pre-existing conditions. Premiums will vary by age, smoking status, geography

One-Stop Shopping: Consumers will be able to compare, select and enroll in coverage more easily

◦ All health plans that participate in the exchange must offer a standard set of defined essential health benefits for each level of coverage (i.e., the “metals” — see next slide)

◦ Web portal will help shoppers compare plans and enroll electronically

The ACA creates a coverage mandate for mental health and substance use disorder (MH/SUD) services, including behavioral health treatment services, as one of the 10 required Essential Health Benefits categories

The ACA mandates parity between behavioral health and physical health benchmark coverage

◦ Treatment limitations and financial requirements may not be more restrictive than those imposed on other medical/surgical benefits

California selected the Kaiser small group product as the “benchmark” plan

Benchmark plan Evidence of Coverage (EOC) includes:◦ Services and benefits for a broad range of mental

health conditions, using the mental disorder definition as supplied by the DSM-IV-TR

Coverage is not limited to a specific list of conditions or diagnoses

CALIFORNIAA Historical Perspective

The Short-Doyle Act was designed to organize and finance community mental health services for persons with mental illness through locally administered and locally controlled community health programs.

This basic structure was reaffirmed through the Bronzan-McCorquodale Act of 1991, also known as program realignment.

Individuals served by the public mental health system are persons with serious mental illness including children and adolescents with severe emotional disturbance, and adults and older adults with serious and persistent mental illness.

In addition, persons who require, or are at risk of requiring, acute psychiatric treatment because of a mental disorder with symptoms of psychosis, suicidality, violence or substantial deterioration are provided services.

However, the state failed to distribute the full savings achieved through the closures of state hospitals to the community mental health system

Unlike services to persons with developmental disabilities, the mental health system was never conceived as an “entitlement”

Mental health services were to be provided “to the extent resources are available”

This essential difference built rationing of services into the framework of mental health service delivery

Specifies a number of rights and protections, including civil commitments procedures for mental health clients. The stated purposes of the Act include:

To end the inappropriate, indefinite, and involuntary commitment of mentally disordered persons, developmentally disabled persons and persons impaired by chronic alcoholism, and to eliminate legal disabilities

To provide prompt evaluation and treatment of persons with serious mental disorders or impaired by chronic alcoholism

To guarantee and protect public interest To safeguard individual rights through judicial review To provide individualized treatment, supervision, and placement

services by a conservatorship program for gravely disabled persons To encourage the full use of all existing agencies, professional

personnel and public funds to accomplish these objectives and to prevent duplication of services and unnecessary expenditures

To protect mentally disordered persons and developmentally disabled persons from criminal acts.

realignment of fundings from state to country for mental health programs

Reaffirm the Short-Doyle Act

Directed by realignment, public mental health services are funded by a dedicated portion of state sales tax dollars (0.5 cent) and vehicle licensing fees collected by the state and distributed to counties.

This money is used, in part, as local matching funds for the Short-Doyle Medi-Cal program.

The counties also receive funds from Medicare and other third party payers.

County funds are also contributed to the mental health budget.

All community-based mental health services

State hospital services for civil commitments

“Institutions for Mental Disease” which provided long-term nursing facility care

Annually, Realignment revenues are distributed to counties on a monthly basis until each county receives funds equal to the previous year’s total

Funds received above that amount are placed into growth accounts – Sales Tax and Vehicle Licensing Fee (VLF)

Federal Medicaid dollars currently constitute the second largest revenue source for county mental health programs, after Realignment

Short-Doyle/Medi-Cal (SD/MC) started as a pilot project in 1971, and counties were able to obtain federal funds to match their own funding to provide certain mental health services to Medi-Cal

eligible individuals

The SD/MC program offered a broader range of mental health services than those provided by the original Medi-Cal program

A Medicaid State Plan Amendment in 1993 added more services under the federal Medicaid “Rehab Option” to the scope of benefits, including:◦ Psychiatric health facility◦ Adult residential treatment◦ Crisis residential◦ Crisis intervention and stabilization◦ Intensive day treatment◦ Day rehabilitation◦ Linkage and brokerage◦ Mental health services◦ Medication support

The Rehab Option* allows services that reduce institutionalization and help persons with mental disabilities live in the community

*CMS last year proposed new rules regarding the Rehabilitation Option that may have a negative effect on California’s specialty mental health Medi-Cal system, if or when they are adopted

From 1995 through 1998, the state consolidated FFS and Short-Doyle programs into one “carved out” specialty mental health managed care program

Counties are given the “first right of refusal” for taking on this new responsibility

All Medi-Cal beneficiaries must receive their specialty mental health services through the county Mental Health Plan. Waiver has been approved until 2020

Any costs beyond that allocation for the state match for Medi-Cal specialty mental health services were to come from county Realignment revenues

In other words, the risk for this entitlement program shifted from the state to the counties…

A lawsuit against the state in the early 1990s resulted in the expansion of Medi-Cal services to Medi-Cal beneficiaries less than 21 years of age who need specialty mental health services to correct or ameliorate mental illnesses, whether or not such services are covered under the Medicaid State Plan (EPSDT)

Counties use realignment funds, county funds, federal Medicaid matching funds, and federal SAMHSA grants, including the Substance Abuse Prevention and Treatment (SAPT) block grant

Not all counties provide DMC services

Services are provided by county-contracted providers, state-direct contracted providers, or by county SUD program providers

The state does not track county funds used to support non-Medi-Cal local SUD programs

2011 Public Safety Realignment – the State retains the responsibility to certify and monitor SUD services, while counties must use realignment funds to pay for those services, including providing the State’s match to federal Medicaid funds

Medi-Cal benefit expansion

Drug Medi-Cal Organized Delivery System waiver –approved in August 2015. County can opt in; must create a single point of entry; full spectrum of services; and, short-term residential SUD treatment in facilities of any size

California is the first state in the country to receive federal approval of an Organized Delivery System waiver (5 years)

Source: 1% of income over $1 million

Funds used to expand, not supplant services

Community Services and Supports to children, transitional age youth, adults and older adults (AB 989, 2011, expands to transitional age foster youth

Housing

Capital facilities and technology

Workforce education and training

Prevention and early intervention (first effort)

Innovative programs

Realignment Revenues

Medi-Cal Specialty Mental Health Managed Care Allocation

Medi-Cal Early and Periodic Screening, Diagnosis and Treatment (expansion of Medi-Cal age limit to 21 in 1996)

Federal funding (SAMHSA)

Mental Health Services Act

Tobacco Settlement Revenues

Requires county mental health departments to provide services to veterans, to the extent that those services are available to other adults and to the extent that resources are available

Added combat related PTSD to target population criteria

Starting 01/01/10, requires Medi-Cal benefits provided to an individual under 21 years of age who is an inmate of a public institution to be suspended, rather than terminated

Would require county offices to establish protocols for communication within 10 days

If the court finds that the defendant's crime was committed as a result of sexual trauma, traumatic brain injury, post-traumatic stress disorder, substance abuse, or mental health problems stemming from military service in the United States military (used to be ‘combat related’), and the court places the person on probation, existing law authorizes the court to place the person into a treatment program, and provides that the defendant receives sentence credits for residential treatment

The bill would authorize the court to request, through existing resources, an assessment to aid in the determination of whether the defendant may be suffering from any of those disorders

Elimination of Dept of Mental Health and Alcohol & Drug Program

Transition of Medi-Cal state administrative functions from DMH and ADP to DHCS in 07/01/12 (AB-102, Health Trailer Bill)

The effectiveness of this combined function under DHCS remains to be seen

CA State Legislature from state government to counties and other local governments the responsibility for providing a number of public services (foster care, child welfare, adoptions assistance, adult protective services, child abuse prevention/intervention/treatment, CalWORKs aid payments)

Law enforcement and public safety services (AB-109: local custody, alternative custody, and alternative supervision services for new adult offenders that are non-violent/non-serious/non-sex offenders; post-release community supervision for adults paroled out of state prison into probation (excluding violent, serious, 3rd

strike, high risk sex offenders))

Care for abused and neglected seniors and children

Mental health and substance abuse recovery programs

Monitoring and detaining specified felony offenders

Became effective on January 1, 2014. Scope is all uninsured adults above 133 percent of poverty (plus discounted 5 percent of income).

To date, 29 states are have expanded Medicaid

Some include non-traditional models such as Medicaid premium support.

Section 29: Adds additional mental health and substance use disorder services benefits for both existing and expansion Medi-Cal populations. Benefits to be consistent with the statewide Essential Health Benefits.

Section 30: Requires Medi-Cal Managed Care plans to provide the added mental health benefits covered in the state plan, excluding those benefits that are already provided by county mental health plans.

Effective since January 1, 2014

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Behavioral Health in Medi-Cal

Updated 1/1/2017

Target Population: Children and adults in Managed Care Plans who meet medical necessity or EPSDT for Mental Health Services

Target Population: Children and adults in Managed Care Plans who meet medical necessity or EPSDT for Mental Health Services

Individual/group mental health evaluation and treatment (Psychotherapy)

Psychological testing when clinically indicated to evaluate a mental health condition

Psychiatric consultation Outpatient services for the

purposes of monitoring medication treatment

Outpatient laboratory, supplies and supplements

Behavioral Health Treatment for individuals under age 21 with Autistic Spectrum Disorders

Routine Screening for Emotional Health and substance misuse

Outpatient Medication and Monitoring for Mental Health Treatment and Medication Assisted Treatment (MAT) for Substance Use Disorders

Brief Counseling/Support/ Education

Screening, Brief Intervention and Referral for Treatment (SBIRT) for Alcohol

Coordinate and link to Regional Centers for Comprehensive Diagnostic Evaluation

Target Population: Children and adults who meet medical necessity or EPSDT criteria for Medi-Cal Specialty Mental Health Services

Mental Health Services (Assessments, Plan Development, Therapy, Rehabilitation & Collateral)

Medication Support Day Treatment Services & Day

Rehabilitation Crisis Intervention & Crisis

Stabilization Targeted Case Management Therapeutic Behavior Services

Residential Services Adult Residential Treatment

Services Crisis Residential Treatment

Services

Inpatient Services Acute Psychiatric Inpatient

Hospital Services Psychiatric Inpatient Hospital

Professional Services Psychiatric Health Facility

services

Target Population: Children and adults who meet medical necessity or EPSDT criteria for Drug Medi-Cal Substance Use Disorder Services

Outpatient Drug Free Intensive Outpatient * Narcotic Treatment Program Naltrexone

Residential Services: Pregnant and Postpartum Women only

*Benefit expanded to all populations

Inpatient Services (Fee-For-Service)

Voluntary Inpatient Detoxification Services (newly expanded with NO restriction for physical medical necessity)

- -

• Effective since January 1, 2014

• Also known as the CHFFA funds (California Health Facilities Financing Authority)

• Expand access to early intervention and treatment services to improve the client

experience, achieve recovery and wellness, and reduce costs

• Expand and add to the continuum of services to address crisis intervention, crisis

stabilization, and crisis residential treatment needs that are wellness, resiliency and

recovery oriented

• Add triage personnel to provide intensive case management and linkage to

services

• One time fund

SB82 – Investment in Mental Health

Wellness Act of 2013

Added Behavioral Health Therapy, including Applied Behavior Analysis, to Medi-Cal for age 0-21 since 07/07/14◦ Responsibility has been given to the managed care health plan since 09/15/14

◦ All other insurances have been covering this services since 07/01/12 based on SB 956/126

◦ Regional Centers have been providing this service up until now for individuals with Medi-Cal

◦ Issues:

Age limitation

Change in DSM 5 diagnosis category

Transition from Regional Centers to health plans – completed July 2016

Shortage of Qualified Autism Service Provider and Professional

Utilization of Qualified Autism Service Paraprofessional

Drug Medi-Cal Organized Delivery Systemo Increase services for SUD

o Mirroring the specialty mental health services

o There will still be silos

o Rate setting issues

o Provider network issues