WHAT HAS CHANGED IN COMMUNITY MENTAL HEALTH SINCE PROP. 63 WAS PASSED STATE BUDGET, REORGANIZATION AND OTHER ISSUES CALSWEC BOARD MEETING Changes The question should be, what HASN’T changed since 2004 Outline How Funding Structure Has Changed www.phwiki.com


Hudson, Corey, Host has reference to this Academic Journal, PHwiki organized this Journal WHAT HAS CHANGED IN COMMUNITY MENTAL HEALTH SINCE PROP. 63 WAS PASSED STATE BUDGET, REORGANIZATION AND OTHER ISSUES CALSWEC BOARD MEETING Patricia Ryan, Executive Director, Cali as long as nia Mental Health Directors Association February 3, 2012 Changes The question should be, what HASN’T changed since 2004 Outline How Funding Structure Has Changed Federal Health Re as long as m: the Accountable Care Act of 2009 Mental Health Parity 2011 Realignment AB 109: Public Safety Realignment AB 100: Changes to the MHSA State Administration Reorganization What’s Next Questions as long as Counties in addition to CalSWEC to Ponder

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How Funding Structure Has Changed The MHSA = A Growing Percentage Statewide as long as Direct Services The MHSA = A Growing Percentage Statewide as long as Direct Services

Federal Health Re as long as m Af as long as dable Care Act of 2009: More People will be Covered Provides tax credits in addition to government subsidies as long as people (individuals, families, in addition to adults without children) with incomes 133% – 400% of the federal poverty level. Employers with 200+ employees will have to offer health benefits to all (including low-income employees). Medicaid Expansion (2014): Covers single adults up to 133 % of federal poverty Those employers with at least 50 employees will be required to pay a fine if they don’t offer health insurance (including fining waiting periods). Exp in addition to ing Coverage – Medicaid Medicaid exp in addition to ing eligibility (as of 2014) with feds picking up 100% share of cost as long as those under 65 who are at or below 133% the Federal Poverty Level This means: $14,404 individual income in addition to $29,326 family of four income. Includes an estimated 16 million new people nationally, 1/5 or more are likely to have mental illness in addition to /or substance use disorder service needs. The Congressional Budget Office estimates almost a quarter of Americans who lack health insurance today will be covered under Medicaid over the next 10 years.

CA’s 1115(b) Waiver Cali as long as nia has received approval as long as a new 5-year Medicaid waiver (2010-2015) as a “bridge to federal re as long as m” The new waiver began in November in addition to will be implemented over the course of 2011 in addition to throughout the demonstration period. Under the “Managed Care Expansion (MCE)” provision, counties may provide the match to exp in addition to coverage to individuals up to 133% of federal poverty be as long as e 2014 in addition to receive 50% federal matching dollars. It is optional as long as counties to participate, in addition to they may set their own eligibility level ( as long as example, all eligible individuals up to 100% of FPL). If savings are achieved & milestones met, it could bring as much as $10B in new federal funds to support exp in addition to ed coverage, access to care, improvements in health care delivery. Minimum MH Benefits Required in 1115(b) Waiver For MCE enrollees (under 133% of FPL), each participating county must provide the following minimum package of mental health benefits: Up to 10 days per year of acute inpatient hospitalization in an acute care hospital, psychiatric hospital, or psychiatric health facility. Psychiatric pharmaceuticals. Up to 12 outpatient encounters per year. Outpatient encounters include assessment, individual or group therapy, crisis intervention, medication support in addition to assessment. If a medically necessary need to extend treatment to an enrollee exists, the plan can optionally exp in addition to the service(s). Substance Use Services are Optional in MCEs. Federal MH/SA Parity

Mental Health & Substance Use Coverage – Parity MH & SU Services must be provided at parity with general healthcare services. This prohibits discrimination of MH/SU against medical/surgical coverage. “Parity” means: Coverage restrictions cannot differ from medical or surgical coverage charges (copayments, deductibles, etc) Lifetime limits/costs must be the same Limits on treatment (number of doctor visits or hospital days covered) must be the same. Parity is included within a range of areas: Large Employers – Parity Act Medicaid – Parity Act in addition to Health Care Re as long as m Legislation Health Insurance Exchanges as long as Individual in addition to Small Group Policies – Health Care Re as long as m Legislation Medicare – Medicare Improvements Act (MIPPA) “Decisions are best made closer to the people, not in Sacramento by those who have the direct knowledge in addition to interest to ensure that local needs are met in the most sensible way.” – Governor Jerry Brown 2011 Realignment 2011 Realignment The primary vehicle as long as 2011 Public Safety Realignment is AB 118, which creates the account structure in addition to initial allocations. Funding Source (~$5.5 billion/year) 1.0625% of existing sales tax revenue Continuously appropriated to counties Account Structure as long as FY 2011-12 at state in addition to county levels Eight accounts, nine subaccounts One account is a “Mental Health Account”

Programs Realigned to Counties Court Security Local Public Safety Subventions Local Jurisdiction of Lowerlevel Offenders in addition to Parole Violators Adult Parole Foster Care, Child Welfare Services, Adoptions Assistance Program, Child Abuse Prevention Adult Protective Services Community Mental Health EPSDT MH Managed Care 1991 MH Realignment Substance Use Treatment Women in addition to Children’s Residential Treatment Services Drug Court Nondrug MediCal Substance Abuse Treatment Services Drug MediCal Not realigned until 2012-13 Realignment Funding as long as Mental Health Since AB 100 diverted MHSA funding in 2011-12, Medi-Cal Specialty Mental Health not realigned until 2012-13. Only the funding source as long as 1991 community mental health realignment changed. Funds will be deposited monthly. New FY 2012-13 Proposed Baseline Allocations as long as Realigned Mental Health Programs In total, reduced by $34.9 M in new figures. Critical to determine adequacy of baseline figures. EPSDT impacted by Katie A., Healthy Families proposal.

AB 109: Public Safety Realignment Effective October 1, 2011. Statewide $354.3 million available in FY 2011-12 as long as two components: Local custody, alternative custody, in addition to alternative supervision services as long as new adult offenders that are either non-violent, non-serious, or non-sex offenders. Post-release community supervision as long as adults paroled out of state prison (excluding violent, serious, 3rd strike, high risk sex offenders). Public Safety Realignment from the County Behavioral Health Perspective County mental/behavioral health directors are in the midst of working at the local level with their probation departments in developing their Community Corrections Partnership Plans pursuant to AB 109 – the public safety realignment of low level parolees from the state to the local level. The state provided funding as long as these parolees, in addition to counties must determine how to make the best in addition to most cost-effective use of the limited funding to help limit avoid recidivism. Many of these parolees have mental health issues in addition to /or substance use disorders that require treatment. AB 100: MHSA Changes

AB 100: MHSA Changes Deleted requirement that the Department of Mental Health (DMH) in addition to the Mental Health Services Oversight in addition to Accountability Commission (MHSOAC) annually review in addition to approve county plans in addition to updates. Deleted requirement that a county annually update the 3-year plan but still required that there be updates. Specified that the “state” instead of DMH will administer the Mental Health Services Fund (MHSF), in addition to issue regulations. Required that starting July 1, 2012 the Controller shall distribute on a monthly basis to counties all unexpended in addition to unreserved funds on deposit in the MHSF as of the last day of the prior month. Specifies that “unreserved funds” are those funds that are not held in trust or are not set as long as th in component allocations. AB 100: MHSA Changes Reduced the state administrative funds reserved as long as DMH, MHSOAC, Cali as long as nia Mental Health Planning Council (CMHPC) in addition to other state agencies from five percent (5%) to three in addition to half percent (3.5%). Provided as long as a one time (2011-12) transfer of $862M from the MHSF, which is not subject to repayment, to be distributed in the following order: $183,600,000 as long as Medi-Cal Specialty Mental Health Managed Care; $98,586,000 as long as mental health services as long as special education pupils ( as long as merly referred to as AB 3632); $579,000,000 as long as Early in addition to Periodic Screening, Diagnosis in addition to Treatment (EPSDT). AB 102: Transfer of Medi-Cal Specialty MH/SU Administration Legislative Intent in AB 102 Improve access to culturally appropriate services Effectively integrate financing of services Improve state accountability in addition to outcomes Provide focused, high- level leadership as long as behavioral health

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Other State Administration Reorganization Proposals DMH Functions Transferred to DHCS MHSA state level issue resolution Suicide prevention Stigma in addition to discrimination Student Mental Health Initiative MHSA housing Training contracts Financial oversight County data collection, reporting Certification, compliance, quality improvement Co-occurring disorders Veterans mental health SAMHSA, PATH grants CA Health Interview Survey MH Planning Council MHSA-Specific Functions Other Functions DMH Functions Proposed to be Transferred to Other Departments/Organizations OSHPD: MHSA WET Regional Partnerships, CalSWEC Stipend Program, Statewide Technical Assistance Center (Working Well Together Collaborative), Psychiatric Residency Program Department of Public Health: MHSA Reducing Disparities Project, Other Cultural Competency Functions; MH Facilities Licensing MHSOAC: Client in addition to Family Member Contracts

What’s Next Questions as long as Counties to Ponder What is the role of the counties with HCR, parity in addition to the 1115 waiver in the context of realignment Will HCR require a change in county structures How will HCR, parity, realignment in addition to the 1115 waiver impact our system’s capacity to provide mental health in addition to substance use services How will MH/SU advocates ensure that sufficient resources in addition to progressive models of service remain available as long as the populations that we serve How can we both protect MHSA resources, in addition to use them strategically to create in addition to maintain the best community-based, recovery-oriented mental health system possible in the context of all of this change Exp in addition to ing County Responsibilities in addition to Maximizing Leadership Counties are providing services during a historic change to the structure in addition to function of state in addition to local government. Local programs will now lead the development in addition to implementation of services resulting from healthcare re as long as m, public safety realignment, economic restructuring etc., They (counties) must take charge of their own destiny in addition to develop new relationships among themselves (e.g., regional partnerships), the state in addition to other relevant partners. CalSWEC Leadership Must Consider How counties in addition to educational programs will meet growing behavioral work as long as ce development in addition to training needs What is CalSWEC’s role Will CalSWEC work with MSW programs in addition to employers to prepare qualified students who are work ready in future integrated health/behavioral health settings brought about by Health Care Re as long as m Can MSW programs become integrated, linking Title IVE services with mental health services, especially in the context of the Katie A. settlement How MSW programs will pay more attention to new proactive models that address adult in addition to juvenile justice, substance use/co-occurring disorder populations, cross disability populations, prevention in addition to early intervention, etc.

Recommendations Become organizationally in as long as med of the changing governance in addition to financing occurring statewide. CalSWEC must communicate sustainability, through long term strategies that recognize the new roles of county mental health, DHCS, CalSWEC, CalMHSA, OSHPD or others. Work more closely with county mental/behavioral health in addition to provider organizations to identify local work as long as ce, education, in addition to training needs to ensure quality among graduates in addition to maintain credibility among employers. Recognize in addition to teach new proactive models that are emerging , such as integrated healthcare, collaborations between child welfare in addition to mental health, local criminal justice in addition to substance use/co-occurring populations. Develop a stronger MSW curricula focus on management practice in addition to policy, e.g., funding as long as MH/SU services. An area of potential mutual interest in addition to partnering opportunities is documenting the positive outcomes of MHSA WET Funds.

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