Quality and Equity Advisory Committee (QEAC) California Department of Health Care Services 1501 Capitol Ave #6001 Sacramento, CA 95814
Re: Feedback on Performance Measures
To Whom It May Concern,
Mental Health America of California (MHAC) provides the following feedback on the Behavioral Health Transformation (BHT) Performance Measures:
Improving Access to Care, Reducing Untreated Behavioral Health Conditions, and Improving Care Experience:
Improving Care Experience
In addition to the listed performance measures, we recommend that performance measures also include the collection of data on the rates of providers and staff completing various cultural competency trainings related to race, religion, ethnicity, or sexual orientation, etc. The data should not just reflect what individuals experience but what providers and staff are doing to improve care experience.
Intervention Measures
BH-12 should be separated into 2 different measures: one for adults and one for adolescents. Parents or guardians are more likely to ensure care for their dependents than an adult is to care for themselves. The combination of the age groups has the potential skew the data.
Reducing Justice Involvement
Goal Measures
We recommend that the performance measures listed be expanded to separately measure adults and youth who are justice-involved. Justice involved youth have higher recidivism rates than adults. By separating performance measures on youth, long term behavioral healthcare strategies can be developed to reduce justice involvement at the earliest possible instance, significantly reducing recidivism as youth age into adulthood.
If you have any questions, or if MHAC can provide any assistance, please do not hesitate to contact me at kvicari@mhac.org or our Public Policy Coordinator, Danny Thirakul, at dthirakul@mhac.org.
In Community,
Karen Vicari Director of Public Policy Mental Health America of California
A-II: Mental Health America of California supports the development of the Office of Social and Behavioral Health. This office will be instrumental in supporting the distribution of funds back to community-based organizations while meeting statewide population-based prevention goals.
A-IV: Mental Health America of California supports the identified priority populations for strategic investments. With 51% of prevention funding allocated to serving youth who are 25 years or younger, it may be helpful to create a more focused priority population just within youth that may include but are not limited to foster youth, justice involved youth, LGBTQ+ youth and rural youth.
A-VI: The Focused Statewide Behavioral Health Prevention Strategic Plan highlights CalHope, CalHope Warmline, and the CalHope Redline. This section must also call out the California Peer Run Warm Line run by Mental Health Association of San Francisco. The California Peer Run Warmline ensures individuals are connected to Peers with similar socioeconomic backgrounds, aligned with the intended priority population named in the guide to be served.
A-IX: Community Engagement Funds that support Community Engagement and Coalition Building must prioritize support and accommodations to stakeholders that face significant barriers to engagement. The County Policy Manuel on the County Integrated Plan outlines allowable uses of BHSA County Planning Funds for stakeholders. CDPH should similarly provide the same support for community stakeholders engaged as members of the public in the activities of the proposed CDEP Advisory Committee, Youth and Family Engagement Network, and Implementation Workgroup. Also, we recommend that CDPH funds be used for training and support for the members of these 3 committees to ensure they are fully prepared for meaningful committee engagement.
Section B:
Mental Health America of California thanks CDPH for recognizing the importance of disaggregated data and their commitment to provide technical assistance to local partners, “ensuring that data systems are capable of capturing disparities across race, ethnicity, language, disability, sexual orientation, and other key [demographics]”
Section C:
Community-Defined Evidence Based Practices and Evidence Based Practices Grant
Program: Thank you CDPH for your focus on CDEPs. This grant program will be vital to supporting disproportionately impacted communities and establish a permanent/reliable funding source for continued investments.
Trusted Messenger Campaign Grant Program: CDPH should explore ways the program can complement efforts with HCAI’s Behavioral Health Scholarship Program for Certified Medi-Cal Peer Support Specialists. There are similarities between the job duties of a Peer Support Specialist and the proposed purpose of a “Trusted Messager.” The Trusted Messenger Campaign Grant Program may provide an avenue to complete the peer training scholarship work requirements or provide financial relief for individuals unable to complete the work requirements.
Regional Implementation of Focused Strategies: The rural north and central valley face significant access barriers and behavioral health disparities. Mental Health America of California supports the regional implementation to ensure that rural and geographically isolated areas in California will not be excluded from the Statewide Behavioral Health Prevention Strategic Plan. Supporting CBOs in these areas will be crucial to ensure successful implementation of statewide prevention strategies.
Section D:
Alignment with other local planning processes could lead to more efficiency and fewer redundancies. However, a reduction in the number of stakeholder meetings also means a higher risk of limiting stakeholder input. Mental Health America of California cautions the streamlining of these processes without careful consideration of how stakeholders, especially those with lived experience, will engage.
Under the draft guide, Local Health Jurisdictions will receive consistent funding between FY 26/27 and FY 27/28. While we support consistent funding for the first two years, If the goal is to ultimately align local planning processes, funding towards Local Health Jurisdictions should reduce over time. The leftover funds should be reallocated to increase funding for CBO grants, Statewide Prevention Strategies, and Community Engagement.
General Comments:
Thank you CDPH for a meaningful community and stakeholder engagement process. The prioritization of funds to CBO’s shows that community input was not only heard but actually considered.
LIVE (LGBTQ+ Inclusivity, Visibility, and Empowerment) should be added to the CDEPS Advisory Committee. CAYEN (California Youth Empowerment Network) should be added to the Youth and Family Engagement Network. MHAC (Mental Health America of California) should be added to CDPH’s BHSA Implementation Workgroup.
Program
CDPH Values My Perspective: Strongly Agree
The Phase 2 Guide provides answers to the questions I have about the BHSA Population based prevention Program: Somewhat Agree
Department of Health Care Services 1501 Capitol Ave #6001 Sacramento, CA 95814
RE: County Policy Manual Module #4 Feedback
To Whom It May Concern,
Mental Health America of California (MHAC) is pleased to provide the following recommendation and concern regarding the County Policy Manual:
Early Intervention Program
Background
The CA Legislature incorporated a guarantee in the Behavioral Health Services Act (BHSA) so that 51% of Early Intervention funds would serve children and youth. This guarantee was made in anticipation of the changing revenue allocations from the BHSA, to protect the vital support and services for our most vulnerable population. The proposed language in Section A.7 would allow Early Intervention Evidence Based Practices (EBPs) and Community Defined Evidence based practices (CDEPs) for parents and caregivers to count towards the 51% requirement if the service is, “for the benefit of that child/youth.”
Recommendation
DHCS must revert to the original language in Section 7A of the County Policy Manual to ensure funding for children and youth remains protected.
Justification
The proposed language serves as a loophole for counties to spend less on children and youth, reducing available services and conflicting with legislative intent. Any EBP or CDEP for parents and caregivers could be justified as a benefit. However, “for the benefit of” and “to serve” are two different things. As written in statute, “A county shall utilize at least 51 percent of the county’s funding allocated for early intervention programsto serve individuals who are 25 years of age and younger.”
Regulatory Authority
Background
California Government Code requires DHCS to adopt regulations to implement the BHSA by July 1st, 2033. Until then, DHCS is allowed to bypass the regulatory process by means of plan or county letters, information notices, plan or provider bulletins, or other similar instructions without taking further regulatory action. This would include the County Policy Manual, which covers a broad range of topics for implementation and enforcement. The Policy Manual Introduction of the County Policy Manual also states that, “the guidance in this manual will serve as regulations.”
Concern
The County Policy Manual prescribes significant rules for counties to follow. Rules such as these should follow the normal regulatory process to ensure appropriate public notice and input. Can a policy manual serve as regulations? Does DHCS intend to submit these regulations to follow the normal regulatory process by 2033? If not, the public perception of this manual may be perceived as “underground regulations” as defined by the Office of Administrative Law. Clarification on the regulatory timeline and authority regarding the implementation of the Behavioral Health Services Act would help enhance public transparency.
MHAC appreciates the opportunity to provide input and is committed to working with DHCS on the successful implementation of the BHSA. If you have any questions, or if MHAC can provide any assistance please do not hesitate to contact me at kvicari@mhac.org or our Public Policy Coordinator, Danny Thirakul, at dthirakul@mhac.org.
In Community,
Karen Vicari Director of Public Policy Mental Health America of California
The Honorable Mia Bonta Assembly Health Committee 1020 N Street, Room 390 Sacramento, CA 95814
RE: MHAC Support for Prohibiting Cost-Sharing Requirements for Children and Youth
Dear Chair Bonta,
Mental Health America of California (MHAC) is pleased to support Assembly Bill 298 (Bonta), legislation that would prohibit healthcare service plans from imposing a deductible, coinsurance, copayment, or other cost-sharing requirement for in-network services to individuals under 21 years of age.
MHAC is a peer-run organization leading the state in behavioral health public policy and advocacy since 1957. The mission of MHAC is to assist and encourage communities, families and individuals to experience hope, wellness and recovery from mental health and substance use disorder issues. The people and communities we aim to serve include those of all ages; sexual orientation, gender identity or expression; language, racial and ethnic backgrounds, national origin, and immigration status; spirituality and religious affiliations; or socioeconomic status. No one should be denied access to vital behavioral health supports and services regardless of their ability to pay.
From 2011 to 2022, expenditures for pediatric behavioral healthcare nearly doubled from 22.4% to 40.2%.[1] Simultaneously, there was an annual 6.4% increase in out-of-pocket expenditures. In 2022, 15.3% of children and youth ages 0-17 in California were living in poverty.[2] Rising healthcare costs make accessing care progressively difficult for low-income individuals and families, particularly children and youth. Co-pays, deductibles, and other cost sharing methods create significant financial barriers that prevent low-income individuals and families from even seeking care.
This bill prohibits those cost sharing methods from being levied onto children and youth under the age of 21. Without these added costs, more children and youth will be able to access care and won’t be deterred due to cost factors. With the demand for youth behavioral health services increasing, this bill will ensure our most vulnerable populations are able to seek care before experiencing a crisis.
It is for these reasons that MHAC supports AB 298 (Bonta). If you have any questions, or if MHAC can provide any assistance on this bill or any behavioral health related legislation, please do not hesitate to contact me at kvicari@mhac.org or our Public Policy Coordinator, Danny Thirakul, at dthirakul@mhac.org.
In Community,
Karen Vicari Director of Public Policy Mental Health America of California
[1] Foster AA, Cushing AM, Hoffmann JA, Nash KA, Lee C, Michelson KA. Expenditures for Pediatric Behavioral Health Care Over Time and Estimated Family Financial Burden. JAMA Pediatr. Published online December 15, 2025. doi:10.1001/jamapediatrics.2025.5181
Honorable Jesse Gabriel (Chair) Assembly Committee on Budget 1021 O Street, Suite 8230 Sacramento, CA 95814
Honorable John Laird (Chair) Senate Budget and Fiscal Review Committee 1020 N. Street, Room 502 Sacramento, CA 95814
Honorable Dawn Addis (Chair) Assembly Budget Subcommittee #1 – Health 1021 O. Street, Suite 4120 Sacramento, CA 95814
Honorable Caroline Menjivar (Chair) Senate Budget Subcommittee #3 – Health and Human Services 1021 O Street, Suite 6630 Sacramento, CA 95814
Honorable Mia Bonta Assembly Budget Subcommittee #1 – Health 1020 N. Street, Suite 390 Sacramento, CA 95814
Honorable Akilah Weber Senate Budget Subcommittee #3 – Health and Human Services 1021 O Street, Suite 7310 Sacramento, CA 95814
Honorable Pilar Schiavo Assembly Budget Subcommittee #1 – Health 1021 O. Street, Suite 4140 Sacramento, CA 95814
Re: Opposition to FY26-27 Budget Proposal to Eliminate the Statewide Medi-Cal Mobile Crisis Benefit & Request to Fully Fund the CalHope/California Peer-Run Warm Line
Dear Budget Subcommittee Chairs and Members,
While we recognize that California is facing a budget deficit, the Governor’s 26-27 January Budget Proposal fails to provide Californians with two essential, cost-effective community-based crisis response and preventative behavioral health services. We urge you to fully fund these two vital programs.
Maintain the statewide Medi-Cal mobile crisis benefit
Currently, the statewide Medi-Cal Mobile Crisis benefit provides critical, timely, and coordinated behavioral health crisis support throughout the state. Since its establishment, mobile crisis teams have successfully diverted individuals experiencing behavioral health crises from emergency departments and law enforcement involvement. Mobile crisis teams have contributed to a significant reduction in arrests and involuntary psychiatric holds, which can be traumatic and have lasting negative impacts on individuals and their families. Mobile crisis teams are now an integral component of community efforts to address homelessness, substance use conditions, as well as the youth mental health crisis.
Attempting to reduce the state’s share of the cost to provide this benefit, the proposed budget shifts the financial responsibility to counties by making this vital service optional for counties to provide. Counties are currently struggling to implement the Behavioral Health Services Act (BHSA), which will shift $1 billion in funding from mental health services to housing. Counties will now be faced with painful decisions regarding whether to scale back or eliminate the mobile crisis benefit entirely, leaving many Californians experiencing a behavioral health crisis vulnerable to arrests, self-harm, and involuntary psychiatric holds.
Fully fund the CalHope/California Peer Run Warmline
The CalHope /California Peer Run Warm Line provides a 24/7, peer-led, trauma-informed, culturally competent, and non-crisis emotional support to stabilize individuals and prevent escalation to a crisis. In 24-25, the Warm Line received $15 million and served over 400,000 Californians. 95% of callers were able to be referred to appropriate services, and only less than 1% of calls required a transfer to crisis services.
In 25-26, the Warm Line received a significant budget cut. The service was no longer able to operate 24/7, the Spanish only line was eliminated, and due to capacity issues was only able to support less than 100,000 calls, leaving hundreds of thousands of other Californians at risk of experiencing a crisis.
Mental Health America of California (MHAC) urges you to fully fund California’s ability to respond to a behavioral health crisis and prevent new crises from manifesting. The Office of Emergency Services may have the potential to increase the 988 Surcharge Rate to equal the 911 Surcharge Rate generating upwards of $1 billion that can fund crisis call centers, mobile crisis response teams, and related infrastructure, allowing for the 988 mobile crisis benefit to remain a statewide benefit. The California Department of Public Health will receive approximately $120 million from the BHSA for population-based prevention. These funds can be used to fully fund the California Warm Line and restore capacity to 2024-25 levels.
If you have any questions or if MHAC can provide any assistance, please do not hesitate to contact me at kvicari@mhac.org or our Public Policy Coordinator, Danny Thirakul, at dthirakul@mhac.org.
In Community,
Karen Vicari Director of Public Policy Mental Health America of California
Rayshell Chambers, Chair Client, Family, & Community Inclusion, Lived Experience, & Diversity Advisory Committee Commission for Behavioral Health 1812 9th Street Sacramento, CA 95811
RE: Innovation Partnership Fund (IPF) Request for Proposal (RFP) Outline
Dear Chair Chambers,
Mental Health America of California (MHAC) is pleased to provide the following feedback on the proposed IPF RFP Outline:
Small Grant Carve Out
MHAC supports the inclusion of a small grant tier that requires the grantee to be a CBO, nonprofit entity, or tribal organization. Given that the Commission will receive $20 million annually for the IPF, we recommend a minimum of 40% ($8 million) be set aside for small grants. In addition, we recommend a minimum of 30% ($6 million) dedicated to large grants where a CBO, nonprofit entity, or tribal organization is the lead or co-lead. This minimum requirement would ensure efficacy and optimization of funds while prioritizing local needs.
Assessing Sustainability
The Commission should consider evaluating whether applicants intend to utilize Medi-Cal billable services, specifically Peer Support, or participate in the Children and Youth Behavioral Health Initiative Fee Schedule. This would demonstrate the ability to continue services beyond the Innovation grant. The Commission may also want to evaluate whether applicants will partner with local CBOs. Multiple local partnerships signal a vested interest within the community and the infrastructure capabilities to continue and support ongoing services.
Conflict of Interest
To avoid any public appearances of impropriety, grant awards to sitting commissioners, or to entities that any Commissioner is affiliated with, should be avoided. In the event a grant is awarded to an organization or entity that a Commissioner has an affiliation with, those grant awards should be accompanied by a document outlining the steps taken to ensure a fair grant process that avoids any conflict of interest.
MHAC appreciates the opportunity to provide input on the IPF Outline. If you have any questions, or if MHAC can provide any assistance please do not hesitate to contact me at kvicari@mhac.org or our Public Policy Coordinator, Danny Thirakul, at dthirakul@mhac.org.
In Community,
Karen Vicari Director of Public Policy Mental Health America of California
Ashneek Nanua Health Program Specialist II The California Behavioral Health Planning Council MS 2706 P.O. Box 997413 Sacramento, CA 95899-7413
RE: Feedback on WET Plan Findings and Recommendations
Greetings Ashneek,
Mental Health America of California (MHAC) serves as a member of the steering committee for the Council’s Workforce and Employment Committee (WEC) and attended virtually the WEC meeting on October 15, 2025, where the California Department of Health Care Access and Information (HCAI) presented its findings and recommendations for the 2026-2030 WET plan. MHAC requests the California Behavioral Health Planning Council consider the following in the creation and adoption of the WET plan:
Enhanced Outreach to Schools in Rural Communities
Rural communities across California struggle to recruit and keep a behavioral health workforce that meets their needs. Enhanced outreach to schools in rural communities will expose youth early on to various behavioral health career opportunities. This targeted outreach will support long-term workforce development of behavioral health professionals that are reflective of the community they serve and reduce rural health disparities.
Relocation Benefit and Incentive
A significant consideration of employment is the location of the employer. Individuals seeking employment will commonly look for opportunities close to where they live, due to the costs of relocation. Providing financial aid or a hiring bonus for relocation increases access to employment opportunities that were previously unavailable to job seekers. This benefit will also significantly help rural communities recruit qualified and experienced providers.
Online Education and Training Investments
Online or virtual education and training offer a non-traditional schooling choice for the non-traditional student, supporting individuals who need to work while going to school or people needing to change careers. Online training options also provide flexibility to current providers needing to complete continuing education requirements. Additionally, individuals living in rural locations, without access to a college or university, can benefit substantially from virtual programs. These investments will allow individuals to choose between a variety of career pathways or pipelines and continuing education programs that best meet their needs.
Regional Provider Network/Cohort
Behavioral health encompasses a wide range of fields, roles, and specializations. A Regional Provider Network/Cohort (RPN/C) will help connect behavioral health providers within a certain region and offer opportunities for mentorship, streamline warm-handoffs or referrals, and support cross sector collaboration to serve individuals with co-occurring mental health and substance use challenges. The RPN/C would also help connect providers with other professionals that are trained to deliver culturally responsive services for the LGBTQ+, Immigrant/Refugee, Black, and Indigenous communities. For instance, an LGBTQ+ RPN/C would allow a community’s gender affirming providers to establish a network that would allow for appropriate gender-affirming care referrals for clients while also allowing LGBTQ+ affirming providers the opportunity to network with and support other similar providers.
Medi-Cal Behavioral Health Scholarship Service Obligation Relief
Future HCAI dollars to train Peer Support Specialists requires those who receive scholarships to become Medi-Cal Certified Peer Support Specialists to work full time for 3 years at qualified Medi-Cal serving facilities. Failure to meet this service obligation will force individuals to pay back the entire scholarship. This requirement is burdensome and disincentivizes peer entry into the behavioral health workforce. HCAI must secure funding to allow peer training organizations to train peers who intend to work part time, or work in settings that see non-Medi-Cal clients. Additionally, we encourage HCAI to develop systems that provide relief to scholarship recipients who are unable to complete the 3-year full time service obligation.
Other Considerations
Shifts in the Behavioral Health Services Act allocations have significantly limited the revenue available for Behavioral Health Supports and Services (BHSS), requiring counties and community-based organizations to do more with less funding and resources. This is already leading to the elimination of services and displacement of providers. Furthermore, the renewed focus on Medi-Cal billing creates an extreme administrative burden for local community-based organizations to become Medi-Cal certified and puts those organizations who are unable to bill Medi-Cal at a disadvantage. Together, these challenges result in a loss of vital behavioral health services provided by CBOs. This loss of services represents a significant workforce issue that should be addressed in the HCAI WET Plan.
We appreciate your consideration of our concerns. If you have any questions, or if MHAC can provide any help in the development of the WET Plan, please do not hesitate to contact me at kvicari@mhac.org or contact our Public Policy Coordinator Danny Thirakul at dthirakul@mhac.org
In Community,
Karen Vicari Director of Public Policy Mental Health America of California
The Honorable Al Muratsuchi Chair, Assembly Education Committee 1020 N Street, Room 159 Sacramento, CA 95814
Re: ACR 16 (Mike Fong) Opportunity Youth in California – SUPPORT
Dear Assemblymember Al Muratsuchi,
On behalf of a diverse coalition of advocates, we are writing to express our strong support of ACR 16 Opportunity Youth in California.
Opportunity Youth (OY) are individuals between the ages of 16 and 24 that are not in school or working, including youth and young adults involved with the foster care, juvenile justice, and homelessness systems of care. They face unique employment, education, and training barriers that often do not align with efforts that center adults. Opportunity Youth facing socio-economic and systemic barriers are oftentimes disconnected from education and workforce training opportunities, preventing young people of color from accessing our state’s prosperity.
Data collected from the 2021 American Community Survey (ACS) of the U.S. Census shows that in California there were 572,756 youth ages 16-24 who were neither in school nor at work (12.5% disconnection rate). Data also indicated the disconnection rate of Black teens and young adults (ages 16-24) was more than twice that of their White peers (22.3% and 10.9%, respectively). Black and Latinx adolescents not only are disproportionately more likely to come from low-income households and have experienced past trauma but are also faced with discrimination that can derail their physical and mental well-being. Additionally, despite declines in youth incarceration, significant gaps remain as youth of color are overrepresented in our criminal justice system. Prioritizing OY will not only expand their education and workforce opportunities but also expand the pool of talent that employers can access to meet their workforce needs.
ACR 16 encourages the State of California to create pathways to success for OY and the need to develop a statewide comprehensive plan that will reduce persistent economic inequities, and prioritize: (1) investments in education and workforce training programs that create pathways to good jobs; (2) expand innovative “earn and learn” opportunities such as apprenticeships, pre-apprenticeships, and work-based learning opportunities; (3) advance dual enrollment implementation to allow OY to earn college credit while earning their high school equivalency; (4) ensure inclusivity of OY in the Cradle-to-Career Data System; (5) remove barriers to access student financial aid programs; and (6) protect social safety net investments that support basic needs such as food, housing, internet access, transportation, childcare, health, and mental health care – enabling OY to complete their education and training goals.
For these reasons, we strongly support ACR 16 and we look forward to our state leader’s support for this important resolution.
If there are any questions, please contact Anna Alvarado at aalvarado@caedge.org.
Sincerely,
Alliance for Children’s Rights Erica Hickey Policy Fellow
Bill Wilson Center Josh Selo CEO
California Alliance of Boys & Girls Clubs Sarah Bedy Director
California Children’s Trust Alex Briscoe Principal
California EDGE Coalition Zima Creason Executive Director
California Forward Action Fund David Nelson Executive Director
California Hospital Association Peggy Wheeler Vice President of Rural Health & Governance
California Opportunity Youth Network (COYN) Sean Hughes Policy Director
California Workforce Association Bob Lanter Executive Director
California Youth Empowerment Network (CAYEN) Heidi L. Strunk President & CEO
Center for Employment Training Pascal Do COO
Children Now Danielle Wondra Senior Policy & Outreach Associate, Child Welfare
City of San Jose Sarah Zárate Director, Office of Administration, Policy, and Intergovernmental Relations, City of San Jose
Civicorps Tessa Nicholas Executive Director
Coalition for Humane Immigrant Rights (CHIRLA) Rita Medina Deputy Director, State Policy & Advocacy
Coalition for Responsible Community Development Mark Wilson President & CEO
EntreNous Youth Empowerment Services Sara Silva Co-Founder & Co-Executive Director
Envision Your Pathway Kendra Fujino O’Donoghue Executive Director
Excite Credit Union John Hogan Vice President Community Relations
Foster Care Counts Jeanne Pritzker President
Foster Greatness Colette Smith Executive Director
GO Public Schools Darcel Sanders CEO
Goodwill Southern California Dr. Luis B. Castañón Strategic Impact Officer
Groundwork Social Sector Consulting Joe Herrity Principal
Growing Big Ideas Shawna N Weir-Wright Chief Possibilities Officer
iFoster Serita Cox CEO
John Burton Advocates for Youth Amy Lemley Executive Director
Juma Ventures Adriane Armstrong CEO
Kids in Common Dana Bunnett Executive Director
Lighthouse Silicon Valley Quency Phillips Executive Director
Linked Learning Alliance Anne Stanton President & CEO
Mental Health America of California Heidi L. Strunk President & CEO
New Door Ventures Kevin Hickey Chief Program Officer
New Ways to Work Robert Sainz President & Executive Director
Pivotal Matt Bell CEO
Regional Economic Association Leaders (REAL) Coalition Cynthia Murray REAL Coalition Education & Workforce Development Chair
San Diego Workforce Partnership Nick DeVico Director of Strategic Youth Initiatives
San Jose Conservation Corps and Charter School Mayra Mejia Director, CFET Youth Programs & Support Services
Santa Clara County Youth Action Board Jocelyn Arenas Board Member
Seen&Heard Regan Williams CEO
Small Business Majority Bianca Blomquist Political Director
Soledad Enrichment Action Nathan Arias President & CEO
The RightWay Foundation Franco Vega Founder & CEO
Alliance for Boys & Men of Color Eric Morrison-Smith Executive Director
UNITE-LA Alysia Bell President & CEO
Urban Strategies Council David A. Harris President & CEO
VOICES Amber Twitchell Director
Youth Will Safia Haidari Director of Policy Advocacy & Organizing
To: Assembly Speaker’s Office Senate Pro Tem’s Office Assembly Health Committee Senate Health Committee Governor Newsom’s Office
Re: Threat to Consumer Mental Health and Substance Use Disorder Coverage Laws Under SB 855 (Chapter 151, 2020)
Dear Members of the Legislature:
Our organizations, which are committed to ensuring that Californians are able to access medically necessary mental health and substance use disorder (MH/SUD) treatment, write to you to express concerns about an attempt to weaken Senator Wiener’s landmark bill, SB 855 (Chapter 151, 2020), which enacted nation-leading MH/SUD coverage protections. We would oppose amendments to SB 855 to allow use of criteria developed by for-profit entities, which is why we were concerned to learn the MCG, one of the primary licensors of for-profit proprietary criteria, has been seeking amendments to do just that.
Under SB 855, Californians in fully-insured, state-regulated health plans have the most comprehensive consumer protections governing coverage of MH/SUD care in the country.
This critical law requires that health plans cover all medically necessary MH/SUD treatment and requires health plans to make medical necessity determinations in accordance with generally accepted standards of care (GASC) for MH/SUD. Prior to SB 855, there was no requirement under California law that health plans make these determinations consistent with GASC.
SB 855 also requires health plans to exclusively use nonprofit clinical specialty association criteria for medical necessity determinations to ensure (1) compliance with GASC and (2) that decisions are not tainted by financial conflicts of interests. Again, prior to SB 855, plans could essentially use whatever criteria they wished, including non-transparent proprietary criteria that put plans’ financial interests ahead of patients’. Such criteria stand in stark contrast to criteria established by nonprofit clinical specialty associations, which are developed through a transparent, consensus-based process. Renowned clinical specialty associations such as the American Psychiatric Association, the American Psychological Association, the American Society of Addiction Medicine (ASAM), the American Academy of Child and Adolescent Psychiatry (AACAP), and the American Association of Community Psychiatry (AACP) go through rigorous processes to ensure that the guidelines and criteria they create reflect GASC and are broadly accepted by MH/SUD clinicians, ensuring that patients’ medical needs come first.
SB 855’s nonprofit medical necessity criteria requirements are critical because such criteria are:
Fully transparent and accessible. Consumers, providers, and other stakeholders can readily access the criteria being used to determine whether specific MH/SUD services are, in fact, appropriate to meet individual patient needs.
Developed through a consensus process that protects against conflicts of interest. The authors and reviewers of nonprofit criteria are publicly identified. Credentials, expertise, and potential conflicts of interests can be evaluated by the public.
Externally validated. Nonprofit clinical criteria are subject to rigorous peer review, validation studies in real-world clinical settings, and are reviewed in professional and scholarly journals.
In fact, as early as 1997, research published in the American Journal of Psychiatry, the official, peer-reviewed journal of the American Psychiatric Association, sounded warning bells, concluding that: “Our findings underscore the necessity of determining the validity of all criteria used to assess the appropriateness of medical care. Wide acceptance of an instrument is clearly not sufficient to justify its use . . . The need for validation studies is particularly great when proprietary criteria are not available for public scrutiny.”1
We note that in 2021, the nation’s largest insurer, United Healthcare (UHC) claimed to have voluntarily switched to nonprofit clinical association criteria by ASAM, AACP, and AACAP throughout the United States for all its level of care determinations. Under its brand name “Optum,” UHC explained why it switched to nonprofit clinical criteria for mental health and substance use disorders:2
The criteria were “[e]xternally validated”
The criteria used a “Common Language [That] Drives Improved Care”
“The six dimensions [of the guidelines] provide a more holistic view of acuity and chronicity of behavioral health condition, thereby promoting more appropriate care for patients and a better overall experience.” (emphasis added)
UHC further noted that the nonprofit clinical specialty association criteria were better than proprietary criteria such as those created by for-profit publishers like MCG (formerly “Millman”) and InterQual, because these nonprofit clinical criteria “adopted a systems of care approach” that was “tailored to the specific age of the member” and better incorporated “the use of wrap-around services.”3 We agree.
Use of the nonprofit clinical specialty association criteria sets a clear, unambiguous standard that protects patients. For example, if a level of care assessment using “The ASAM Criteria” indicates that an individual needing substance use disorder treatment is most appropriately treated in a Clinically Managed Residential Withdrawal Management (ASAM Level 3.2-WM) facility, under California law, the insurer must cover this level of treatment. Or if a young person with early psychosis symptoms needs Coordinated Specialty Care, as is clearly recommended by the American Psychiatric Association’s “Practice Guideline for the Treatment of Patients With Schizophrenia,” the health plan must cover these life-saving services.
The centrality of SB 855’s non-profit clinical criteria requirements is why we were alarmed to learn that MCG is pushing for amendments to SB 855’s clinical criteria provisions. MCG seeks to amend SB 855 so that its proprietary criteria, which it sells to providers on a subscription basis, will also be considered acceptable in California for making medical necessity determinations. Though skeptical, our organizations agreed to meet with MCG. However, in order to allow us to fully review and evaluate its MH/SUD criteria after this initial meeting, MCG insisted that our organizations execute Non-Disclosure Agreements. We refused, because such a constraint and lack of transparency only play into the numerous problems inherent in secret, for-profit clinical criteria that broadly impact public health.
That other states are following California’s lead demonstrates the importance of having one set of allowed clinical criteria – the criteria that are developed by the leading nonprofit clinical specialty associations. After SB 855’s enactment, Illinois and Oregon enacted nearly identical language requiring the use of nonprofit clinical association criteria for MH/SUD medical necessity determinations. And, in reviewing health plans’ mental health level of care criteria, the New York State Office of Mental Health rejected all 69 plans’ guidelines as flawed and inconsistent with GASC. Critically, New York State automatically deemed mental health criteria from AACP and AACAP as automatically compliant. Numerous other states have also mandated nonprofit criteria such as The ASAM Criteria.4
Lastly, it is important to note that SB 855 purposely addresses gaps in situations that are not expressly addressed by existing nonprofit clinical association criteria. The use of for-profit clinical criteria is permitted if they (1) are outside the scope of the relevant nonprofit professional criteria or(2) relate to advancements in technology or types of care not covered by the nonprofit criteria. However, efforts to open the door to for-profit criteria within the scope of nonprofit criteria invites profound confusion and will undermine the creation of a common language necessary to improve access to quality care.
Therefore, we request that you oppose any effort to change SB 855’s provisions relating to medical necessity criteria. Amending SB 855 will hinder the state’s response to the ongoing mental health and addiction crisis and invite new arbitrary denials that California has come so far in trying to prevent. It’s not only patients that have a lot to lose, but taxpayers who must pay for the cost when insurers inappropriately deny needed treatment – exactly the point that the California Department of Justice took in a recent federal amicus brief.5
Thank you for your efforts to improve access to life-saving care. We hope that you’ll oppose efforts to weaken California’s nation-leading laws.
Sincerely,
Lauren Finke The Kennedy Forum
Jared L. Skillings, PhD, ABPP American Psychological Association
Adrienne Shilton California Alliance of Child and Family Services
Robb Layne California Association of Alcohol and Drug Program Executives
Chad Costello California Association of Social Rehabilitation Agencies
Paul Yoder California State Association of Psychiatrists
Danny Thirakul California Youth Empowerment Network
Katelin Van Deynze Health Access California
Heidi Strunk Mental Health America of California
Karen Fessel Mental Health & Autism Insurance Project
Danny Offer National Alliance on Mental Illness California
Fred Seavey National Union of Healthcare Workers (NUHW)
Joy Burkhard Policy Center for Maternal Mental Health
Randall Hagar Psychiatric Physicians Alliance of California
Tara Gamboa-Eastman Steinberg Institute
1 Goldman RL, Weir CR, Turner CW, Smith CB. Validity of utilization management criteria for psychiatry. Am J Psychiatry. 1997 Mar;154(3):349-54. doi: 10.1176/ajp.154.3.349. PMID: 9054782.
2 The mental health criteria UHC voluntarily switched to were the Level of Care Utilization System (LOCUS),which is developed by AACP, for adults; the Child and Adolescent Level of Care/Service Intensity Utilization System (CALOCUS-CASII), which is developed jointly by AACP and AACAP, for children and adolescents ages 6-18; and the Early Childhood Service Intensity Instrument (ECSII), which is developed by AACAP, for children ages 0-5. UHC also voluntarily switched to using The ASAM Criteria, but the notice to providers (see note 2) was specifically related to the mental health nonprofit criteria.
3 Optum. “Optum Clinical Criteria for Behavioral Health Conditions Change to LOCUS, CASII, ECSII: Frequently Asked Questions.” (2021). https://public.providerexpress.com/content/dam/opeprovexpr/us/pdfs/clinResourcesMain/guidelines/optumLOCG/locg/LCE-FAQs.pdf.
4 Legal Action Center and Partnership to End Addiction. “Spotlight on Medical Necessity Criteria for Substance Use Disorders.” November 2020. Note, this report predated enactment of SB 855 or the laws in Illinois or Oregon.
5 See https://oag.ca.gov/news/press-releases/attorney-general-bonta-files-brief-support-access-mental-healthcare-services.
The Honorable Gavin Newsom California State Governor 1021 O Street, Suite 9000 Sacramento, CA 95814
RE: Request for Signature of Assembly Bill 432 (Bauer-Kahan)
Dear Governor Newsom,
Mental Health America of California (MHAC) is pleased to support Assembly Bill 432 (Bauer-Kahan), legislation that would require health plans to cover services for the evaluation and treatment of perimenopause and menopause.
MHAC is a peer-run organization leading the state in behavioral health public policy and advocacy since 1957. The mission of MHAC is to assist and encourage communities, families, and individuals to experience hope, wellness and recovery from mental health and substance use disorder issues. The people and communities we aim to serve include those of all ages; sexual orientation, gender identity, or expression; language, racial and ethnic backgrounds, national origin, and immigration status; spirituality and religious affiliations; or socioeconomic status. In alignment with our mission, MHAC supports expanding coverage of physical health care to prevent related mental health challenges from developing.
Women going through menopause can see shifts in their hormone levels, putting them at elevated risk for depression and anxiety. According to the Anxiety & Depression Association of America, between 45% and 60% of women experience depression during menopause.[1] Expanding coverage for perimenopause and menopause services would allow women to access care in a timely manner, reducing the risk of associated mental health challenges. This bill ensures that health plans will cover these services, leading to improved mental health outcomes for women.
It is for these reasons MHAC supports AB 432 (Bauer-Kahan) and asks for your signature. If you have any questions, or if MHAC can provide any assistance on this bill or any behavioral health legislation, please do not hesitate to contact me at kvicari@mhac.org or our Public Policy Coordinator, Danny Thirakul, at dthirakul@mhac.org.
In Community,
Karen Vicari Director of Public Policy Mental Health America of California
