Position Category: MHAC

Mental Health Coalition Comments to California Department of Insurance on Proposed SB 855 and AB 988 Rules


July 9, 2024

California Department of Insurance
Attn: Sarah Sullivan, Attorney III
Health Equity and Access Office
300 Capitol Mall, Suite 1700
Sacramento, CA 95814

Via email CDIRegulations@insurance.ca.gov

Re: Mental Health and Substance Use Disorder Coverage Requirements, Article 15.2 (commencing with section 2652.1) of Subchapter 3 of Chapter 5 of Title 10 of the California Code of Regulations, pursuant to the authority granted by Insurance Code sections 10144.4, 10144.5, 10144.51, 10144.52, 10144.53, and 10144.57

We appreciate the opportunity to comment on California Department of Insurance’s Notice of Proposed Action for the Department’s Mental Health and Substance Use Disorder Parity in Health Insurance Rulemaking (REG-2021-00008) dated May 24, 2024, to implement Senate Bill 855 (Wiener, Chapter 151, 2020) and Assembly Bill 988 (Bauer-Kahan, Chapter 747, 2022). We are grateful for the Department’s engagement with us on numerous issues related to the drafted regulations. The Department’s proposed Rule lessens the possibility that disability insurers will exploit ambiguities to inappropriately limit insureds’ access to mental health and substance use disorder (MHSUD) care
We encourage this comprehensive Rulemaking to be finalized as soon as possible and offer support for the following key provisions, as currently drafted:

● Use of nonprofit professional association utilization review criteria and gap-filling criteria aligned with generally accepted standards of care (GASC). The exclusive use of nonprofit professional association criteria, unmodified, is essential to ensuring that insureds receive the appropriate intensity and duration of services to meet their specific needs in a manner consistent with generally accepted standards of care. The proposed Rule clearly states that it is the responsibility of disability insurers to use nonprofit professional association utilization review criteria in a manner established or approved by the association and to document how the plan is meeting these requirements.

We also support the Department’s development of gap-filling criteria for use when there are not established nonprofit professional association utilization review criteria for a MHSUD condition or service. All criteria, including gap-filling criteria, should be consistent with GASC to ensure that every MHSUD condition is measured against appropriate clinical standards. These standards are squarely in-line with the intent and letter of the law.

● Obligation of health insurers to arrange and pay for out-of-network care and insureds’ rights to arranging out-of-network coverage, including requirements that insurers must be required to enter into an agreement with out-of-network providers when geographic and timely access standards are not met. We support the Department’s specificity on obligations of insurers in arranging out-of-network care, including:

○ The insurer’s obligation to identify and secure out-of-network health care providers or facilities within time and distance standards;
○ The insured’s right to timely authorization of out-of-network services;
○ The insured’s right to in-network cost-sharing for out-of-network benefits when an insurer fails to secure in-network care;
○ Where appointments/admissions are not available within 90 calendar days, that an insured shall be allowed to schedule the appointment/admission beyond this timeframe;
○ The insurer’s explicit responsibility to cover the entire course of medically necessary treatment;
○ Transitioning an insured to an in-network provider or facility should involve “clear and convincing evidence” that such a transition is in the best interest of the patient, and not for the convenience or cost-savings of the insurer.

● Explicit coverage requirements for crisis services, including those accessed through 988, including mandates that emergency crisis services be covered:

○ without medical necessity reviews;
○ without prior authorization;
○ without regard to provider network status; and
○ that insureds are subject to only in-network cost sharing on these claims.

● Requirements that utilization reviewers have appropriate qualifications. We support the Department’s inclusion of qualifications and standards for utilization reviewers conducting reviews on MHSUD claims. Utilization reviewers should have proper training and experience in the field of behavioral health care that is under review. We further appreciate the Department’s specificity on qualifications for SUD reviews, a field in which the practice of unqualified utilization reviewers results in disproportionately high denials for SUD care. We encourage the Department to consider adding such specificity for other specialty areas with high rates of denials, such as eating disorder care, gender affirming care, and treatment for autism spectrum disorders.

● Ensuring continuity of care by requiring insurers to bear the burden of demonstrating by clear and convincing evidence that ongoing MHSUD services arranged out-of-network (due to network inadequacy) are interrupted only in accordance with generally accepted standards of care. The Department’s explicit requirements that an insurer reimburse for the entire course of treatment is aligned with the intent of the law and the clinical standards for MHSUDs.

● Formal education programs, including requiring insurers to sponsor a formal education program created by relevant nonprofit professional associations. Ensuring insurers are using relevant nonprofit professional association trainings, as available, ensures alignment and proper use of clinical review criteria in the manner in which the clinical association intended. Such trainings should include targeted outreach and be made available to both in and out-of-network providers and facilities, as well as members.

● Transparency in utilization review and training, by requiring insurers make education materials, trainings, and utilization review criteria available to network providers, group policyholders, insureds and their authorized representatives, and out-of-network providers.

● Definition of health care provider that is aligned with statute and inclusive of often-denied providers such as associates and trainees. Providers continue to report claim denials when associates appropriately provide medically necessary services under existing laws. Aligning the definition of health care provider with how it is defined in statute makes unambiguous that the use of associate providers is permitted under the statute.

While the above-mentioned components of Rulemaking offer strong protections for insureds seeking MHSUD care, we provide the following comments to further bolster insureds’ rights and lessen their burden in obtaining medically necessary MHSUD care. We hope the Department will consider the following comments for inclusion in its Final Rulemaking.

● Coverage requirements for frequently denied care. While we appreciate the proposed Rule’s clarity on the exclusive use of nonprofit professional association utilization review criteria, we encourage the Department to consider listing coverage requirements for frequently denied services and levels of care.

● Frequency and duration of treatment reviews. 28 CCR 1300.74.721(d) states that “a health plan shall not conduct repeated utilization review of a case at intervals more frequent than those prescribed or recommended by the relevant nonprofit professional association criteria or guidelines.” We encourage the Department to adopt similar language limiting the frequency and duration of treatment reviews, to align with the statute’s definition of medically necessary treatments that are “clinically appropriate in terms of type, frequency, extent, site, and duration.”

● Out-of-state provider coverage for out-of-network care. While we support the Department’s specificity on insureds’ rights to out-of-network coverage, we request further specificity that insureds’ rights to arranging out-of-network care are not limited to in-state providers once a plan has failed to arrange for in-network coverage. The state has limited facilities appropriate for certain populations. For example, there is a shortage of longer-term residential facilities as well as high quality programs that can address needs of specific populations; the state’s Department of Education has responded well to this issue by creating a list of out-of-state schools that can additionally serve special youth populations under IEP. Out of state status should not be a disqualifying issue for receiving medically necessary MHSUD care if appropriate care cannot be found in-state.

● Inclusion of nonprofit clinical criteria for eating disorder care. The REDC Level of Care Criteria are the most detailed, up to date, clinical level of care guidelines for eating disorder care. These criteria define eating disorder levels of care and criteria for admission for each level of care and were vetted across clinical and research evidence as well as across the eating disorders field to gain clinical consensus. We encourage the Department to list these criteria as part of its allowed nonprofit clinical criteria.

● Instituting reporting requirements to track compliance including yearly insurer reporting requirements on timely access and out-of-network referrals. Regular data collection efforts will allow the Department to proactively identify compliance issues without relying on trends in insured complaints to understand violations of these laws.

● Distributing department-produced educational materials on SB 855 and AB 988 to insureds including know-your-rights materials. We additionally encourage the Department to add a requirement that health plans provide insureds with copies of these Department-produced materials to better ensure insureds receive such information, as well as including them in the Evidence of Coverage manual.

● Requiring plans to incorporate the list of services into their evidences of coverage. While we appreciate the requirements in the proposed rules related to evidences of coverage, we believe more should be required of plans in order to ensure that enrollees get access to necessary information regarding covered services. CDI should require plans to include a list of all the services outlined in Section 2562.05 in their evidences of coverage and to explain that all of those services are covered when meeting the medical necessity criteria. In addition, plans should be required to add a statement emphasizing that the list is not exhaustive and that other MHSUD services not listed in the evidence of coverage are covered when medically necessary.

● Allowed health care providers. Health plans and insurers often disallow certain eligible providers from providing and billing services; associates, trainees, and autism providers, for example, are frequently not considered eligible providers, despite their clear inclusion in statute, resulting in continued denials for claims for medically necessary MHSUD care under current law. We support the Department’s definition of “health care provider” and believe it is clearly inclusive of these often-denied providers. To ensure adherence to the statute, we request that the Department include clarifying language that confirms listed providers cannot be denied reimbursement for MHSUD services rendered on the basis of their provider status (as associates, trainees, etc.).

● Issuing Notices/Bulletins/General Counsel opinion letters upon adoption of final Rules regarding particular areas of enforcement concern.

We encourage the consideration of our above-stated comments and the swift promulgation of comprehensive regulations. Once again, we thank you for considering our comments and considerations for finalization of the proposed Rules. As always, our organizations stand ready to assist you in any way we can.

If you have any questions, please contact Lauren Finke (lauren@thekennedyforum.org). For matters requiring physical or printed communication, please send to 1121 L Street, Sacramento, California 95814 suite #300.

Sincerely,

Adrienne Shilton
California Alliance of Child and Family Services

Robb Layne
California Association of Alcohol and Drug Program Executives, Inc

Joy Alafia
California Association of Marriage and Family Therapists

Chad Costello
California Association of Social Rehabilitation Agencies

Tyler Rinde
California Psychological Association

Paul Yoder
California State Association of Psychiatrists

Danny Thirakul
California Youth Empowerment Network

Alison Ivie
Eating Disorders Coalition
REDC

Karen Fessel
Mental Health & Autism Insurance Project

Heidi Strunk
Mental Health America of California

Jessica Cruz, MPA/HS
National Alliance on Mental Illness

Héctor Hernández-Delgado
National Health Law Program

Benjamin Eichert
NUHW

Randall Hagar
Psychiatric Physicians Alliance of California

John Drebinger III
Steinberg Institute

Lauren Finke
The Kennedy Forum

CC:
Ricardo Lara, Stesha Hodges, Department of Insurance
Senator Scott Wiener
Assemblymember Bauer-Kahan

AB 2352 (Irwin) Mental health and psychiatric advance directives – Oppose unless amended

April 5, 2024

The Honorable Ash Kalra
Chair, Judiciary Committee
California State Assembly
1020 N Street, Suite 104
Sacramento, CA 95814

RE: AB 2352 (IRWIN) as Amended March 21, 2024 – OPPOSE UNLESS AMENDED

Dear Chair Kalra:

Disability Rights California (DRC) is California’s federally mandated protection and advocacy agency, working to advance and protect the rights of Californians with disabilities. Mental Health America of California (MHAC) is a peer-run organization leading the state in behavioral health public policy and advocacy since 1957. MHAC works to encourage hope, wellness and recovery from mental health and substance use disorders through voluntary services, delivered locally with compassion and respect for everyone’s dignity and autonomy.

We reluctantly submit this letter in opposition to AB 2352 (Irwin). We support psychiatric advance directives (PADs) and proudly sponsored AB 1029 (Pellerin), Chapter 171, Statutes of 2023, to promote their use. We understand from the author’s office that AB 2352 is intended to further the work of a seven-county Innovation Project sponsored by the Mental Health Services Oversight and Accountability Commission. DRC has been working with the project team and along with MHAC we suggest the bill be substantially amended to focus exclusively on what we understand to be the bill’s intent: create a legal framework to facilitate the testing and use of a digital platform which, in turn, will hopefully further promote the use of PADs.

BACKGROUND ON ADVANCE HEALTH CARE DIRECTIVES AND PADS

Many people are familiar with an Advance Health Care Directive, (AHCD) a legal document executed by a person in anticipation of medical decisions that may need to be made when the person lacks capacity to make those decisions. One example is a person facing surgery who wants to be sure their loved ones and health care providers know their treatment preferences if something unexpected occurs. An AHCD often, but not always, includes designation of an agent with power of attorney to make decisions.

A PAD is a type of AHCD. It may be a standalone document, or it may be included as part of an overall AHCD. A PAD specifies a person’s preferences regarding mental health treatment in the event of a future mental health crisis. This may include information about medications known to be effective, an individual’s preferences for emergency care, and more. PADs are demonstrated to reduce the need for coercive interventions during mental health crises and increase participants’ feelings of autonomy, self-determination and empowerment.1

PADs can also improve mental health outcomes by facilitating conversations between mental health providers and an individual in mental health crisis. When psychological distress results in a mental health crisis, a person may be subjected to involuntary treatment, which can be traumatizing and demoralizing, and ultimately less effective than voluntary care, in part because treating providers lack knowledge about which services or treatments are likely to be most effective for an individual.

AB 2352 GOES FAR BEYOND CREATING THE NECESSARY FRAMEWORK FOR TESTING PADS

In numerous instances, AB 2352 goes far beyond what is needed to test a digital platform for PADs. In so doing, the bill pushes mental health policy away from the original intent of PADs.

AB 2352 increases the use of PADs in CARE Court. These sections should all be stricken from the bill.

We opposed CARE Court when it was enacted two years ago.2 Among the reasons we sponsored AB 1029 last year was the surprise inclusion of PADs in CARE Court. Welfare and Institutions Code Section 5971 specifies the “graduation plan” in CARE Court may include a PAD. Because we believe CARE Court to be coercive, and because coercion has no place in a PAD, AB 1029 made sure PADs would fall under the Health Care Decisions law, which governs AHCDs. AB 2352 authorizes a CARE plan to include a PAD. The CARE plan is created early in a respondent’s CARE Court journey. Whether or not “graduation” is coercive, surely a CARE plan imposed on a respondent meets that definition. In addition, if a PAD is part of a CARE plan, how is the respondent’s right to privacy protected? Further, the bill contemplates the use of a health care advocate for PADs but with respect to CARE Court, appears to require (but at a minimum permits) that same health care advocate to also serve as the individual’s CARE supporter. This expansion of the health care advocate’s duties into CARE Court dramatically changes the duties of the advocate and risks changing the advocate’s role from neutral to coercive.

AB 2352 attempts to update California law post Proposition 1 by replacing “mental health” with “behavioral health” in numerous instances. These changes have unintended consequences. They should be removed from AB 2352 and considered in a separate bill that carefully and thoughtfully updates the law.

Proposition 1, passed by voters on March 5, 2024, renames the Mental Health Services Act (MHSA) as the Behavioral Health Services Act (BHSA). Prop 1 also renames the Mental Health Services Oversight and Accountability Commission (MHSOAC) as the Behavioral Health Services Oversight and Accountability Commission (BHSOAC). Beyond these changes, there is no wholesale substitution of “behavioral health” for “mental health” in the many sections of law amended by Proposition 1 containing the term “mental health.”

“Behavioral Health” is a broad term with many different definitions, but it generally refers to substance use disorders and mental health disorders of any severity. Some state laws and programs apply to mental health, some apply to mental health with co-occurring substance use disorders, and some apply to standalone “mild to moderate” substance use disorder or “severe” substance use disorder. The term “behavioral health” is not interchangeable with the term “mental health.” By replacing “mental health” with “behavioral health,” throughout statute, even beyond those code sections amended by Proposition 1, AB 2352 makes expansive changes to current law. At best these are unintended consequences, but they are problematic all the same. Below are some examples.

• AB 2352 substantially expands Assisted Outpatient Treatment

By changing “mental health” to “behavioral health” in the state’s Assisted Outpatient Treatment (AOT) law, the bill applies AOT to any person “suffering from a behavioral health illness.” AOT does not currently apply to people with a standalone SUD; any SUD must be co-occurring with mental illness. By applying AOT to standalone SUD, this proposed change opens the door to involuntary treatment for large numbers of Californians not currently eligible for AOT. Furthermore, this same section of the bill refers to Health & Safety Code Section 5600.3(b)(2) and (3) for the definition of “behavioral health illness,” but “behavioral health illness” is not defined in those paragraphs. This raises serious concerns, because if “behavioral health illness” is later defined within the Health &Safety Code, this definition would likely impact a vast number of other code sections in untold ways. Changes to current law this significant deserve careful consideration and public debate; they should not be dropped into a piece of legislation that may not receive a lot of scrutiny because it is viewed as simple code cleanup.

Along those lines, in this same section, we have concerns that by replacing “mental health professional” with “behavioral health professional”, we inadvertently allow licensed SUD counselors to refer individuals for AOT or determine whether an individual has capacity to consent to psychotropic medication. This should not be permitted.

•AB 2352 expands the LPS “gravely disabled” definition beyond what was enacted last year in SB 43.

The Legislature enacted SB 43 (Eggman), Chapter 637, Statutes of 2023 to, among other things, expand the definition of “gravely disabled” under the Lanterman Petris Short Act (LPS) to include individuals with “severe” SUD. Prior to SB 43, a person with SUD would be considered gravely disabled only in the presence of a co-occurring mental health disorder. The changes proposed by AB 2352, in replacing “mental health” with “behavioral health,” have the effect of expanding SB 43’s expansion to cover ANY substance use disorder, not just a SEVERE substance use disorder.

To add to the confusion of replacing “mental health” with “behavioral health,” section 36 (CARE Court) defines a licensed behavioral health professional as a licensed mental health professional. This makes no sense, and we see no purpose in changing the term “licensed mental health professional” anywhere in code.

Incorrect and confusing definitions and cross-references should be fixed or deleted.

There are many instances in the bill where the use of specific terms would add confusion to the law. This occurs most notably with the creation of a “health care advocate” for PADs. For example, the bill’s two definitions of “PAD” include a “health care advocate,” which appears to be optional in one instance and required in the other. In Section 10 of the bill, amendments to Probate Code Section 4674 require a signature by an ASSIGNED advocate and in Section 6 of the bill, amendments to Probate Code Section 4672 permit the NOMINATION of an advocate.

There are definitions for PAD and “health care advocate” in Section 42 of the bill with proposed amendments to Welfare and Institutions Code Section 21001. Other sections in the bill cross-reference Section 21001, which was added by AB 1663 (Maienschein), Chapter 894, Statutes of 2022. DRC sponsored AB 1663, which reformed probate conservatorships and provided a framework for supported decision making. The changes in AB 2352 are out of step with the statutory structure for supported decision making and appear to be unnecessary and confusing.

The bill establishes different witness requirements for a PAD and an AHCD. There is no identified reason for different requirements. Based on longstanding law, the requirements should remain the same.

Section 9 of the bill amends Probate Code Section 4673 related to legal sufficiency of AHCDs. Under existing law, AHCDs and PADs (which are a type of AHCD) would have the same witness signature requirements, i.e. two witnesses or a notary public. The bill eliminates the ability to use a notary for a PAD and requires only one witness. This makes no sense. There is no reason for a PAD, whether it is standalone or part of a larger AHCD, to have different witness requirements.

AB 2352 SHOULD FOCUS ON WHAT IS NEEDED FOR DIGITAL PADS TO BE TESTED UNDER THE INNOVATION PROJECT. CONFUSING, UNECCESARY AND EXPANSIVE CHANGES TO LAW SHOULD BE ELIMINATED

A PAD is a type of Advance Health Care Directive. It MAY be a standalone document, but this is not required. The bill blurs that point by including specific requirements, duplications and exemptions for PADS as compared to all AHCDs, which makes it seem all PADs will be standalone. This is a mistake. Existing AHCDs with or without an inclusive PAD, and existing standalone PADs, should not need updating because of this bill. For an example of an inclusive AHCD, the Veterans Administration offers a template that includes mental health in an advance directive.

At its heart, the bill seeks to create a framework for digital PADs. That is what the MHSOAC seven-county innovation project is all about. We support that intent but want to be sure everyone understands what a digital PAD is and how it is created, stored and accessed. This bill does not do that. The sponsor is using a proprietary platform in the innovation project. Will that become the standard? With MHSA Innovation funding eliminated by Proposition 1, how will counties sustain the digital platform long term? Will hospitals have to purchase the platform? Will there be competitors? Over the last ten years we have seen the challenges in implementing Electronic Medical Records under the Affordable Care Act. It is about more than digital signatures – it is the content in the platform. The bill needs to do a better job there so that a PAD can be easy to complete and may be accessed by specific entities, i.e. law enforcement and hospitals, when appropriate. Access does not mean all parts of a PAD are accessible to all who need parts of it. It is important to ensure law enforcement and health care providers each have access to only those portions of the PAD relevant for their jobs.

For these reasons, DRC and MHAC respectfully oppose this bill unless it is amended to address our concerns. Please contact us if you have any questions about our position or if I can provide any further information.

Sincerely,

Deb Roth
Senior Legislative Advocate
Disability Rights California

Karen Vicari
Director of Public Policy
Mental Health American of California

cc: Honorable Members, Assembly Judiciary Committee
The Honorable Jacqui Irwin, California State Assembly
The Honorable Gail Pellerin, California State Assembly
Alison Merrilees, Assembly Judiciary Committee
Charmaine Mills, Office of Assemblymember Pellerin

1 Murray H & Wortzel HS. Psychiatric Advance Directives: Origins, Benefits, Challenges, and Future Directions. Journal of Psychiatric Practice, 2019;25(4):303-0

2 SB 1338 (Eggman), Chapter 319, Statutes of 2022.

SB 1397 (Eggman) Behavioral Health Services Coverage – Support

May 31, 2024

The Honorable Mia Bonta
Assembly Health Committee
1020 N Street, Room 390
Sacramento, CA 95814

Subject: Support for SB 1397 (Eggman) Behavioral Health Services Coverage

Dear Chair Bonta,

Mental Health America of California is pleased to support SB 1397 (Eggman), legislation which would allow county behavioral health agencies to be reimbursed for full-service partnership services through health plans and insurers that cover medically necessary mental health and substance use disorder treatment.

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 through voluntary services that are delivered in their local community with compassion and respect for everyone’s dignity and autonomy.

To improve access to care in local communities, this bill allows counties to be reimbursed for services provided and covered through an individual’s health insurance. By reducing costs to counties and ensuring maximum coverage and access to care, this bill seeks to address some of the funding limitations imposed by Proposition 1. It supplements a portion of the lost revenue by requiring health plans to reimburse counties for medically necessary mental health and substance use disorder treatments.

For these reasons, we support SB 1397 (Eggman). If you have any questions or if MHAC can be of assistance on this or any other behavioral health bill, please feel free to contact me or our Public Policy Director, Karen Vicari, at kvicari@mhaofca.org.

In Community, 

Heidi L. Strunk 
President & CEO

SB 1238 (Eggman) Designated Facilities – Opposed

June 14, 2024

The Honorable Mia Bonta
Chair, Assembly Committee on Health
California State Assembly  
1020 N Street, Room 390
Sacramento, CA 95814

RE: Opposition to SB 1238 (Eggman)

Dear Chair Bonta,

Mental Health America of California (MHAC) respectfully opposes Senate Bill 1238 (Eggman), legislation which seeks to expands the definition of “facility designated by the county for evaluation and treatment” or “designated facility” for the purpose of involuntarily holding and treating people with standalone substance use disorder.

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 through voluntary services that are delivered in their local community with compassion and respect for everyone’s dignity and autonomy. Access to voluntary support and services are vital to preventing people from experiencing mental and behavioral health crises.

Last year, Senate Bill 43 (Eggman) expanded the definition of “gravely disabled” to include individuals with substance use disorder, allowing them to be placed on a 5150 hold and receive forced treatment. Senate Bill 1238 (Eggman) seeks to address the increase in people being held for standalone substance use disorder by permitting designated facilities to admit individuals with SUD. Those placed on a 5150 hold must be taken to a designated facility that meets specific safety standards, has the proper resources, and complies with state and federal laws. Our primary concerns with this bill are as follows:

  1. Ineffectiveness of Involuntary Treatment

      Involuntary treatment for individuals with substance use disorder is ineffective. Forcing people into environments not properly suited for recovery can cause additional trauma. When resources and services are available, people are more likely to seek help voluntarily. This bill does not ensure that individuals will be placed in facilities with the proper infrastructure or resources needed for a healthy recovery.

      2. Bypassing the Regulatory Process

      The amended language in the bill allows the Department of Health Care Services (DHCS) to bypass public notice and comment requirements in the rule-making process. This means the DHCS can “implement, interpret, or make specific [the bill], in whole or in part, by means of plan or county letters, information notices, plan or provider bulletins, or other similar instructions, without taking any further regulatory action.”

      Expanding the capabilities of facilities to involuntarily hold and treat individuals with standalone substance use disorders jeopardizes their health and places them in environments that are not conducive to recovery. For this reason, we oppose SB 1238 (Eggman) and ask for your “No” vote. If you have any questions, or if MHAC can provide any assistance on this bill or any other behavioral health legislation, please do not hesitate to contact me or our Public Policy Director, Karen Vicari, at kvicari@mhaofca.org.

      In Community,

      Heidi L. Strunk

      President & CEO

      SB 1184 (Eggman) Involuntary Treatment and Antipsychotic Medication – Oppose

      June 5, 2024

      The Honorable Chair Mia Bonta
      Assembly Health Committee
      California State Assembly
      1020 N Street, Room 390
      Sacramento, CA 95814

      Subject: Oppose Senate Bill 1184 (Eggman)

      Dear Chair Bonta,

      Mental Health America of California (MHAC) opposes Senate Bill 1184 (Eggman), which seeks to extend the timeframe during which a person is deemed incapable of refusing and can be compelled to receive antipsychotic medication during the various phases of an involuntary psychiatric hold.

      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 challenges through voluntary services that are delivered in their local community with compassion and respect for everyone’s dignity and autonomy. The use of forced treatment takes away people’s autonomy to choose the services and supports that best supports their recovery.

      Current law provides for the rights of individuals when undergoing involuntary treatment. Sections 5332, 5334, and 5336 of the Welfare and Institutions Code details the rights of an individual regarding the involuntary administration of antipsychotic medication, the process for determining a person’s incapacity, and the timeframe of how long a determination of incapacity lasts. Senate Bill 1184 (Eggman) would ensure that a person’s determination of incapacity to refuse medication remains in effect during each phase of an involuntary psychiatric hold. While new amendments require a petition at each phase of the hold to determine incapacity, the bill still subjects individuals to prologued forced administration of antipsychotic medication until the court hears a petition for that detention period and issues a decision.  

      The initial 72-hour involuntary hold is significantly different from the potentially 30 days of continued intensive treatment. It is vital for people that find themselves in crisis to be provided with every opportunity to have their own self-determination of care at every phase of an involuntary hold.  For this reason, we oppose SB 1184 (Eggman) and ask for your “No” vote. If you have any questions, or if MHAC can provide any assistance on this bill or any other behavioral health legislation, please do not hesitate to contact me or our Public Policy Director, Karen Vicari, at kvicari@mhaofca.org. 

      In Community, 

      Heidi L. Strunk 
      President & CEO

      SB 1011 (Jones) Encampment Restrictions – Oppose

      April 2, 2024

      The Honorable Aisha Wahab
      Chair, Senate Public Safety Committee
      California State Senate
      1020 N Street, Room 545
      Sacramento, CA 95814

      RE: Senate Bill 1011 (Jones) — OPPOSE

      Dear Senator Wahab:

      Mental Health America of California (MHAC) stands in opposition to Senate Bill 1011 (Jones), legislation that prohibits individuals from sitting, lying, sleeping, or storing personal property on streets or sidewalks if they have access to a homeless shelter or are within 500 feet of a public or private school, open space, or major transit stop. The bill also mandates a 72-hour notice before any enforcement action can be taken against individuals found in violation of these provisions.

      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 through voluntary services that are delivered in their local community with compassion and respect for everyone’s dignity and autonomy.

      This legislation poses a significant threat to the safety and well-being of individuals living with mental and behavioral health challenges, particularly those experiencing homelessness. Approximately 25% of unhoused individuals in California live with a serious mental illness (SMI), with 71% of them unsheltered.[1] To effectively provide necessary services and support, including shelter, resources must be easily accessible to all in need. Unfortunately, this bill fails to allocate any additional funding to assist individuals on their path to recovery. Instead, it penalizes them for circumstances beyond their control, exacerbating rather than alleviating their challenges. This concern is underscored by the 2018 decision by the 9th U.S. Circuit Court of Appeals in the Boise, Idaho case, affirming that it is unconstitutional to criminalize homelessness when adequate shelter is unavailable.[2]

      Moreover, this legislation is unduly broad and would appear to modify the penal code to potentially affect all Californians, extending beyond the intent of impacting the unhoused community. As written, individuals would be prohibited from hosting picnics or barbeques in parks or open spaces. Anyone waiting for the local bus at a transit stop would also be prohibited from placing their personal property at their feet. Additionally, street vendors may be at risk of losing their ability to conduct business in public spaces under the proposed changes.

      For these reasons, we strongly oppose Senate Bill 1011 and ask for your “No” vote. If you or your staff have any questions, or if Mental Health America of California can be of any assistance on this or any other behavioral health bill, please do not hesitate to contact me at hstrunk@mhac.org, or our Interim Director of Public Policy, Karen Vicari at kvicari@mhacofca.org.

      In Community,

      Heidi Strunk
      President & CEO
      Mental Health America of California

      [1] Coc homeless populations and subpopulations reports – Hud Exchange. HUD Exchange. (n.d.). https://www.hudexchange.info/programs/coc/coc-homeless-populations-and-subpopulations-reports/

      [2] Robert Martin v. City of Boise. 9th U.S. Circuit Court of Appeals. (n.d.-b). https://cdn.ca9.uscourts.gov/datastore/opinions/2018/09/04/15-35845.pdf

      SB 999 (Cortese) Mental Health and Substance Use Disorders Health Coverage – Support

      March 18, 2024

      The Honorable Dave Cortese
      California State Senate
      1021 O Street, Suite 6630
      Sacramento, CA 95814

      RE: Senate Bill 999 (Cortese) — Support

      Dear Senator Cortese:

      Mental Health America of California (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 through voluntary services that are delivered in their local community with compassion and respect for everyone’s dignity and autonomy. MHAC is pleased to support Senate Bill 999 (Cortese), legislation which would increase access to mental health and substance use disorder care.

      SB 999 (Cortese) ensures utilization review determinations are made by a healthcare provider practicing in the relevant clinical specialty with the same level of education and experience as the health care provider requesting the authorization. By ensuring that individuals making the utilization review determination have relevant experience and knowledge as a provider, a more informed decision can be made about the necessity of the request, which can lead to more individuals receiving the care they want and need.

      Additionally, this bill requires health plans or insurers to provide direct access and communication between health plans or insurers and health care providers. Increasing access to direct communication reduces the time it takes to conduct a utilization review and increases the delivery of care in a timely manner.  

      Furthermore, the legislation guarantees certain rights to healthcare providers and health plan enrollees such as the name and credentials of the individual or health care provider performing utilization review, the basis for a denial including citations to the clinical guidelines reviewed, and an analysis of why the health plan enrollee did not meet the clinical criteria. Should a utilization review result in denial, a health plan enrollee can appeal using the provided information, empowering individuals to self-advocate for their care.  

      For these reasons, we support Senate Bill 999 (Cortese). If you or your staff have any questions, or if Mental Health America of California can be of any assistance on this or any other behavioral health bill, please do not hesitate to contact me at hstrunk@mhac.org, or our Director of Public Policy, Karen Vicari at kvicari@mhacofca.org.

      In Community,

      Heidi Strunk
      President & CEO
      Mental Health America of California

      SB 997 (Portantino) Access to Narcan – Support

      March 26, 2024

      The Honorable Richard D. Roth
      Chair, Senate Health Committee
      California State Senate
      1021 O Street, Room 3310
      Sacramento, CA 95814

      Subject: Support for Senate Bill 997 (Portantino)

      Dear Senator Roth,

      Mental Health America of California (MHAC) is pleased to support Senate Bill 997 (Portantino), legislation which would permit middle school and high school students to carry federally approved opioid antagonist medicines, such as Narcan, while they are on campus. Additionally, SB 997 requires middle schools and high schools stock fentanyl testing strips and notify students on the location of the strips.  

      MHAC is a peer-run organization leading the state in behavioral health public policy and advocacy since 1957. Our mission is to assist and encourage communities, families and individuals to experience hope, wellness and recovery from mental health and substance use disorder issues through voluntary services that are delivered in their local community with compassion and respect for everyone’s dignity and autonomy.

      In response to the rising fatalities from opioid overdoses, the California Department of Public Health (CDPH) has issued guidelines for fentanyl and opioid overdose prevention, aimed at saving lives. One guideline emphasizes the use of naloxone, a medication that can reverse opioid overdoses.[1] By equipping our youth with naloxone, we can avert needless deaths and educate them about the risks associated with substance use. Additionally, CDPH acknowledges the importance of fentanyl testing strips as a preventive measure to reduce accidental deaths in cases where substances may be laced with fentanyl.  

      For these reasons, we support SB 997 (Portantino) and ask for your “Aye” vote. If you have any questions, or if MHAC can provide any assistance on this bill or any other behavioral health legislation, please do not hesitate to contact me or our Interim Public Policy Director, Karen Vicari, at kvicari@mhaofca.org.

      In Community,

      Heidi L. Strunk
      President & CEO

      [1] Health, D. of P. (n.d.). Fentanyl & Overdose prevention. Fentanyl & Overdose Prevention. https://www.cdph.ca.gov/Programs/OPA/Pages/Communications-Toolkits/Fentanyl-Overdose-Prevention.aspx

      SB 26 (Umberg) Community Assistance, Recovery, and Empowerment (CARE) Scholarship Program at HCAI – Oppose

      May 31, 2024

      The Honorable Thomas Umberg
      1021 O St, Suite 6530
      Sacramento, California 95814

      Re: SB 26 – as amended 1/11/24
      OPPOSE UNLESS AMENDED

      Dear Senator Umberg:

      The undersigned organizations regret that we must respectfully oppose your SB 26, which would establish the Community Assistance, Recovery, and Empowerment (CARE) Scholarship Program at HCAI, unless it is amended to broaden the scholarship to more comprehensively address mental health workforce needs related to the population SB 26 seeks to serve.

      Our organizations share your interest in expanding the workforce available to support individuals living with serious mental illness who are unlikely to survive safely in the community without supports, and whose condition is substantially deteriorating. As you described in your author’s statement about SB 26, many of these individuals are unhoused in our community and face high risks for repeated hospitalization, incarceration, institutionalization, mental health conservatorship, and premature death. The numbers show that California does not have enough mental health professionals, peers, and outreach workers specialized in supporting this population, and we agree that the State must immediately take steps to fill this gap.

      In light of this need, we urge you to expand SB 26 to incentivize mental health professionals to serve in an array of roles and programs evidenced to meet the needs of individuals with serious mental illness and housing instability. The undersigned organizations will oppose SB 26 unless it is amended to expand the proposed scholarship program to accept applicants who agree to work for a county behavioral health agency for at least 3 years in support of any of the county’s programs to treat individuals with serious mental illness and housing instability, not just CARE Court as SB 26 currently proposes.
      In addition to our proposed amendments, we recommend expanding scholarship opportunities to assist the certification of other critical types of professionals who serve individuals with serious mental illness and housing instability, such as certified peer support specialists.

      Counties across California have myriad unfilled job postings for licensed mental health professionals to serve this exact population in outpatient care, outreach and case management roles, crisis response
      programs, and other settings. Counties are also working to roll out new mental health programs that will require significant personnel, such as mobile crisis teams. However, SB 26 proposes to only incentivize licensed mental health professionals to serve in roles related to CARE Court, a new program that has no evidence basis or proven results, while leaving counties still unable to fill roles in their existing and other emerging programs.

      This year, the challenging budget climate will limit the new programs state agencies can create, and many existing safety-net mental health programs are at risk due to changes to the Mental Health Services Act. It is critical that California builds systems that stabilize and strengthen its existing mental health programs and all its new initiatives, rather than hyper-focusing workforce development and funding efforts on untested CARE Court initiatives.

      Our commitment to these proposed amendments is further reinforced by our conviction that CARE Court is the wrong approach to address the growing houselessness and mental health crises in California and is likely to do real harm to the populations it aims to help. Our concerns are deepened by the striking lack of research evidence for any clinical or social benefits deriving from court-ordered outpatient programs such as CARE Court when compared to voluntary community-based treatment. California and its counties are already dedicating overwhelming funding and operations resources to CARE Court while other, less restrictive, more effective approaches flounder for lack of funding and personnel. Let us not also take this faulty approach to addressing mental health workforce shortages.

      We should consider whether counties’ difficulty finding mental health professionals to work in CARE Court programs is rooted in reasons deeper than the mental health workforce crisis. Arguably, the court-based and coercive setting of CARE Court programs conflicts with the core principles of many mental health professions, who have a duty to provide services in the least restrictive environment. For example, as articulated in their professional code of ethics, social workers have an ethical responsibility to “respect and promote the right of clients to self-determination and assist clients in their efforts to identify and clarify their goals.” Emerging professionals may be unwilling to provide services in an environment that invites moral and ethical conflict and lacks evidence basis for success, but perhaps would be willing to work in other county programs serving the same population if they had financial incentive to do so via SB 26 as we propose to amend it.

      For these reasons, our organizations will respectfully oppose SB 26 unless it is amended to broaden the scholarship applicant pool and address workforce shortages across all county-based programs that serve high-risk individuals living with serious mental illness.

      Sincerely,

      Carmen-Nicole Cox, Director of Government Affairs
      ACLU California Action

      Danny Thirukal, Public Policy Coordinator
      California Youth Empowerment Network (CAYEN)

      Deb Roth, Senior Legislative Advocate
      Disability Rights California

      Karen Vicari, Director of Public Policy
      Mental Health America (MHA) of California

      cc: Members and Committee Staff, Assembly Health Committee

      AB 2466 (Carrillo) Timely Access to Behavioral Health Services for Medi-Cal Recipients – Support

      April 5, 2024

      The Honorable Mia Bonta
      Chair, Assembly Health Committee
      California State Assembly
      1020 N Street, Room 390
      Sacramento, CA 95814

      Re: Support for AB 2466 (Carrillo)

      Dear Chair Bonta:

      Mental Health America of California (MHAC) is pleased to support AB 2466 (Carrillo), legislation which would improve timely access to behavioral health services for Medi-Cal recipients by strengthening appointment standards, establishing repercussions for non-compliance, and establishing requirements for data collection and reporting.

      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 through voluntary services that are delivered in a timely manner in their local community with compassion and respect for everyone’s dignity and autonomy. 

      Delays in the delivery of services can mean the difference between managing one’s mental health challenges and experiencing a mental health crisis. According to an audit of the Department of Managed Health Care, non-urgent appointments had an average wait time of 23 days, surpassing the standard time frame by nearly two weeks.[1] Urgent appointments saw an average wait time of 13 days, exceeding the standard urgent appointment time frame by 9 days.

      AB 2466 (Carillo) aims to address these delays and ensure accountability among Medi-Cal managed health plans. For these reasons we support AB 2566 and ask for your “Aye” vote. If you have any questions, or if MHAC can provide any assistance on this bill or any other behavioral health legislation, please do not hesitate to contact me or our Interim Public Policy Director, Karen Vicari, at kvicari@mhaofca.org.

      In Community,

      Heidi L. Strunk
      President & CEO

      [1] Department of Health Care Services and Department of Managed Health Care. Report 2023-115. (n.d.). https://www.auditor.ca.gov/reports/2023-115/index.html