Background: The Children's Mental Health Work Group (CMHWG) was established by Engrossed Second Substitute House Bill 2439 (2016). Part of the stated purpose of the CMHWG is to identify barriers to accessing mental health services for children and families, and to advise the legislature on statewide mental health services for this population. The Work Group published its final report and recommendations in December 2016.

Medicaid Managed Care for Children. The Health Care Authority (HCA) administers Apple Health, the state-federal Medicaid program that provides health care for eligible low-income individuals. Apple Health for Kids is available at low or no cost for children whose families meet income eligibility criteria. Benefits for children and youth up to age 21 who are enrolled through Apple Health managed care organizations (MCOs) include the Early and Periodic Screening, Diagnosis and Treatment Program (EPSDT), which covers regularly scheduled health screening (well-child visits) to evaluate a child's growth, development, and general physical and mental health.

When purchasing managed care for Medicaid participants, HCA must ensure that MCOs demonstrate the ability to supply an adequate provider network. Federal regulations and state law require MCOs to maintain a network of appropriate providers sufficient to provide adequate access to all services covered under the contract.

Behavioral Health Organizations. The Department of Social and Health Services (DSHS) contracts with behavioral health organizations (BHOs) for the provision of community-based mental health and substance use disorder treatment services. BHOs are operated by a county authority or group of county authorities and provide a network of services in a specific region. BHOs provide services to Medicaid enrollees and others who have a medical need. To access BHO mental health services funded by Medicaid, the client must meet Access to Care Standards established by the DSHS.

By January 1, 2020, behavioral health services must be fully integrated into managed care organizations that provide physical and behavioral health services to Medicaid clients.

Telemedicine. Telemedicine is the use of electronic communications to provide health care services to a patient at a distance. Electronic communication through audio-visual equipment allows real-time interaction between a patient and provider. Health plans offered by health carriers and MCOs must reimburse health care providers for eligible health care services provided through telemedicine. In addition, originating sites other than a person's home may charge a facility fee for infrastructure and preparation of the patient.

Mental Health in K-12 Schools. In October 2016, the Joint Legislative Audit Review Committee (JLARC) completed an inventory of mental health services available to students through schools, school districts, and educational service districts. JLARC reported that of the approximately 55,000 children aged 5-17 who received Medicaid-funded mental health services in 2015, approximately 10,000 students received those services in their schools. The remainder of students who received Medicaid-funded mental health services were served through MCOs or BHOs.

Child Care Consultation Pilot. In 2008, the Department of Early Learning (DEL) conducted a childcare consultation pilot project and project evaluation. The pilot linked childcare providers with resources to support the care of infants and young children with behavioral concerns. Services included targeted consultation and training on social and emotional supports for providers.

Partnership Access Line. The Partnership Access Line (PAL) is a telephone consultation service based at Seattle Children's Hospital and is available at no charge to primary care providers who wish to consult with a pediatric psychiatrist. The DSHS implemented PAL as a pilot program in 2008 in partnership with the University of Washington. In 2016, the Legislature authorized the HCA to implement the PAL Plus expansion pilot to provide limited, regionally based, in-person counseling sessions for Medicaid patients.

Mental Health Workforce. The Workforce Training and Education Coordinating Board (Workforce Board) advises the Governor and Legislature on workforce development policy. The Workforce Board convenes and provides staff support to the Health Workforce Council (Council). The Council researches factors affecting shortages in the healthcare professions and recommends strategies to ensure an adequate supply of health care personnel.

The Accreditation Council for Graduate Medical Education (ACGME) accredits medical education and residency programs and associated sponsoring institutions. Examples of psychiatry residency programs in Washington include the Providence Psychiatry Residency located at the Spokane Teaching Health Clinic on the Washington State University (WSU) Spokane campus, and the University of Washington (UW) Child and Adolescent Psychiatry Residency Program based at Seattle Children's Hospital.

Summary of Bill (First Substitute): Medicaid Managed Care for Children. Until June 30, 2020, HCA must oversee the coordination of mental health resources and services for Medicaid-eligible children, regardless of whether the referral occurred through primary care, school-based services, or another practitioner. HCA must require each managed care organization to develop adequate capacity to facilitate child mental health treatment services by:

ensuring individuals secure and complete appointments,
tracking individual utilization of services,
coordinating with primary care providers on individual treatment plans and medication management,
providing information to plan members and primary care providers about the behavioral health resource line, and
maintaining an accurate list of providers contracted to provide mental health services to children and youth. The list must contain current information about provider availability and be made available to plan members and primary care providers.

The HCA must report on the number of children's mental health providers available in the previous year and the overall percentage of providers who were actively accepting new patients in its annual report to the legislature on the status of access for behavioral health services for children.

Depression Screenings for Children and Adolescents. Beginning January 1, 2018, HCA must require universal screening and provider payment for depression for children ages 11-21 as recommended by the Bright Futures Guidelines of the American Academy of Pediatrics.

Telemedicine. Beginning January 1, 2018, BHOs contracting with DSHS must reimburse providers for behavioral health services provided through telemedicine. DSHS must adopt rules to implement this requirement.

Mental Health Leads in Educational Service Districts. Each Educational Service District (ESD) must establish a lead staff person for mental health. The Office of the Superintendent of Public Instruction (OSPI) must employ a children's mental health services coordinator to provide support for the ESD leads. The OSPI must designate one ESD as a "lighthouse" to provide technical assistance to the other ESDs, including technical assistance with Medicaid billing for schools and school districts.

Childcare Provider Consultation. DEL must establish a childcare consultation program for providers caring for young children who exhibit behavioral concerns.

Mental Health Workforce. The Workforce Board must conduct a workforce survey for clinicians qualified to provide children's mental health services and report the results to the Legislature by December 1, 2018.

WSU and UW must each offer one 24-month residency position to a resident specializing in child and adolescent psychology. The WSU residency must be located in Eastern Washington and UW residency must be located in Western Washington.

Staff Summary of Public Testimony on Original Bill (Human Services, Mental Health & Housing): The committee recommended a different version of the bill than what was heard. PRO: I have a family member who should have been diagnosed at a young age with a mental illness. Thankfully she is now getting help. These recommendations came out of the CMHWG. We have tried to address issues such as availability of care, training for mental health providers, and the resources needed by providers and schools. Now is the time to reduce childhood mental illness. More than one in five children are diagnosable with a serious mental illness. This bill provides a compassionate state model recognizing that intervention is possible early in life to provide for a stronger future. It empowers families to intervene appropriately. Our priority is to transform our mental health system to emphasize prevention and early intervention. The needs of kids are severely underaddressed. At our hospital, we frequently admit children in mental health crisis. We have no resources to provide counselling beyond medication management. Children are often discharged home without receiving appropriate care. We need to be thoughtful about how we use precious resources, and use scarce dollars responsibly. This bill focuses on prevention, expanding the workforce, and accountability. MCOs have consultation available, but there is a disconnect where kids aren't getting care. We need to make sure that available services are used. Please add coverage for maternal depression screens. We support the delivery of care through telemedicine. WSU is ready to deliver the residency called for in the bill. There are only a handful of trained adolescent psychiatrists on the eastern side of the state. Workforce issues are prominent; the shortage is most pronounced in children's mental health. Please add explicit language to require school districts to collaborate with community behavioral health agencies. The foster care population has been exposed to trauma and has an above average need for behavioral health services. We support universal depression screening and accountability for MCOs. We have concerns about accountability for tracking and reporting when there is a handoff between the MCO and BHO. We support the PAL line but please don't transfer the payment obligation to health plans. Every day in schools we see the impact of unmet mental health needs. We can't fulfill our mission to give every child the opportunity to graduate without meaningful behavioral health support and whole child services.

CON: Children's needs should not lead to a psychiatric label and drugging. Seventy percent of children with ADHD in Washington took medication, while only 38 percent received behavioral health care. Universal screening is uncertain with at most a moderate net benefit. Physical causes of behavioral can mimic behavioral health disorders. If you think that behavioral is a disease, you will have vast needs. Please clarify the division between behavior and disease.

OTHER: We have a request for technical changes. Please do not impose fees and assessments on health plans to support the expansion of the PAL line. Increased costs will be reflected in premium rates. Health carriers are already under tremendous pressure and uncertainty due to the Affordable Care Act.

Staff Summary of Public Testimony on First Substitute (Ways & Means): PRO: This bill was the result of a workgroup. I participated in thiswork group and see a strong need for mental health involvement with our children, especially the workforce; we are lacking in this state. We need to be looking at in a more in-depth manner. I testify in support of this bill. Yes, there is a significant cost to this bill. Yes, there is a significant cost if we don't invest in prevention and early intervention. However, without this legislation the system will continue to be crisis-driven. This is reflected in the Governor's budget for items such as jail and other boarding issues, over-crowded psychiatric hospitals and homelessness, and at the back end, the police use of deadly force. We talked to the Governor's Office about prevention, but the response was that there wasn't enough money. The money is used at the back end. How can we reverse this dynamic and focus on prevention and intervention? The taskforce did a good job. We need to move in this direction. This will reduce costs down the road. This will reduce the need for children to be on medication and will help keep them out of the emergency room. This is about access and accountability. Parents have difficulty accessing services. This prolongs the problem and adds to costs. Changes are being made on the House side that we hope will bring the costs down. I speak to you in favor of this bill as a mother who lives with a bi-polar son. When he retuned home, he didn't have a treatment plan and couldn't find a psychiatrist. This bill establishes services at schools. This bill will eliminate the need for luck and privilege. My son is now doing well. This bill will provide parents the support they need for their kids. Where a physician does her medical residency is where she stays to do her practice. There is a dearth of pediatric psychiatrists. We need attention in those areas. The cost is $200,000 per resident. Specifically to section 4, provider screening and payments, this is a great way to ensure access to services—specifically to the foster care population. We think this will help us get to integration quicker.

CON: We are concerned about the mental health screening contained in this bill. When looking at the cost of the bill, about 4 percent of our children are accessing mental health services. The bill wants to increase this, but this isn't contained in the fiscal note. The USPSTF made the recommendation for universal depression screening, but admit only moderate certainty that screening for major depression in adolescents will have a moderate benefit. We believe the collaboration across agencies is the most positive thing that came out of the taskforce.