Meadows Mental Health Policy Institute
What Happened in Mental Health – 2015 Legislative Session
The Meadows Mental Health Policy Institute (MMHPI) was launched in April 2014, providing a relatively short lead-time to prepare for the 84th Legislature that began ten months later in January 2015.
Regardless, MMHPI found itself substantially engaged in the legislative process on a number of fronts. CEO Tom Luce’s appointment by Speaker Straus to the Sunset Advisory Commission brought the Institute directly into legislative work while the state’s health and human services agencies were under review. As detailed later in the next section, broad positive reform was brought to the agencies and to behavioral health in particular.
MMHPI processed its legislative work through five key principles.
Observers agree that there was a heightened level of discourse surrounding behavioral health this legislative session. Partly attributed to Sunset but also because advocates, institutions, and legislative leaders understand the fiscal and societal benefits of a modern mental health system.
Once every 12 years, state agencies are placed under review by the Texas Legislature to ensure they are meeting the goals set for them in law, are managing resources properly, and are serving the purposes and populations they were designed to address.
Two key pieces of Sunset legislation (SB 200 relating to the Health and Human Services Commission and SB 202 relating to the Department of State Health Services), along with select riders in the appropriations bill and amendments found in other bills, will reshape the state’s role in behavioral health and how the state works better to partner with local service delivery agencies.
Below are select results of the Sunset reviews of the Health and Human Services Commission (HHSC), Department of State Health Services (DSHS), Department of Aging and Disability Services (DADS), the Department of Assistive and Rehabilitative Services (DARS), and the Department of Family and Protective Services (DFPS). In addition, HB 1 (the general appropriations bill) and SB 20 (state agency contracting bill) are partly responsible for some of these changes.
Health and Human Services consolidation
This reorganization aims to improve services to clients and make the state’s complex system work better through a staged approach to promote accountability, reduce fragmentation, and streamline operations across Texas health and human services systems. It consolidates the functions of DARS and DADS at HHSC in a phased, two-year approach to be completed by 2017. It also transfers certain functions from DSHS (including mental health and substance abuse services) and DFPS to HHSC in order to consolidate health service purchasing and keep these agencies focused on their primary public health and protective services missions.
Comprehensive legislative oversight
Sunset legislation created an oversight committee that will include three members of the public working alongside members of the Legislature. Unlike previous short-term efforts, this committee’s jurisdiction extends into 2023 allowing for a thorough and robust legislative oversight of implementation.
Alignment of system administrative functions
Seeks to improve overall performance and strengthen contract management functions by requiring enhanced oversight across the system and increasing options to respond to particularly problematic contracts. The legislation requires more scrutiny on foster care redesign and DSHS’ behavioral health contracts in particular. It also consolidates information technology (IT) oversight authority and personnel to improve planning and interoperability across systems and elevates oversight of data analysis and reporting to better manage, use, and share system data for improved service delivery.
Transitions the long-standing NorthSTAR pilot for behavioral health service delivery to an integrated funding approach aligned with the rest of the state by creating a new local model in the North Texas region to integrate physical and behavioral health funding and allow enhanced access to federal funds. It also mandates statewide long-overdue consolidation of basic front-door assessment, screening, and referral for mental health and substance abuse services and includes a review of regulations for community-based treatment facilities to reduce unnecessary barriers to care.
Modernized bed allocation
Requires an updated, locally driven methodology for allocating state-funded mental health hospital beds. (Also see SB 1507 by Senator Garcia.)
Behavioral Health Legislative Achievements (Non-Sunset)
Relating to the creation of a grant program to support community mental health programs for veterans with mental illness.
In Fall 2014, Texas leaders announced a $1 million pilot program to support veterans’ mental health projects around the state. While there are several programs in Texas that provide assistance to veterans, this program is unique because it includes 100 percent matching funds from the private sector and other local sources to support community mental health programs for veterans. This bill formally establishes the program under the Health and Human Services Commission, which must contract with a private entity to support and administer the grant program. $10 million per fiscal year ($20 million total) in general revenue is included in the 2016-17 state budget for the state’s portion of the matching grants.
Relating to measures to support or enhance graduate medical education in this state.
The need for additional residency slots in Texas is increasing due to the state’s growing population and higher numbers of medical school graduates as new medical schools are established in Texas. This bill improves strategies for graduate medical education by specifying types of residency programs targeted for expansion (including psychiatry), supporting existing residency slots, and studying and targeting areas of critical medical care shortages. It also establishes the Permanent Fund Supporting Graduate Medical Education by transferring certain assets from the Texas Medical Liability Insurance Underwriting Association.
Relating to student loan repayment assistance for certain mental health professionals.
Texas’ mental health professional shortage is a public health emergency given the difficulty that too many Texans face when seeking care for mental health and substance abuse disorders. Access is key to avoiding situations where individuals end up being treated through costly stays in emergency rooms and county jails. This bill requires the Higher Education Coordinating Board to establish a program to provide loan repayment assistance for certain medical health professionals who commit to work in underserved areas of the state. Repayment assistance may be received for up to five years, and certain criteria regarding time, amount, and type of mental health service apply.
Relating to presumptive eligibility for the Medicaid and child health plan programs for certain children.
A significant number of youth committed to the Texas Juvenile Justice Department has a suspected or confirmed substance use or mental health need. Texas terminates, rather than suspends, a juvenile’s Medicaid benefits when a juvenile enters a detention facility, causing an interruption in the reinstatement of benefits after the juvenile is released from detention. This interruption can result in an inability to obtain necessary medical care. This bill would allow for suspension of Medicaid benefits instead of termination.
Relating to the appointment of a forensic medical director responsible for statewide coordination and oversight of forensic mental health services provided by the Department of State Health Services.
This bill seeks to improve statewide coordination and oversight of mental health and related services provided to individuals who are determined to be incompetent to stand trial, committed to court-ordered mental services, or found not guilty by reason of insanity. These services can include community-based outpatient competency restoration, jail-based restoration, or inpatient restoration at a state mental health hospital. Note: The bill contains a Sunset component that requires the Health and Human Services Commission to alter the regional allocation of state-funded inpatient mental health beds. The executive commissioner of HHSC must adopt an initial allocation methodology, and DSHS must submit a report including a summary of plans to develop or update the bed day allocation methodology to the Legislative Budget Board every two years.
Relating to the authority of a psychologist to delegate certain care to an intern.
Pre-doctoral supervised internships can be difficult to obtain, particularly in private practice settings. This bill expands the authority of a licensed psychologist to delegate and receive reimbursement for psychological tests or services to pre-doctoral interns, which will serve to increase internship opportunities and access to care. The Texas State Board of Examiners of Psychologists would determine which services and tests are appropriate for delegation.
Behavioral health highlights from HB 01, the 2016-17 fiscal biennium appropriations legislation are below. All dollar amounts are subject to verification. Please do not refer to funding amounts in this document as official.
Based on our analysis, the state budget will show an additional $244.2 million in general revenue over FY 2014-2015 levels for mental health programs across agencies throughout the state. Because of increases in the 2013 session that were included in the base budget (a significant improvement in and of itself), this additional funding will do even more to support important state systems.
Funding for behavioral health and substance abuse specifically at the Department of State Health Services includes $2.7 billion in all funds for the biennium, including $2.0 billion in General Revenue Funds and General Revenue – Dedicated Funds, which is an increase of 2.3 percent All Funds, and 8.9 percent General Revenue Funds and General Revenue – Dedicated Funds over the 2014-15 biennium.
Select Appropriations Riders
Multiple state agencies:
All state agencies with mental health functions must now work together under a statewide mental health strategic plan. The rider requires the HHSC Executive Commissioner’s concurrence. This is a significant mental health planning and coordination requirement set by the Legislature. (Article IX, Section 10.04)
Over and above funding increases for baseline veterans mental health programs, this funds the Texas Veterans’ Initiative (SB 55) at $10 million per year for two years. (Article II, HHSC Rider 68)
The agency must review managed care organization data and develop a dashboard of Medicaid indicators. (Article II, HHSC Rider 94)
HB 01 directs HHSC to apply for an Excellence in Mental Health Planning grant, subject to budget neutrality and consistency with the state’s value-based purchasing priorities. (Article II, HHSC Rider 79)
Tying in with Sunset, HB 01 assumes discontinuation of the NorthSTAR behavioral health program in January 2017, with a transfer of funding to the mental health and Medicaid programs operating in the rest of the state. The rider also includes additional one-time General Revenue funds are provided for the transition period. These amounts do not include Medicaid expenditures. (Article II, DSHS Rider 85)
Home and Community Based Services (HCBS). Funds included in the existing strategy for a HCBS program for adults included requirements to seek approval of a Medicaid 1915(i) amendment for federal financial participation. DSHS was directed to implement an expansion of the 1915(i) waiver program to divert populations from jails and emergency rooms into community treatment. $32 million was allocated for the biennium. (Article II, DSHS Rider 61)
Mental Health Program for Veterans. Funds included in the baseline strategies for the MH program for Veterans were increased. The department was also required to submit a detailed report no later than December 1 each year. Note: This is not the Texas Veterans’ Initiative (listed above under HHSC). (Article II, DSHS Rider 62)
Requires allocated funds be used to increase equity on a per capita basis among the Local Mental Health Authorities and NorthSTAR (including its successor agency). (Article II, DSHS Rider 71)
Community Based Crisis and Treatment Facilities Review. This new rider requires the agency to evaluate contract funding requirements and standards governing community-based crisis and treatment facilities for persons with mental health and substance abuse disorders. (Article II, DSHS Rider 80)
What’s Next: The Interim
While the 84th Session of the Texas Legislature was a highly productive one for mental health policy, more work remains to be accomplished and MMHPI will remain engaged.
The Institute will actively monitor implementation of priority legislation such as Sunset, appropriations riders, the new program for Texas veterans, and will engage in other opportunities that will arise.
Renewal of the Medicaid 1115 Transformation Waiver is at the top of the behavioral health community’s list of priorities. Continuing that program is absolutely critical to the state’s ability to provide quality care.
MMHPI is already working to determine potential subjects for interim study in advance of the 2017 legislative session. The process for developing priorities for the next session has begun and MMHPI will provide assistance, guidance, and unbiased, non-partisan support for decision makers.
Additionally, the Institute will conduct extensive local collaborations across the state and will engage elected officials in the work affecting their regions.