A Guide to Understanding Mental Health Systems and Services in Texas 3rd Edition – 2016 Acknowledgement The foundation would like to acknowledge Senior Student Associate Rachel Gandy, Graduate Research Assistants Matti Hautala, Megan Randall, and Lindsey Zischkale, along with Policy Fellow Alison Boleware for the many hours of research, writing and editing needed to update this guide. Their commitment to developing a quality product illustrates their commendable work ethic and professionalism. Hogg FoundAtion For mentAl HeAltH The Hogg Foundation for Mental Health has been promoting mental health in Texas since 1940, when the children of former Texas Governor James S. Hogg established the foundation at The University of Texas at Austin. Over the years, the foundation has awarded millions of dollars in grants to continue the Hogg family’s legacy of public service and dedication to improving mental health in Texas. Other donors have established smaller endowments at the foundation to support its mission. Today the foundation continues to support mental health services, research, policy analysis, and public education projects in Texas. The foundation focuses its grant making on key strategic areas in mental health and awards grants through a competitive proposal process. The foundation is part of the Division of Diversity and Community Engagement at The University of Texas at Austin. For more information, visit www.hogg.utexas.edu. lAnguAge usAge Behavioral health is the term typically used when referring to mental health and substance use. The foundation acknowledges the ongoing discussions and differing perspectives about utilizing the terms “behavioral health” and “mental health.” In this document, the Hogg Foundation uses the term “behavioral health” when referring to both mental health and substance use services and supports. Our belief is that the priority goal of behavioral health policy must be recovery. First Edition: November 2012 Second Edition: November 2014 About tHe guide Suggested Citation: Hogg Foundation for Mental Health. (November 2016). A guide to understanding mental health systems and services in Texas. Retrieved from www.hogg.utexas.edu The Hogg Foundation has made every effort to ensure the accuracy of the information and citations in this report. The foundation encourages and appreciates comments and corrections as well as ideas for improving this guide. Specific comments should reference the applicable section and page number(s). Please include citations for all factual corrections or additional information. All comments and recommendations should be emailed to [email protected]. The online version of this resource guide is available at: www.hogg.utexas.edu 2 Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas Contents Introduction and Overview 13 Texas Environment 17 Select Committee on Mental Health 17 Office of Mental Health Coordination 18 Statewide Behavioral Health Coordinating Council 18 Mental Health Workforce in Texas 20 Contributing Factors to the Workforce Challenges 21 Loan Repayment Program for Mental Health Professionals 23 Peer Support Services/Peer Re-entry Pilot 23 Mental Health and Substance Use Parity 26 Lawsuit Against the Department of Family Protective Services on Behalf of Long-Term Foster Youth 27 Behavioral Health Integration Advisory Committee (BHIAC) 29 Boarding Homes and Housing Choices 29 Services for Individuals with Intellectual/Developmental Disabilities Experiencing Co-occurring Mental Health Conditions 30 Health and Human Services System Transformation 32 HHS Transformation 32 Highlights 33 Discontinuation of NorthSTAR 34 HHS Advisory Committee Reorganization 35 Austin State Hospital (ASH) - Austin State Supported Living Center (AuSSLC) Location Feasibility Study 36 Behavioral Health Advisory Committee 36 1115 Waiver: Texas Health Care Transformation and Quality Improvement Program 37 The Uncompensated Care (UC) Pool 37 The Delivery System Reform Incentive Payments (DSRIP) Pool 38 Funding for Texas’ 1115 Waiver 40 Cost Savings and Outcomes of DSRIP Projects Under the 1115 Waiver 41 Telemedicine and Telehealth Services 42 Benefits ofTelemedicine and Telehealth Services 43 Teladoc Lawsuit Against Texas Medical Board 44 Texas Dual Eligible Integrated Care Project 44 Children’s Services: YES Waiver, STAR Kids, and STAR Health 45 YES Waiver 46 STAR Kids 46 STAR Health 47 National Context 55 SAMHSA 55 The Helping Families in Mental Health Crisis Act – H.R. 2646 55 Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas 3 The Cassidy-Murphy Mental Health Reform Act of 2015 — S. 1945 56 The Mental Health Reform Act of 2016 — S. 2680 57 Updates on the Implementation of the Patient Protection and Affordable Care Act (ACA) 58 Medicaid Expansion Under the ACA 58 Rule Changes to CMS Managed Care 60 Mental Health Parity and Addiction Equity Act (MHPAEA) 61 Supplemental Security Income (SSI) and Social Security Disability Insurance (SSDI) 62 Public Behavioral Health Services in Texas 67 Texas Health and Human Services System 69 Policy Concerns 72 Fast Facts 72 Organization Chart 72 Changing Environment 74 HHS Transformation: SB 200 (84th, Nelson/Price) Highlights 75 Highlights 75 Discontinuation of NorthSTAR: SB 200 (84th, Nelson/Price) 77 HHS Advisory Committee Reorganization: SB 200 (84th, Nelson/Price) and SB 277 (84th, Schwertner/Sheffield) 77 Network Adequacy in Medicaid Managed Care: SB 760 (84th, Schwertner/Price) and HHSC Rider 81, HB 1, 78 Article II (84th, Otto/Nelson) Evaluation of Substance Use Treatment Benefit in Medicaid: HHSC Rider 44, HB 1, Article II (84th, Otto/Nelson) 79 Integration of Behavioral Health Services with Medicaid Managed Care: SB 58 (83rd, Nelson/Zerwas) 79 Programs Transferring from DARS to HHSC and TWC 80 Programs Transferring from DADS to HHSC 81 HHSC Funding 82 MEDICAL AND SOCIAL SERVICES DIVISION 85 Office of Mental Health Coordination 86 Medicaid & CHIP Services 89 Medicaid 89 State Medicaid Agency 90 Medicaid Managed Care 91 Medicaid Funding 94 Medicaid Eligibility and Services 95 Demographics of Medicaid Recipients 98 Children’s Health Insurance Program 98 CHIP Eligibility 98 CHIP Funding 99 Enrollment 99 COMMUNITY SERVICES 103 INTELLECTUAL AND DEVELOPMENTAL DISABILITIES & BEHAVIORAL HEALTH SERVICES 105 Behavioral Health Services (formerly provided through the Department of State Health Services) 106 Policy Concerns 106 Fast Facts 106 Background 107 Sunset and Transformation Highlights 108 Changing Environment 108 Discontinuation of the NorthSTAR Program 108 4 Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas Forensic Director Position 109 Ongoing Jail-based Competency Restoration Pilot Program 110 Continued Expansion of Peer Support Services 111 Implementation of the Statewide Expansion of the YES Waiver 112 Improvement of Client Outcome and Performance Measures 113 Rider 58 114 Rider 82 115 Behavior Health Funding 116 Service Providers 118 Medicaid Managed Care Providers 118 Local Mental Health Authorities 119 NorthSTAR 122 Federally Qualified Health Centers (FQHCs) and Other Community Providers 122 Community Mental Health Services 123 Texas Resilience and Recovery Framework 123 Medicaid 128 Individuals Considered Medically Indigent 129 Priority Populations 130 System Utilization (Community Mental Health Services) 131 Waitlists for Community-Based Mental Health Services 134 Crisis Services 136 Inpatient Mental Health Hospital Services 138 Introduction to Inpatient Services and the Admissions Process 138 Civil Commitments 139 Forensic Commitments 139 Maximum vs. Non-Maximum Security Placements 140 Types of Inpatient Settings 140 State Hospitals 140 Staffingand Functional Capacity of State Hospitals 142 Funding for Inpatient Care 143 Institutions for Mental Diseases (IMD) Exclusion 143 Inpatient Services at State Hospitals: Utilization and Costs 144 State-Funded Community and Private Hospitals 146 Continuing Issues 148 Addressing the Shortage of Publicly-Funded Inpatient Beds 148 Improvements to Aging State Hospital Infrastructure 150 Other Issues Associated with Inpatient Services 152 Reducing the Use of Seclusions and Restraints 152 Increasing Access to Timely Competency Restoration Services 152 Inpatient Competency Restoration 154 Jail-Based Competency Restoration 154 Outpatient Competency Restoration 154 Substance Use Services 156 Access to Substance Use Services 158 Funding for Substance Use Services 159 Eligibility for Substance Use Services 159 Priority Populations 160 Co-occurring Mental Health and Substance Use Disorders 160 Substance Use Services: Utilization and Costs 161 Substance Use Services: Quality of Care Measures 162 Systems of Care and The Texas Recovery Initiative 163 Hogg Foundation for Mental Health | A Guide to Understanding Mental Health Systems and Services in Texas 5 Intellectual and Developmental Disability Services Department 165 Policy Concerns 165 Fast Facts 165 Mental Health Needs of Individuals with Intellectual/Developmental Disabilities 165 Prevalence of Mental Health Conditions for People with Disabilities 166 Mental Health Needs of Aging Texans 167 Changing Environment 167 Funding 170 Programs and Services for People with Disabilities Who Have Co-occurring Behavioral Health Conditions 171 Community Long-Term Services and Supports 171 Medicaid 1915(c) Waiver Services 171 Role of Local Intellectual and Developmental Disability Authorities