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Executive Summary:

The COVID-19 pandemic has created immense challenges for California’s community-based behavioral health care system and the people it serves. Traditional in-person service models for mental health and substance use disorders (SUDs) presented a risk of contagion as the pandemic took hold. At the same time, deferring care for weeks or months created grave risks for individual health and welfare, particularly as pandemic-related stressors drove an increase in the prevalence and severity of behavioral health conditions. Recognizing these challenges, both the federal and California state governments implemented numerous legal reforms aimed at supporting providers’ efforts to slow the spread of the coronavirus while preserving access to needed services in a time of social distancing and economic crisis.

This report discusses the impact of those legal reforms on outpatient and residential behavioral health services in California. The authors focus on legal changes that were adopted and implemented during the early months of the COVID-19 pandemic (January to July 2020), and also identify opportunities for longterm reform. Although focused primarily on Medi-Cal (California’s Medicaid program), the report also addresses legal changes that affected the Medicare program and commercial health plans. Because this report focuses specifically on outpatient and residential care — commonly referred to as “community behavioral health care” — it does not address acute behavioral health services furnished in the hospital emergency department or inpatient settings.

The authors undertook two primary tasks in preparing this report. First, they prepared a compendium of the relevant legal actions adopted in response to the COVID-19 pandemic through California and federal laws, regulations, waivers, or other regulatory guidance (the “Legal Compendium”). Second, they conducted interviews with four stakeholders who collectively possess a deep and diverse set of experiences in California’s behavioral health system. (See Appendix B for additional details.) The authors provided the Legal Compendium to these interviewees and asked them to consider which legal changes had the greatest impact on the delivery of behavioral health care in California during the pandemic and which changes should be preserved — or expanded upon — after the pandemic subsides.

In Table 1 (page 4), the authors outline both the temporary response measures that were most important in supporting access to high-quality community behavioral health services and those that are the most promising opportunities for long-term reform. Many of these policies have long been supported by advocates in pursuit of a more accessible and efficient community behavioral health system. They fall into four general categories:

  1. Coverage for telehealth services
  2. Medi-Cal’s cost-based reimbursement system
  3. Controlled substances and prescription drugs
  4. Provider licensure and operating standards

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