October 29, 2015
Response to the DHCS:
How is Peer Certification Different from “Other Qualified Provider”?
These responses reflect the current version of SB 614, as amended August 31st
How is a Peer Support Specialist Different?
Some County Behavioral Health Plans as well as providers presently utilize peers as
part of their system of care for clients. However there is no standardized training, code
of ethics, or definition of services. Using the Other Qualified Provider is inadequate for
it offers no training or service definition and it is cumbersome to bill. It merely is a
catch-all category for an employee with a high school diploma or its equivalent who is
18 years of age and working within the system. (This can be confirmed by the Working
Well Together taskforce materials.)
Peer support is an evidence based practice with a specific definition of service and
provided under a distinct code of ethics and within a scope of practice. Like other
mental health providers serving the public, there should be state oversight regarding
quality of the provider. SB 614 provides a framework to certify and train peers and
family members as specified, defines the service of peer support, and enables
California to obtain new federal funding for this purpose. It offers a more
comprehensive approach to train and utilize this valuable workforce.
Why is it needed now?
Establishment of peer specialist certification and inclusion of these services within the
Medi-Cal Program will enable California to better serve Medi-Cal enrollees with
behavioral health care needs, will improve and expand our behavioral health care
workforce, and provide new federal Medicaid (Medi-Cal) funding.
Specifically, it is advantageous for several reasons as follows:

Work Force. Peers offer a strong ability to diversify and extend the health and
behavioral health workforce. Certification provides for portability to other
counties in the State.

Better Outcomes. Peer support specialist services are an evidenced-based
practice. Services will enable California to better serve Medi-Cal enrollees with
behavioral health care needs. They improve treatment outcomes and service
treatment efficiency.
Studies demonstrate that peer support specialists improve patient functioning,
reduce hospitalizations and hospital days, increase patient satisfaction, alleviate
depression and other symptoms, reduce family burden, and increase patient
activation.
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
Improved Care Coordination. Peer support specialist services are provided as
part of a care team and are an integral component of a health and behavioral
health care delivery system.

Increased Federal Funds. CA could receive additional federal funds (50%
match) for these services. Federal CMS approval is needed to obtain statewide
Medi-Cal reimbursement.

Inclusion in 1115 Medi-Cal Waiver Renewal. The Brown Administration has
included peer support specialists as part of its Waiver Renewal under Workforce
Development (Page 23 of Waiver). Legislation is needed to incorporate this and
SB 614 can be used for this purpose.
What is meant by “Peer Certification”?
Peer Certification is an official recognition by a certifying body that the practitioner has
met qualifications that include lived experience, and training from a standardized
curriculum on behavioral health care issues.
The standardized curriculum has been approved by the certifying body and includes a
mandatory number of hours of training in various topics pertaining to behavioral health,
working with specific populations, strength-based planning, developing wellness plans
and related aspects. Core competencies of a peer are identified according to a
recognized process.
Like any other profession, the certification defines the level of care and services so that
the parameters established by the standardized curriculum and certification
requirements are respected and understood statewide. Defining and standardizing the
classification of peer specialists through certification prevents engagement outside
one’s expertise.
What are Peer provided services?
Examples of peer services include the following:

Peer mentoring or coaching—developing a one-on-one relationship in which a peer
leader with recovery experience encourages, motivates, and supports a peer in
recovery;

Peer recovery resource connecting—connecting the peer with professional and
nonprofessional services and resources available in the community;

Recovery group facilitation—facilitating or leading recovery-oriented group activities,
including support groups and educational activities; and

Building community—assisting peers build healthy social networks through emotional,
informational, and affiliation types of peer support.
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How Would Peer Services Operate within the System?
Section 14045.22 directs the DHCS to amend California’s Medi-Cal Plan to include
peer, parent, and family support specialists and their distinct service into the Medi-Cal
Program to enable California to receive federal funds for this purpose.
Peer services would be provided to Medi-Cal beneficiaries as part of a comprehensive,
individualized plan of care within a managed care environment provided under the
authority of either the State’s Specialty Mental Health Managed Care system operated
by County Behavioral Health Departments, or Medi-Cal Managed Health Care (under
the 1115 Waiver).
Federal CMS requires for the services to be provided through a system of care and
these are the systems of care in California. No separate fee-for-service peer support
specialist services would be provided or reimbursed. Further, under the 1915 b Waiver,
there is no freedom of choice. An individual enrolled in Medi-Cal can only receive their
specialty mental health care from the county.
Any “Scope of Practice” Issues?
SB 614 does not present any “scope of practice” issues. It clarifies that peers provide a
distinct service, and that certification and training will occur.
Section 14045.14 (c) provides the DHCS with the authority to define the range of
responsibilities and practice guidelines for the categories of peer support specialists
listed in SB 614. As such, all functions of these peer categories must meet State and
federal CMS requirements and be employed within a system of care—i.e., Specialty
Mental Health Managed Care or Medi-Cal Managed Health Care.
Section 14045.12 provides the intent of the Legislature in enacting the bill and this lays
out a framework, including the following:
“(b) Provide support, coaching, facilitation, and education to beneficiaries with
mental health needs, substance use disorder needs, or both, and to families or
significant support persons.”
“(c) Collaborate with others providing care or support to the beneficiary or family.”
“(f) Assist parents, when applicable, in developing coping beneficiary or family.”
“(i) Promote socialization, recovery, self-sufficiency, self-advocacy, development of
natural supports, and maintenance of skills learned in other support services.”
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Is this a clinical classification?
No, it is not and this legislation is not establishing a licensure category either. SB 614
makes this explicitly clear in Section 14045.19 which says the following:
“This article shall not be construed to imply that an individual who is certified
pursuant to this article is qualified to, or authorize that individual to, diagnose an
illness, prescribe medication, or provide clinical services.”
The federal CMS letter makes it clear as well that peers are not a clinical designation.
We specifically reference the federal CMS letter in Section 14045.14(b).
Is there Clinical Supervision of the Peer?
Yes. Section 14045.14(g) states that the DHCS shall determine clinical supervision
requirements for personnel certified under this article but that at a minimum, peers shall
work under the direction of a mental health rehabilitation specialist or substance use
disorder professional.
Mental health rehabilitation specialists are defined in the State’s 1915b Specialty Mental
Health Waiver and have the following key qualifications: Is a person with a B.A. and
four years of experience in mental health, social adjustment or vocational adjustment.
The substance use disorder professional
Federal CMS requirements state that supervision must be provided by a competent
mental health professional as defined by the State. SB 614 provides for clinical
supervision and also allows for the DHCS, through federal CMS approval, to increase
this level of supervision through their administration of the program
What about Background Checks (Fingerprinting, etcetera)
Peer Support Specialists would be employed as part of a system of care under
Specialty Mental Health Managed Care or Medi-Cal Managed Care. Both of these
systems conduct standard background checks and have strict contracting requirements.
Which entity is intended to actually perform the certification activities?
As California’s designated “Medicaid Agency”, the DHCS must approve and authorize
all aspects of the Medi-Cal Program. But DHCS can choose to authorize contractors or
other public agencies to work under their oversight.
Section 14045.14 requires the DHCS, as the sole state Medicaid agency, to establish
the certification program. Paragraph (a) then requires the DHCS to establish a
certifying body, either within the department, through contract, or through an
interagency agreement, to provide for the certification.
The intent here is to offer the Administration choice in making this determination but to
utilize only one entity as the certifying body. By utilizing one certifying body it avoids
any potential for conflict and assists in ensuring consistency.
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A key responsibility of the certifying body would be to ensure the curriculum meets any
federal CMS requirements and meets content requirements. Integrity of the curriculum,
training and testing is essential. Strong integrity of this component will go a long way in
obtaining and maintaining federal CMS approval.
There is California specific training ongoing presently (e.g., Pacific Clinics, California
Social Rehabilitation Association (CASRA), NAMI CA, and other non-profits), as well as
national practice guidelines for core curriculum. The federal SAMHSA also has
substantial information here for ready access. Thirty-five States are presently doing this
so there are many models to emulate. Additional information can be provided on this,
just let us know please.
The minimal standards for certification of a peer under the program are contained in the
legislation (See Sections 14045.15, 14045.16, 14045.17 and 14045.18) and in the
federal CMS letters previously provided. In essence, certification means that the
individual has self-identified lived experience, can demonstrate leadership and
advocacy, is in recovery, has completed the curriculum and training, and has passed an
examination.
All Certified Peer Specialists would be working under supervision as noted in the
legislation and within a managed care environment as required by the legislation as well
as by the federal CMS letter. There is absolutely no Fee-for-Service component here.
County Mental Health Plans and Health Plans participating under the Medi-Cal
Managed Care Program may provide to eligible Medi-Cal enrollees peer support
specialist services (Section 14045.22(a)(2). Therefore, a Certified Peer Specialist
would either be employed directly by a County MHP or Health Plan, or be employed by
a community-based entity that contracts with the County MHP or Health Plan. All of the
governing components of California’s 1915b Waiver (renewed for 5 years) and 1115
Waiver would be applicable for these services would occur in the managed care
environment and through a contract with the State (between the County MHP or Health
Plan participating in the Medi-Cal Managed Care Program).
Further, existing contract language under the Medi-Cal Program for these contractors
requires background checks and verification of any required credentialing for
employment. Peers would have employment contracts with their agency (contracting
agency or managed care plan). Standard, existing aspects of this process can be
utilized for purposes of this program potentially. For example, Los Angeles County
requires its contracting agencies to designate licensed staff members to attest to
training verification information.
Further details can be worked out with the Administration through the workgroup
process as contained in Section 14045.20. This is why implementation would not occur
until 2017. However, I would reiterate that substantive work has already been done and
that County Behavioral Health Plans are presently employing Peers, contractors are
training Peers, and the DHCS includes Peers in its 1115 Waiver Renewal submittal.
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