NCYL is working to improve access to mental health services for California's "out-of-county" foster children: children placed in foster care outside the county where they lived when they first became dependents of the state. More than 80,000 children live in foster care in California, the largest foster care population in all 50 states. Of those, 20 percent (approximately 16,000) are placed across county lines. Due to the administrative structure of mental health care delivery and funding in California, out-of-county children experience frequent and lengthy delays in getting mental health services, or do not receive them at all. Given the prevalence of both mental health needs and placement instability among foster youth, such delays are harmful to their development and well-being, and in some instances are life-threatening.

Foster children have a legal right to mental health services under Medicaid, a cooperative federal-state program that funds medical care for low-income individuals. In California, foster youth under 21 are eligible for a full range of services, including Early and Periodic Screening, Diagnosis and Treatment (EPSDT). EPSDT imposes a clear obligation on states to provide medically necessary care.

The state Department of Mental Health is the state agency responsible for administering California's county-based mental health system. Almost all of California's 58 counties have a Mental Health Plan (MHP), in contract with the state. Each MHP, in turn, contracts with local private service providers (or uses county mental health staff) to deliver services. When a foster child is placed out-of-county, his or her care remains the responsibility of the county of origin, financially and otherwise. This leads to a number of problems:

• Since it is the county of origin rather than the host county that receives state funds for this child, the host county will have to recover its expenditure on the child from the county of origin. This is a slow and uncertain process, given the absence of an efficient reimbursement mechanism between counties. Providers face similar reimbursement problems. As a result, the child will often be denied services in the host county, or experience long delays.
• It is difficult for a county of origin to connect a foster child with services in another county: the social worker is handling the child's case long distance and may be unfamiliar with providers in the host county. Inadequate coordination between social services and mental health aggravates the problem.  In some cases, the MHP in a child's county of origin is unaware that the child has been placed in another county.
• When the county of origin identifies a provider in the host county and offers to contract with them, providers may be reluctant: providers are already under contract with their own county's MHP and may have insufficient capacity to serve children from both in and out of the county.  Local providers may also wish to avoid the administrative burden associated with contracting with a different county for a small number of children. Even if providers are otherwise willing, the rates offered by the county of origin may be insufficient to cover costs.

NCYL is working to eliminate these problems to ensure that out-of-county foster children get the mental health care they need. The Center's efforts include:

• Actively advocating for a more expansive interpretation of Senate Bill 785, which addresses several aspects of the out-of-county problem, including streamlining the contracting process between the county of origin and providers, and establishing time frames. NCYL has recently drafted regulatory language to reflect this broader interpretation to improve access to services for children who have either been adopted or placed in a legal guardianship. This language will be included in a DMH Information Notice, a regulatory instrument that dictates county practices.
• Compiling a report documenting the out-of-county problem and proposing solutions. Working with other advocates, especially those engaged in individual client representation, NCYL is building a constituency of advocates committed to supporting efforts to solve this problem.
• NCYL attorney Zahra Hayat, who is heading up this effort, is working with the California Child Welfare Council (CWC), a statutory body comprised of California Supreme Court judges, and state and county officials and advocates. They are charged with making specific recommendations to improve foster care to the governor, legislature, and Judicial Council. Through presenting on the problem and preparing informational materials, NCYL is working to place the out-of-county problem high on the CWC's agenda.