Medicaid and Behavioral Health Screenings What the Law Requires

   

Jay E. Sicklick, Deputy Director Center for Children’s Advocacy

Director – Medical Legal PartnershipJanuary 9, 2014

Overview and Goals

What does the law have to do with mental health screenings?

Medicaid as foundation for screenings Best practice vs. overburdening requirement Massachusetts case study

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Case Study: Billy M. 4 years old In primary care office for well-care exam Presents with no speech or language delays Academically solid in pre-school setting

Psycho-Educ. Eval. at above normal range

But conduct poor due to “behavioral issues” (Mom called frequently to pick son up early)

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Case Study: Billy M.

Mom shares that Billy has recently been described as using aggressive behavior and inappropriate language

Unbeknownst to you, Mom has history of bipolar disorder

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Case Study: Billy M.

What is the PCP’s next step?1. Tell mom to wait and see what

happens and call back? 2. Make a referral? To whom? 3. Conduct a brief validated screen

for mental health red flags?

Why or Why Not?

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Screening: Why vs. Why Not

Why? – Medicaid/Husky A

insured child under 21… law requires screening

– Reimbursement available for developmental and behavioral screens

Why? – Commercial

insurance will reimburse as well

– Appropriate practice as defined by AAP

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What If We Do Not Screen? In any given year, more than 1 in 5

Connecticut children struggle with mental health or substance abuse

More than 50% do not receive treatment 51% had - or were at risk of - court

involvement, juvenile justice intervention, court referral for families with service needs

Source: Andrea M. Spencer, PhD, Center for Children’s AdvocacyBlind Spot: Impact of Missed Early Warning Signs on Children’s Mental Health (2012)

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Medicaid 101

• Title XIX of SSA (1965)• Join federal/state program• CMS federal agency oversees Medicaid • State agency compliance thru

administration & waiver system

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Mental Heath Screening = Primary Care or Mental Heath Screening ≠ Primary Care?

Federal Medicaid Law• Early and Periodic Screening, Diagnosis

and Treatment (EPSDT)* (Medicaid’s child health component)

• EPSDT mandatory set of services and benefits for children under 21 enrolled in Medicaid

• 1 in 3 U.S. children under 6 are eligible for Medicaid

*Source: 42 U.S.C. § 1396d(r)(1) et seq.

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Origins of EPSDT

“…the early years arethe critical years … Our goal must be clear –to give every child thechance to fulfill his promise.”(Special Message to theCongress Recommending a12 Point Program forAmerica's Children and YouthFeb. 8, 1967)

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What is EPSDT?

• Early ‒ Identify problems starting at birth• Periodic ‒ Check children's health at periodic,

age-appropriate intervals• Screening ‒ Conduct physical, mental,

developmental, dental, hearing, vision, and other screening tests to detect potential conditions

• Diagnosis ‒ Perform diagnostic tests to follow up when a risk is identified

• Treatment ‒ Treat the conditions identified

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EPSDT and Screening

EPSDT vital to ensure that young children receive appropriate health, mental health, and developmental services

Screening to detect physical and mental conditions must be covered at established, periodic intervals

(periodic screens) and whenever a problem is suspected

(inter-periodic screens)42 U.S.C. § 1396d(r)(1) et seq. (emphasis added).

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EPSDT and ScreeningWhat is Screening under EPSDT?

– Includes comprehensive health and developmental history, unclothed physical exam, appropriate immunizations, laboratory tests, and health education.

– Dental, vision, and hearing services are required, including appropriate screening, diagnostic, and treatment.

Treatment component of EPSDT is broadly defined. Federal law states that treatment must include any "necessary health care, diagnostic services, treatment, and other measures" that fall within the federal definition of medical assistance (as described in Section 1905(a) of the Social Security Act) that are needed to "correct or ameliorate defects and physical and mental illnesses and conditions discovered by the screening services.”

42 U.S.C. § 1396d(r)(1) et seq. (emphasis added).

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EPSDT and Screening:What is Covered?

All medically necessary diagnostic and treatment services within the federal definition of Medicaid medical assistance must be covered, regardless of whether or not such services are otherwise covered under the state Medicaid plan for adults ages 21 and older.

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EPSDT Non-Compliance? Bring on the LawsuitsRosie D. v. Romney

Mass district court screening delivery system in primary care was woefully inadequate for state’s Medicaid children and lack of community-based mental health systems violated EPSDT

Ordered MASS Health (Medicaid Agency) to design comprehensive screening and referral system for children at risk insured through MA

Compliance ensured through data collection (EPSDT numbers)

Rosie D. v. Romney, 410 F. Supp. 2d 18 (2006).

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Rosie D. Outcomes

2008 Q1 2009 Q4 2011 Q30.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

14%

58%

67%

Reported Mental Health Screenings at Well-Child Visits

Reported Mental Health Screenings at Well-Child Visits

Teen Screen at Columbia University, Rosie D. and Mental Health Screening (2010); MassHealth Quarterly Screening Data: April-June 2011.

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Positive Screen = ReferralsRosie D. Outcomes

2008 Q1 2009 Q30

10,000

20,000

30,000

40,000

50,000

60,000

1,533

50,535

Number of Children Screened Positive for Mental Health Disorders

Teen Screen at Columbia University, Rosie D. and Mental Health Screening (2010)

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Referrals = InterventionRosie D. Outcomes

FY 2010 FY 2011 0.00%

0.50%

1.00%

1.50%

2.00%

2.50%

3.00%

3.50%

4.00%

4.50%

5.00%

3.50%

4.70%

Number of Youth Receiving Any Remedy Service

Def.’s Report on Implementation(Jan. 1 2012).

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Positive Screens = Referrals

Oregon Study utilized ASQASQ compared to Pediatric Developmental Impression (PDI)PDI on scale from typical–questionable–delayed

224% increase in referral rate in a year PDIs alone = 42% of referrals

Hollie Hix-Small et al., Impact of Implementing Developmental Screening at 12 and 24 Months in a Pediatric Practice, 120 PEDIATRICS 381 (2007).

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Importance of Screening Instruments

PDIs missed children at risk 67.5% of delayed cases only identified by ASQ 45.1% of early intervention eligible children

missed by PDI Generally

38% of 12 month cases missed by PDI 23% of 24 month cases missed by PDI

Hollie Hix-Small et al., Impact of Implementing Developmental Screening at 12 and 24 Months in a Pediatric Practice, 120 PEDIATRICS 381 (2007).

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Where Has It Led?

CCA Proposed Legislation2011 Session of Connecticut GA

DSS to develop reimbursement strategies to provide support for PCPs to conduct screenings in primary care setting

DSS requested convening of a task force rather than pursue legislative initiative

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Where Has It Lead? Behavioral Health Screening Task ForceExamination of delivery systems to ensure that screenings are promoted, supported and reimbursed in primary care.

PlayersDSSDCFCT Chapter – AAPCT Council of C&A Psychiatrists (CCCAP)ACAPDDS – Birth to ThreeCHDICT Behavioral Health Partnership (CT-BHP)School based health centers (SBHC)Early Childcare Systems – Head Start OPMCHN – CT

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Where Has It Led?

BH Task Force met monthly Aug 2012 – Mar 2013

Experts in-state and out-of-state (Mass e.g.) Information obtained, recommendations provided

Mass Experience – PCC feedback Not exceptionally burdensome,

infrastructure working MCPAP as a workable idea and resource

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Where Has It Led?

Massachusetts Feedback PCPs balked at screenings Curriculum developed Validated screens – in public domain PCP’s found …

50% already receiving BH treatment 40% handled with practical advice –

clinician training 10% referred to “system” for BH treatment

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Where Does It Lead? Task Force Recommendations - Mar 2013 R/Q PCPs in MA/HUSKY Program to perform

annual behavioral health screens using validated instrument from ages 1 - 17

Instruments used must be validated and recommended by AAP (and approved by DSS)

Providers will receive $18 per screen through DSS DSS must maintain claims data and report quarterly DSS to work with AAP to develop curriculum and

trainings for PCPs

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Where Does It Lead?

Recommendations (continued) DSS work with Behavioral Health experts (CT Council

on Child & Adol. Psychiatrists and CHDI, etc.) to assist PCP’s on the “What to do Next” questions …

DSS shall participate in formation of child psychiatry access project in CT – if enacted by GA

Task force meets semi-annually to review data and revise recommendations etc.

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Where Does It Lead?

General Themes Develop support to encourage PCPs to meet the

challenge of conducting MH screens Education to PCPs that reimbursement is available for

those practices not already seeking or to those practices where reimbursement is not included (in bundled rate)

Support DSS’s Person Centered Medical Home (PCMH) initiative (resources)

Know that the threat of a lawsuit lurks in the background (a la Rosie D.)

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Jay E. Sicklick, Esq.Deputy Director, Center for Children’s Advocacy

Director, Medical-Legal Partnership Project

jsicklick@kidscounsel.org