Medicaid and Behavioral Health Screenings What the Law Requires

1. Medicaid and Behavioral Health Screenings What the Law Requires Jay E. Sicklick, Deputy Director Center for Children’s Advocacy Director – Medical Legal Partnership January 9, 2014

2. 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 MLPP

3. 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) MLPP

4. 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 MLPP

5. Case Study: Billy M. What is the PCP’s next step? • Tell mom to wait and see what happens and call back? • Make a referral? To whom? • Conduct a brief validated screen for mental health red flags? Why or Why Not? MLPP

6. 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 MLPP

7. What If We Do Not Screen? Source: Andrea M. Spencer, PhD, Center for Children’s AdvocacyBlind Spot: Impact of Missed Early Warning Signs on Children’s Mental Health (2012) • 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 MLPP

8. Medicaid 101 • Title XIX of SSA (1965) • Join federal/state program • CMS federal agency oversees Medicaid • State agency compliance thru administration & waiver system MLPP

9. Mental Heath Screening = Primary Care orMental Heath Screening ≠Primary Care? *Source: 42 U.S.C. § 1396d(r)(1) et seq. 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 MLPP

10. Origins of EPSDT “…the early years are the critical years … Ourgoal must be clear – togive every child the chance to fulfill his promise.” (Special Message to the CongressRecommending a 12 Point Program for America'sChildren and Youth Feb. 8, 1967) MLPP

11. 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 MLPP

12. EPSDT and Screening 42 U.S.C. § 1396d(r)(1) et seq. (emphasis added). • EPSDTvital 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) MLPP

13. EPSDT and Screening 42 U.S.C. § 1396d(r)(1) et seq. (emphasis added). What 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.” MLPP

14. 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. MLPP

15. EPSDT Non-Compliance? Rosie D. v. Romney, 410 F. Supp. 2d 18 (2006). Bring on the Lawsuits Rosie 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) MLPP

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

17. Positive Screen = Referrals Teen Screen at Columbia University, Rosie D. and Mental Health Screening (2010) Rosie D.Outcomes MLPP

18. Referrals = Intervention Def.’s Report on Implementation (Jan. 1 2012). Rosie D.Outcomes MLPP

19. Positive Screens = Referrals Hollie Hix-Small et al., Impact of Implementing Developmental Screening at 12 and 24 Months in a Pediatric Practice, 120 Pediatrics 381 (2007). • Oregon Study utilized ASQ ASQ compared to Pediatric Developmental Impression (PDI) PDI on scale from typical–questionable–delayed • 224% increase in referral rate in a yearPDIs alone = 42% of referrals MLPP

20. Importance of Screening Instruments Hollie Hix-Small et al., Impact of Implementing Developmental Screening at 12 and 24 Months in a Pediatric Practice, 120 Pediatrics 381 (2007). • 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 MLPP

21. Where Has It Led? CCA Proposed Legislation 2011 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 MLPP

22. Where Has It Lead? Behavioral Health Screening Task ForceExamination of delivery systems to ensure that screenings are promoted, supported and reimbursed in primary care. Players DSS DCF CT Chapter – AAP CT Council of C&A Psychiatrists (CCCAP) ACAP DDS – Birth to Three CHDI CT Behavioral Health Partnership (CT-BHP) School based health centers (SBHC) Early Childcare Systems – Head Start OPM CHN – CT MLPP

23. 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 MLPP

24. 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 MLPP

25. 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 MLPP

26. 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. MLPP

27. 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.) MLPP

28. Jay E. Sicklick, Esq.Deputy Director, Center for Children’s Advocacy Director, Medical-Legal Partnership Project jsicklick@kidscounsel.org