Behavioral Health in the Medicaid Benefit for Children and Adolescents: Connecticut

(As of April 2013)

At a Glance

• Strong partnership between Connecticut’s Department of Social Services (Medicaid), Department of Mental Health and Addiction Services, and Department of Children and Families works to integrate public behavioral health services
• Primary care providers can receive separate payments for mental health screenings
• Enhanced Care Clinics receive higher reimbursements to provide timely routine and urgent mental health evaluation services, as well as follow-up

 

Introduction

Connecticut has made strides to reduce fragmentation in its behavioral health system and advance a system-wide vision that reduces unnecessary admissions to, and lengths of stay in hospitals and residential treatment facilities. A multi-agency partnership—called the Behavioral Health Partnership—that includes the state Department of Social Services (DSS) seeks to create an integrated behavioral services system for enrollees in state health plans (Medicaid and CHIP, which are housed in the DSS). Behavioral health services to Medicaid beneficiaries in Connecticut have been provided through an administrative services organization (ASO) model since 2006. Under this model, an entity (referred to as an ASO) is contracted to administer the behavioral health benefit and coordinate services, though claims are submitted to the Department of Social Services on a fee-for-service basis.

 

Connecticut created the Behavioral Health Partnership and transitioned to the ASO model as part of an effort to make a more cohesive and focused behavioral health system. The involvement of the Department of Children and Families helped to focus these reforms on children. The state has pointed to a significant drop in hospital discharge delay days for children in the custody of the state who have behavioral health problems as evidence that the partnerships between the state’s Medicaid and child welfare agencies has been successful.

 

Coordination and Collaboration

 

Since 2005, the DSS has partnered with the Department of Children and Families (and subsequently the Department of Mental Health and Addiction Services, as well) to integrate public behavioral health services for children and families under the Connecticut Behavioral Health Partnership (CTBHP), The Behavioral Health Partnership Oversight Council oversees ongoing implementation of the CBHP. The Oversight Council is comprised of stakeholders representing policy, provider, and patients. The participating departments have contracted with ValueOptions to serve as the ASO, authorizing and managing behavioral health services for all Medicaid participants. ValueOptions produces a provider manual for participating behavioral health providers. The state’s fiscal agent, HP Enterprise Services, processes claims for behavioral health services.

 

State agencies outside the DSS have also coordinated to better meet the behavioral needs of children. Through the RWJF Resources for Recovery program, which concluded in December 2006, Connecticut developed common contract terms and procedures for use by two agencies—the Department of Children and Families and Court Support Services—in the purchase of treatment services for youth called Multisystemic Therapy (an intensive family-and community-based treatment program that focuses on the entire world of chronic and violent juvenile offenders). This reduced the burden on providers and allowed for the monitoring of the quality of services. Multisystemic Therapy is reimbursed by Medicaid for enrollees under age 21 as a Rehabilitative Behavioral Health Service.

 

Screening, Assessment and Referrals

Children in Connecticut have several avenues through which to access developmental or behavioral health screens under the Medicaid children’s benefit, including in primary care offices, free-standing clinics, and school-based health centers. Connecticut’s Medicaid program reimburses pediatricians for developmental and mental health screenings. The state uses both the 96110 and 96111 codes (developmental testing with interpretation and report, limited and extended, respectively) to support developmental screens. The state also added CPT code 99420, “Administration and interpretation of health risk assessment instrument,” to its Medicaid fee schedule as of January 1, 2012. This allows primary care physicians to be paid for mental health screenings separately from the well-child visit reimbursement; these screenings can be billed in conjunction with a well-child visit. However, DSS does not require providers to use specific standardized developmental or mental health screening tools and no recommendations are provided other than the list of instruments compiled by the CTBHP (described below).

 

The CTBHP produces lists of covered services for providers participating in Medicaid. The list for independent or group practitioners (e.g. medical doctors) clarifies that Medicaid and the Children’s Health Insurance Program reimburse for psychological testing, initial psychiatric interview examinations, and interpretation of the results of psychiatric examinations. The CTBHP has compiled a long list of psychological tests to aid practitioners; the list catalogs existing screening and evaluation instruments, as well as classifying each by type (e.g. behavioral rating scale or chemical dependency), the ages for which the instrument is intended, and the expected duration in minutes. Many of these instruments are designed specifically for children.

 

As discussed below, behavioral health clinics designated as “Enhanced Care Clinics” must have memoranda of understanding with at least two pediatric primary care practices. These memoranda must include provisions for the clinic conducting annual education and training events for primary care providers and their staff related to “prevention, screening, evaluation and family-centered management of behavioral health disorders in primary care.”

 

The state also encourages the provision of behavioral health screens in other care settings. Medicaid reimburses school-based health centers (SBHCs) for “diagnostic and treatment services involving mental, emotional or behavioral problems and disturbances and dysfunctions, or the diagnosis and treatment of substance abuse.” Although no specific tools are recommended, the Department of Social Services’ SBHC provider manual is clear that mental health evaluations, assessment procedures, and the interpretation of assessment results will be reimbursed by Medicaid. Among a range of mental health services, SBHCs and Federally Qualified Health Centers can bill for Psychiatric Diagnostic Evaluations (CPT 90791) and Psychiatric Diagnostic Evaluations with Medical Services (CPT 90792).

 

In a 2012 policy transmittal, CMAP announced that independent practice licensed or certified behavioral health practitioners could provide behavioral health assessment and treatment services to individuals under age 21 who are covered under Connecticut’s HUSKY C and HUSKY D programs (Medicaid for the aged, blind, and disabled population and Medicaid for low-income adults, respectively).

 

Treatment

Around the time that the state switched behavioral health Medicaid benefits to an ASO model, Medicaid also began to address outpatient behavioral health access issues in the state. The state did this by creating a new designation for select behavioral health service providers: Enhanced Care Clinics (ECCs). Clinics receiving this designation receive higher reimbursements for all routine outpatient services—on average, 25 percent above the standard fee schedule—for guaranteeing timely emergent access.

 

Enhanced Care Clinics are expected to provide enhanced care across five domains of service, originally listed in Appendix A of the Request for Applications to participate as an ECC: access, coordination of care, members services and supports, quality of care, and cultural competence. The ECCs must offer not only routine and urgent mental health evaluation services, they must have the capability for follow-up. ECCs are required to have the capability to see clients with emergent needs within two hours, clients with urgent needs within two days, and clients with routine needs within two weeks. Other requirements for ECCs include that they use evidence-based practices in behavioral health and that they coordinate care with primary care providers.

 

A 2008 policy transmittal from the Department of Social Services notified ECCs of new requirements that they develop formal relationships with primary care practices in order to retain their designation as ECCs. The document established that “Each ECC that serves children or adolescents must enter into an MOU with two or more pediatric primary care practices.” The memoranda of understanding were required to include several elements, including: protocols for referrals of primary care patients to the ECC; protocols for the referral of ECC patients to the patient’s primary care provider; communication guidelines; and education and training around “prevention, screening, evaluation and family-centered management of behavioral health disorders in primary care.” A recent evaluation of Connecticut’s outpatient mental health system for children prepared for the Department of Children and Families found that the ECC system has “significantly reduced the length of time from referral to intake” for children.

 

ValueOptions, the ASO managing the Medicaid behavioral health benefit, also provides intensive care management for high-needs children with behavioral health issues, including those with a history of unsuccessful connections to care. Intensive care managers connect Medicaid-enrolled children to care and are responsible for follow-up to ensure that the child stays connected to services. Children who need wraparound services may be referred by intensive case managers to Community Collaboratives for care coordination that are supported by the state’s Department of Children and Families to serve children with serious emotional disturbances who need intensive coordination of an array of services. Case management services can also be provided by community based providers.  In such circumstances, case management is billed using a T1016 code (“Case management, each 15 minutes”), unless they are part of an approved curriculum-based home service model.

 

Acknowledgements

The authors wish to thank the many state officials and stakeholders who contributed to and reviewed the information in this document.

This document was prepared by NASHP for the Centers for Medicare & Medicaid Services (CMS) under a contract to NORC at the University of Chicago. It does not reflect the views of CMS.