Behavioral Health in the Medicaid Benefit for Children and Adolescents: New York

(As of April 2013)

At a Glance

• Behavioral health services for Medicaid-enrolled children are available primarily through a public behavioral health delivery system supported by the state’s Office of Mental Health and Office of Alcohol and Substance Abuse Services
• Multiple coordination activities between state agencies are aimed at providing developmental and behavioral health services to children, as well as helping primary care providers to more effectively treat or refer children with behavioral health issues
• In addition to services delivered through Office of Mental Health clinics, the state is supporting tele-psychiatry, co-location of primary care and behavioral health providers, home and community-based service waivers for children

Introduction

New York has developed a robust system for providing behavioral health services under the Medicaid children’s benefit (also known as the Early and Periodic Screening, Diagnosis, and Treatment benefit or EPSDT) using its public behavioral health delivery system. In New York, non-SSI/SSI-related children enrolled in managed care organizations (MCOs) receive their mental health services through their MCO, while others receive these services on a fee-for-service basis. However, most substance abuse services provided by clinics certified by the state Office of Alcohol and Substance Abuse Services (OASAS) are carved out of managed care so all children receive these services through fee-for-service Medicaid.

 

Mental health services provided through the Office of Mental Health (OMH) designated clinics for children with a diagnosis of Serious Emotional Disturbance (SED) are also carved out of managed care. The Department of Health, which houses Medicaid, issues annual reports on managed care plan performance, which includes plan performance on behavioral health quality indicators. It also produces managed care access and utilization reports that include plan-specific information on mental health utilization.

 

A Medicaid Redesign Team (MRT) convened by the governor in 2011 took the lead in proposing reforms to the state’s Medicaid program, including reforms to the delivery of behavioral health services. Under recommendations from the team that were enacted into law, the OMH and OASAS have authority to contract jointly with behavioral health organizations (BHOs) and phase out the utilization of most fee-for-service Medicaid behavioral health services. In 2012, five regional BHOs began monitoring inpatient behavioral health services for Medicaid enrollees not receiving those services through a Medicaid managed care plan; this includes children with an SED diagnosis covered by Medicaid and receiving care in an OMH clinic. In a second phase of implementation beginning in 2013, BHOs will begin risk-bearing Medicaid managed care for adults and children with serious mental illnesses or substance use disorders. State agencies (the Office of Children and Family Services (OCFS), Department of Health (DOH), Office of Mental Health (OMH), Office of Alcoholism and Substance Abuse Services (OASAS), and the Office for People with Developmental Disabilities (OPWDD)) established workgroups to ensure that individuals with significant behavioral health needs are enrolled in qualified, specialized and integrated managed care plans. New York State’s MRT goal is to have most children receive their behavioral health services through a managed care plan or BHO by April 2015.

 

Coordination and Collaboration

The New York Title V and Medicaid agencies work closely with each other and with the New York State Division of Managed Care. The state’s provider manual for the Medicaid children’s benefit was a joint Title V/Medicaid effort, an example of Title V- Medicaid cooperative agreements. These agencies partnered with New York’s Office of Mental Health and an active group of stakeholders to revamp the manual and ensure that it addressed child and adolescent emotional and behavioral health and incorporated evidence based practices. The state also has a Medicaid/EPSDT – Title V Action Plan that identifies shared goals and shared specific objectives for both programs.

In 2008, nine state agencies—including the Department of Health and the Office of Mental Health—developed the Children’s Plan to improve the social and emotional well-being of children and their families. In accordance with the state’s Children’s Mental Health Act of 2006, the plan includes recommendations to “provide comprehensive, coordinated mental health prevention, early intervention, and treatment services for children through age 18.”

 

The state also has a Coordinated Children’s Services Initiative, a multi-agency initiative that supports county-level provision of cross-systems services to children with SED who are at risk of residential placement. At the state level, participating partners include the Department of Health and the Office of Mental Health. Every county in New York has designated a Single Point of Access to link children to OMH resources.

 

The OMH, the American Academy of Pediatrics, the New York State Chapter of the American Academy of Family Physicians, and the Conference of Local Mental Hygiene Directors have collaborated to launch Project TEACH (Training and Education for the Advancement of Children’s Health). This initiative offers primary care physicians education and training on mental health treatment for children and adolescents with mild to moderate mental health issues. It also offers referral or linkage services, as well as case consultation and phone consultation services to pediatricians by connecting them to child and adolescent psychiatrists in real time.

 

Screening, Assessment and Referrals

Separate payment for developmental or behavioral screens is at the discretion of the MCOs; these screens are not paid separately in fee-for-service Medicaid. Instead Medicaid, and many managed care plans, define their well-child visit to include all necessary screening.

 

In New York’s EPSDT/CTHP Provider Manual For Child Health Plus A (Medicaid), providers are referred to the Bright Futures in Practice:  Mental Health Volume 2 Tool Kit for screening tools, including the Pediatric Symptom Checklist. However, there are no requirements for the use of specific screening tools. In March 2009, a OMH/OASAS Subcommittee on Youth  and Adolescents recommended the use of Child Behavior Checklist and the Pediatric Symptom Checklist as mental health screening instruments in OMH State Certified Programs. It also recommended the CRAFFT, Global Appraisal of Individual Needs (GAIN-SS), and Problem Oriented Screening Instrument for Teenagers (POSIT) for substance use disorder screening. No specific assessment instrument was recommended. However, use of these instruments is not a requirement.

 

New York Medicaid covers Screening, Brief Intervention and Referral to Treatment (SBIRT) services for all Medicaid beneficiaries who are 10 years of age and older. Formerly, these services were covered only in hospital outpatient and emergency departments, as well as free-standing diagnostic and treatment centers (including School-Based Health Centers), but the Medicaid Redesign Team recommended an expansion of SBIRT to additional settings. As of September 1, 2011 SBIRT services provided by office-based primary care practitioners can be reimbursed as well.

 

The Medicaid provider manual for the children’s benefit offers the following outline to guide physicians who refer a child to a mental health practitioner: 1) Conduct psychiatric evaluation of child/teen, 2) Option – Discuss case with mental health colleague, 3) Option – Counsel the patient and/or parent(s) yourself, 4) Anticipate the child, adolescent and parents’ concerns (worries, resistance, etc.) about the referral, 4) Present the referral to the patient and parent(s) and discuss their concerns, 5) Do not make the first appointment with the mental health professional – it is very important that the parent(s) are responsible and make the appointment, and 6) Discuss the mental health referral and treatment at future visits or by phone.

 

Treatment

 

Behavioral health treatment services to children are generally available through the OMH or OASAS system, both for children receiving services on a Medicaid fee-for-service basis and for children receiving services through MCOs. Managed care contracts in New York requireMCOs to “include a full array of mental health and Chemical Dependence Services providers in its networks, in sufficient numbers to assure accessibility to Benefit Package services for both children and adults, using either individual, appropriately licensed practitioners or New York State Office of Mental Health (OMH) and Office of Alcohol and Substance Abuse Services (OASAS) licensed programs and clinics, or both.”

 

Medicaid funding can be used to support OMH-licensed outpatient programs, including day treatment programs for children that integrate mental health and special education services. Children served by these programs must have a designated mental illness diagnosis, as well as an extended impairment in functioning due to emotional disturbance or a current impairment in function with severe symptoms. The OMH also offers clinic treatment programs providing outpatient mental health services; a Clinic-Plus service combines screening, comprehensive assessment, in-home treatment, and evidence-based treatment. Inpatient mental health services and Residential Treatment Facilities are also provided through the OMH’s system.

 

In late 2011, the OMH announced the availability of one-time funds to support co-location of mental health and primary care services for children. The funds supported the start-up costs of establishing children’s satellite mental health clinics in pediatric or family practice primary care settings. The goal of the program is to encourage the development of integrated care approaches that enable children and families who might not otherwise seek mental health treatment to access it. These grants are available to OMH-licensed children’s outpatient mental health clinics, which are facilities that Medicaid-enrolled children would be likely to use.

 

Following Medicaid Redesign Team proposals to develop innovative telemedicine applications, in October of 2011 the state expanded telemedicine services, incorporating tele-psychiatry into the model. OMH’s Division of Child and Family Services has established a New York Consultation and Telepsychiatry (NYCaT) program to address child psychiatric consultation needs in areas of the state with workforce shortages. The program supports mental health treatments for children in mental health programs as well as in primary care practices.

 

Children with severe levels of need receive additional behavioral health services through the state Medicaid agency’s home and community-based services waivers. New York has several home and community-based services waivers that target services to children with behavioral health issues. A developmental disabilities waiver, operated by the New York Office for People with Developmental Disabilities (OPWDD), allows enrollees to access a set of wraparound services. Children with autism can take advantage of the habilitation and respite services available through the waiver. These services are often offered by school districts that contract with the state OPWDD.

 

The Medicaid agency’s waiver for children with serious emotional disturbances offers children between the ages of 5 and 17 an array of social services not funded through Medicaid, including care coordination, respite, family support services, intensive in-home services, crisis response and skill building. In addition, there are three Bridges to Health (B2H) waivers for children in foster care: B2H for children with developmental disabilities; B2H for children with serious emotional disturbance; and B2H for medically fragile children.  Children may remain in the waivers after discharge from foster care, as long as they remain otherwise eligible. 

 

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.

 

About NASHP

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