OLR Research Report


CT BHP AND EPSDT

By: Robin K. Cohen, Principal Analyst


QUESTION
You asked a series of questions about the Connecticut Behavioral Health Partnership (CT BHP) and its relationship to the federal Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program.

We list the questions and responses below.

What diagnostic, treatment, and other “measures” are covered under the CT BHP Value Options (the partnership's administrative services organization) contract?

According to the CT BHP Provider Manual, the partnership offers a number of services. Some are covered by the CT BHP (ValueOptions); others are considered “medical benefits,” meaning payment and oversight are the responsibility of DSS or Community Health Network of Connecticut (the ASO for all of HUSKY). Both sets of services offer the state Medicaid reimbursement when the person receiving them is Medicaid-eligible.

Table 1 lists those services covered by the that are CT BHP.

Table 1: BHP Services

Hospital Outpatient Services

● Outpatient, intensive outpatient, extended day treatment, and partial hospitalization services

● Psychiatric evaluation and treatment services related to a medical diagnosis

Freestanding Outpatient Medical Clinic Services

● Evaluation and treatment services provided by a licensed behavioral health professional if the member has a primary behavioral health diagnosis

 

Freestanding Mental Health and Ambulatory Substance Use Clinic Services

● All services regardless of the member's diagnosis

 

Emergency and Inpatient Hospital Services

● 23-hour observation if person has a behavioral health primary diagnosis

● All psychiatric hospital services and associated charges, regardless of the member's diagnosis

● Inpatient and residential detoxification (i.e., inpatient hospital or inpatient freestanding clinic services) if the member has a primary diagnosis of substance use

● Inpatient general hospital services if the member has a primary behavioral health diagnosis

● Professional psychiatric services provided in an emergency department by a community psychiatrist that meets certain qualifications

● Professional services related to a behavioral health diagnosis provided during a medical hospital stay

● Crisis stabilization beds

 

Individual Practitioner Services (by a licensed behavioral health provider)

● Outpatient evaluation and treatment services if the member has a primary behavioral health diagnosis

● Psychological and developmental testing if the member has a primary behavioral health diagnosis

● Consultation and case management services if the member has a primary behavioral health diagnosis

 

Home Health Agency Services

DSS (through its contracting ASO) must authorize and manage these services if (1) they are required solely for a medical diagnosis, (2) they are required for medical and behavioral health diagnoses and the medical diagnosis is primary, or (3) the member's treatment needs cannot be safely managed by the psychiatric nurse or aide.

ValueOptions must authorize and manage these services if (1) they are required solely for a behavioral health diagnosis, (2) they are required for medical and behavioral health diagnoses and the behavioral health diagnosis is primary, (3) the member's behavioral health issues are so complex they cannot be safely managed by the medical nurse or aide, or (4) autism is one of the member's first three diagnoses.

Other Services

● Methadone maintenance services

● Adult mental health group homes

● School-based health center treatment and assessment services

● DCF residential treatment centers and mental health group homes

● Electro convulsive therapy

● Psychiatric residential treatment facilities

Source: CT BHP Provider Manual, http://www.ctbhp.com/members/info/Member_Handbook-English.pdf, last visited on December 4, 2013.

Are CT BHP services covered under Medicaid? If so, how does the state seek federal matching funds?

According to DSS officials, federal Medicaid reimbursement is available for all of the CT BHP services. This means that the Medicaid State Plan, the state's blueprint for the services the state provides. These services include behavioral health, which is an optional Medicaid service.

As it does with any other Medicaid-covered service, the state pays 100% of the cost of a service and bills the federal government for half.

Does the federal EPSDT program require the state to provide services that CT BHP does not presently cover?

Technically yes, but it is a bit more complicated than that. Under the federal EPSDT law, any state running a Medicaid program must offer EPSDT to all Medicaid-eligible children under age 21. The program must cover medically necessary screenings, diagnosis, and treatment to this population.

With respect to mental health services, federal law requires states to provide coverage for medically necessary screenings, at prescribed intervals (commonly referred to as periodicity schedules), to determine the existence of certain physical or mental illnesses or conditions. At a minimum, the screening must include a comprehensive health and development history (including assessment of both physical and mental health development). Inter-periodic screenings must also be available (42 USC 1396d(r)(1)(A)(ii)).

DSS regulations provide that EPSDT services are those that the Medicaid State Plan does not cover, provided

1. they are medically necessary,

2. the need for the service is identified in an EPSDT screen,

3. the service is provided by a Medicaid participating provider, and

4. the service is a type of service that may be covered by a state Medicaid agency and qualifies for federal matching funds (Conn. Agency Regs., 17b-262-912).

DSS officials assert that Connecticut's Medicaid State Plan offers a robust set of behavioral health services. Thus, BHP CT has not had to pay providers for EPSDT claims for a service not listed in the state plan. There have been a few requests for EPSDT-related services not covered by the state's plan, according to the officials. In at least one case the request was denied after a fair hearing process. If it had been granted, the state, presumably, would pay one half of the service cost and the federal government would pay the other half.

The CT BHP Provider Manual seems to suggest that EPSDT case management services are available to members (Provider Manual, p. 57). But according to DSS officials, these services, which include making and facilitating referrals and developing and coordinating a plan of services that will help children and youth under age 21 who are Medicaid recipients access the services they need, are in the state's Medicaid state plan and hence are not EPSDT-covered services.

How are families and physicians made aware of the EPSDT services, as required by federal law?

Federal EPSDT regulations require state Medicaid agencies to provide to EPSDT beneficiaries who request such screenings information about the program. These screening are defined as regularly scheduled examinations and evaluations of the general physical and mental health, growth, development, and nutritional status of infants, children, and youth, including what the services are and where and how to obtain them (42 CFR 441.56). The agencies must provide the information no later than 60 days from the date the family's or individual's Medicaid eligibility is determined (State Medicaid Manual 5121).

Families enrolled in the HUSKY A program receive a member handbook. HUSKY A is Medicaid for children and their caretaker relatives. The member handbook, published by CHN-CT, which is the ASO responsible for administering the HUSKY Health program, includes a description of EPSDT. The description includes a table showing the periodicity schedule for well-child pediatric visits, up to age 21. A separate section of the handbook addresses behavioral health services with a description of the BHP-CT.

According to DSS, primary care providers (PCPs) are aware of EPSDT. Information about the program generally is conveyed through provider bulletins that DSS publishes and transmits periodically to enrolled Medicaid providers.

How does DSS intend to seek EPSDT reimbursement, as required under Section 4 of PA 13-178?

Section 4 of PA 13-178 directs DSS to seek existing public or private reimbursement for mental, emotional, and behavioral health services offered through DSS under the EPSDT program. Based on what we have described above, it is not clear what children's mental health services may not be in the Medicaid state plan that would necessitate an EPSDT claim. DSS did not respond to this particular question when we posed it.

We believe that it may relate recommendations made by a task force on children's mental health screenings, treatment, and reimbursement protocols. DSS convened this task force in 2012. The group's recommendations, according to a slide show presentation at a hospital grand rounds by Atty. Jay Sicklick, Deputy Director of the Center for Children's Advocacy, included requiring annual mental health screenings from ages one to 17 and an $18 per screen reimbursement from DSS. These recommendations suggest that primary care providers (PCPs) currently are not performing such screens even though according to DSS, they already have the ability to bill for them. The recommendations go on to say that DSS would work with the American Academy of Pediatrics to develop the curriculum and training for PCPs. (Attorney Siklick also referenced Massachusetts. In 2006, a federal court ordered the state's Medicaid providers to include a behavioral health screening as part of the regular EPSDT well-child visit in response to a class-action lawsuit.)

We asked DSS for additional information on the task force recommendations and will forward it to you once we receive it.

How many children have been “treated” under the ValueOptions contract?

Minor children served by HUSKY A (Medicaid) and HUSKY B comprise almost half of total BHP CT enrollment. In calendar year 2012, their membership totaled 328,726, up from 277,519 in calendar year 08. Table 2 shows detailed membership data for the period calendar years 08 through 12.

Source: ValueOptions Calendar Year 2012 Enrollment Data

RESOURCES

The Connecticut Behavioral Health Partnership, OLR Report 2013-R-0045

Sicklick, Jay, Mental Health Screenings in Primary Care: A Legal Overview, Grand Rounds at Stamford Hospital, May 16, 2013

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

Study Pushes Early Identification of Kids' Mental Health Problems, http://c-hit.org/2012/09/14/study_pushes_early_identification_of_kids_mental_health_problems

EPSDT Information, DSS Provider Manual, Chapter 5.11

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