Presentation on theme: "M EDICAID & M EDICARE : W HAT A RT T HERAPISTS N EED TO K NOW (P ART 2) Medicaid for Kids with Mental Health Needs Advancing art therapy to restore and."— Presentation transcript:
M EDICAID & M EDICARE : W HAT A RT T HERAPISTS N EED TO K NOW (P ART 2) Medicaid for Kids with Mental Health Needs Advancing art therapy to restore and enhance lives September 2013
POLICYINTOPRACTICE Advocacy Resources for Art Therapists Medicaid for Kids (and Youth) With Mental Health Needs Overview Eligibility Services - - - - - - - - - - Medicaid & Schools Mandatory and Optional Services EPSDT Mental Health Services Rehabilitation Services
POLICYINTOPRACTICE Advocacy Resources for Art Therapists
WHY MEDICAID IS IMPORTANT Over 30 million children and youth have health coverage through Medicaid Almost 10 million additional children and youth have health coverage under a related program, the State Children’s Health Insurance Program (SCHIP) Medicaid is the biggest payer of mental health services in the United States, contributing more than any other private or public source of funding POLICYINTOPRACTICE Advocacy Resources for Art Therapists
MEDICAID BASICS Federal/State: Medicaid is jointly funded and administered by the federal government and the states – each state, working within federal guidelines, creates their own state Medicaid plan Eligibility: States have to provide Medicaid to specific groups of eligible children and youth Services: State Medicaid programs must cover some services – there are also optional services they can choose to cover. Every state makes different choices. Waivers: States can submit Medicaid “Waivers” to cover specific populations (such as children with traumatic brain injuries) and to include specific services, such as art therapy Lead Agencies: The lead Medicaid agency is the U.S. Department of Health and Human Services’ Centers for Medicare and Medicaid Services (CMS) State Medicaid agencies set state Medicaid policy and local city/county Medicaid offices handle applications
SOME OF THE ELIGIBILITY CATEGORIES FOR CHILDREN… Children from birth to age 5 in families with income at 133% of the federal poverty level or lower Children ages 6-19 with family incomes up to 100% of poverty Children who get Supplemental Security Income (SSI) benefits from the Social Security Administration because of disability or blindness
Medicaid SCHIP FAMILIES WITH HIGHER INCOMES BUT NO HEALTH INSURANCE State Children’s Health Insurance Program (SCHIP or CHIP) Provides matching funds to states for health insurance to cover uninsured children in families with incomes that are too high to qualify for Medicaid Partnership between federal and state governments – states design SCHIP programs within broad federal guidelines State choices: Create new child health program that is completely separate from Medicaid New programs can be (1) modeled on private insurance plans or (2) uniquely designed and approved by the Secretary of Health and Human Services Use SCHIP funds to expand their Medicaid program to cover SCHIP children.
MEDICAID BENEFITS The Medicaid benefits package is broad and flexible States can contract with managed care plans to deliver Medicaid benefits, use a traditional fee-for-service approach, or use both Mandatory services – those all states must cover Optional services – those the state can choose to cover
MANDATORY SERVICES On the list of services state Medicaid programs must cover: E P S D T Early and Periodic Screening, Diagnosis and Treatment
EPSDT Medicaid’s EPSDT coverage is the most comprehensive child health program in either the public or private sector Services provided through EPSDT cover physical, emotional, and developmental needs States are mandated to inform all people with Medicaid about EPSDT services and how to access them BUT Many families, Medicaid case workers and even Medicaid agencies in some states do not understand the right to treatment under EPSDT
Early and Periodic Screening, Diagnosis and Treatment Federal Law: “[O]ther necessary health care, diagnostic services, treatment, and other measures... to correct or ameliorate defects and physical or mental illnesses and conditions discovered by screening services, whether or not such services are covered under the State plan.
Screening Screening does not have to be formal Any contact with a health care professional can be considered a screen that triggers diagnosis and treatment Mental Health Screens Diagnosis
Treatment All necessary treatment To “correct or ameliorate” (i.e., improve) physical and mental illnesses and conditions Even if the service is not covered under the state plan Services must be covered if they correct, compensate for, or improve a condition, or prevent a condition from worsening – even if the condition cannot be prevented or cured.
POLICYINTOPRACTICE Advocacy Resources for Art Therapists Inadequate outreach and information to families and providers to inform them of available services under EPSDT Result? Families, physicians, practitioners, mental health professionals and providers have not made specific requests for the full range of "medically-necessary" services mandated by federal law. PROBLEM
POLICYINTOPRACTICE Advocacy Resources for Art Therapists Medicaid covers a very broad range of mental health benefits.
Mental Health Benefits Mental health services and benefits are not specifically defined in the Medicaid law However the Parity Act now requires state to treat mental health conditions as the do medical conditions. It is through Medicaid’s generic categories of benefits that mental health services are provided EPSDT is the category that many mental health services will fall under for children, youth and young adults
MEDICAL NECESSITY Generally defined as “the decision by a health care professional that a person’s condition requires a service or course of treatment to address or improve a condition.” As a general rule, if you can get a treating professional/provider to confirm in writing that the service is medically necessary, you should be able to convince the state Medicaid agency to cover the service for a child, as long as it fits into a Medicaid service category.
Mental Health Services Under EPSDT, children who have Medicaid have the legal right to virtually any home or community-based mental health service that a health care practitioner determines is medically necessary. Some of the mental health services covered through EPSDT: Diagnostic evaluation and intervention Individual therapy and group therapy Case management Therapeutic behavioral intervention (including in-home behavior therapy provided by a one-on-one behavioral aide to carry out a treatment plan designed by a behavior specialist) Psychiatric rehabilitation (which can include art therapy) Substance abuse services Partial hospitalization, such as psychiatric day treatment Mobile treatment and crisis intervention services Any other mental health service recommended by a physician or other licensed "practitioner of the healing arts," within the scope of his or her practice under State law. All services must be provided in the setting deemed most beneficial to the child, with a preference for the child's "natural environment," such as home or school.
Rehabilitation Services “Rehabilitative services” is the category that gives states the most flexibility in designing and delivering services: “Other diagnostic, screening, preventive, and rehabilitative services, including any medical or remedial services (provided in a facility, a home, or other setting) recommended by a physician or other licensed practitioner of the healing arts…for the maximum reduction of physical or mental disability and restoration of an individual to the best possible functional level.” Psychiatric rehab services can be provided by a wide range of mental health professionals in a variety of settings. Many states use the rehabilitation services category to creatively address mental health needs of teenagers in the foster care system who are transitioning to adulthood (research shows as many as 75% of children in foster care have significant mental health needs)
Example - Pennsylvania Community Based Mental Health Rehabilitative Services “Services include Psychiatric, medical, and psychological testing; Art therapy, movement therapy, and music therapy; Psychotherapy and counseling (including individual, group, and family); Rehabilitation services; and Medication management.” Medicaid Waiver – Family Driven Support Services (FDSS) “Therapies may include, but are not limited to: Physical therapy, Occupational therapy Music therapy Art therapy Speech therapy”
DRA = Deficit Reduction Act of 2005 States given the option of modifying their approach to delivery of services to children enrolled in Medicaid The DRA does not affect the requirement that states cover all EPSDT services for children While “benchmark equivalent” packages are adequate for the majority of healthy children, new state health care plans must contain a wrap- around package for children and youth with special health care needs.
Individuals with Disabilities Education Act IDEA requires states to ensure a free, appropriate public education to children with disabilities Under IDEA, schools must: o Develop an individualized education plan (IEP) that identifies the educational and supportive services a child needs. o Provide related services that help the child benefit from education. The American Art Therapy Association is advocating on a federal level for the IDEA to be reauthorized for continued and increased funding. SCHOOLS AND MEDICAID
Medicaid and IDEA IDEA does not provide states with funding for medical and health care needs. For this reason, federal law provides for payment under Medicaid for the health and mental health services that may be identified in a Medicaid-enrolled child’s Individualized Education Plan (IEP).
LEAs can contract with Medicaid as EPSDT providers. In this capacity, they are authorized to provide EPSDT screens and mental health services provided by licensed practitioners* Number of LEAs billing Medicaid for covered services varies widely: Oklahoma - 6% of LEAs currently bill Medicaid for services Illinois - 50% of LEAs Massachusetts - 70% of LEAs The methods used to bill Medicaid for IDEA services vary from state to state – in many states it’s very labor intensive – Concerns about student privacy inhibit identification of Medicaid-eligible children who are receiving special education services. LOCAL EDUCATION AUTHORITIES (LEAs)
MEDICALLY NECESSARY SERVICES vs. EDUCATIONALLY NEEDED SERVICES The developmental, educational, mental health, and medical needs of the child or adolescent should be determined first. Issues of who provides the appropriate services and who pays comes after that…
EPSDT Problem (or Opportunity?!) Although the Medicaid statute has very specific EPSDT language, the U.S. Department of Health and Human Services has not revised the federal EPSDT regulations since 1984. The absence of federal agency guidance has added to the challenges of EPSDT administration over the years. Advocates in some states have found that the lack of agency rules can mean expanded opportunities for creative advocacy.
POLICYINTOPRACTICE Advocacy Resources for Art Therapists There are many opportunities for art therapists who work with children and youth who have Medicaid coverage… Review your state’s regulations to determine how Medicaid is uniquely administered in your state.