Medicaid Support for Infant and Early Childhood Mental Health: Lessons from Five States By Kay Johnson and Elisabeth Wright Burak Summary Introduction The policy and advocacy experiences related to Given the outsized role of Medicaid coverage for young Medicaid support for infant and early childhood children, understanding how to leverage financing for mental health (IECMH) in five states (California, Col- early childhood health, mental health, and developmental orado, Michigan, North Carolina, and Washington services is important to ensure equity and optimal devel- State) offer lessons for other states seeking to more opmental outcomes. Medicaid has the largest reach of effectively prevent, identify, and address mental any public program providing services to young children, health conditions among young children in Medic- covering more than 40 percent of young children ages birth aid. Lessons below speak to the importance of: to six and three-fourths of low-income children under age 6 in 2021.1 More than 40 percent of infants and more than 1. Leadership 6 in 10 Black, Hispanic, and Native American/Indigenous 2. Strategic Partnerships babies are covered by Medicaid. Enrollment data in 2022 3. Advocacy shows more than half of the nation's children are covered by 4. Incremental Progress Medicaid and CHIP, which likely extends to young children 5. Medicaid Policy Levers as well. The vast majority of young children (90 percent) 6. Addressing the full Continuum of Care from receive one or more health care visits in a year, which offer Prevention to Treatment important changes to strengthen promotion, prevention, States seeking to apply the lessons from these and and early intervention services for children and their fami- other states can get started in a number of ways lies. Medicaid's Early Periodic Screening, Diagnostic, and depending on state policy context and political Treatment (EPSDT) child health benefit is designed to focus will: cultivating leadership, engaging a range of on prevention and early intervention by financing an array public and private partners, creating a strategic of services children need to correct or ameliorate identi- plan with clear priorities, linking IECMH to broader fied conditions. At the same time, coverage for health and state health reform efforts, identifying state-specific developmentally-appropriate services to aid healthy early Medicaid opportunities and taking steps toward childhood development, particularly early childhood mental health equity by engaging with and listening directly to families. 1 Georgetown University Center for Children and Families analysis of US Census Bureau 2021 American Community Survey (ACS) Public Use Microdata Sample (PUMS). September 2023 CCF.GEORGETOWN.EDU MEDICAID SUPPORT FOR CHILDHOOD MENTAL HEALTH 1 health services, are not consistently recognized or broadly widely recognized as leaders in IECMH. Interviews sought understood by the more adult-focused traditional health to better understand the evolution of state leadership, policy system. The EPSDT benefit is implemented by states under change, and investments. Interviewees were asked their broad federal guidelines, and wide variations can be seen perspectives on 1) the forces and key actions that led to among state interpretation and implementation impacting Medicaid policy change, 2) the extent to which Medicaid is access to health care services. being used to finance and support access to a continuum Together, the Georgetown University Center for Children of early childhood mental health services from prevention to and Families, National Center for Children in Poverty, and early intervention and treatment, 3) the role and impact of Johnson Group Consulting conducted a 2022 survey, which Medicaid delivery system structures (i.e. managed care or provides up-to-date and point-in-time information about accountable care), 4) the most important Medicaid policy or how state Medicaid policy and financing are evolving in process innovation, and 5) next steps in their state's work to relationship to the field of early childhood mental health. improve access to mental health services for young children in Medicaid. (See interview questions in Appendix B.) As awareness has grown, a number of states have used Medicaid to finance early childhood mental health services This report highlights what we heard and learned, describing for several decades or have made recent policy changes key themes and strategies that have been used in these with potential for large-scale change. This report summa- five states. We found that use of inside-outside government rizes lessons learned based on interviews with Medicaid leadership, cross sector partnerships, and knowledge of the officials, child advocates, and early childhood mental health levers that can lead to change in Medicaid financing were leaders in five select states: California, Colorado, Michigan, the most important strategies. The role of champions and North Carolina, and Washington State. (See list of individ- advocates with vision and determination cannot be overstat- uals interviewed in Appendix A.) The states were selected ed. Aiming to strengthen systems of care and close gaps from a dozen or more who have effectively used Medicaid left between fragmented or siloed programs and providers to finance infant and early childhood mental health services is another key theme. For more details about the current (IECMH) and represent variations in policy development. status of Medicaid policy related to mental health services for children from birth to 6 years, see the 2022 survey. While many states use Medicaid to finance specific pre- vention and intervention services related to infant and early childhood mental health, these five states are among those September 2023 CCF.GEORGETOWN.EDU MEDICAID SUPPORT FOR CHILDHOOD MENTAL HEALTH 2 Key Findings 1. LEADERSHIP MATTERS Opportunities for meaningful change increase dramatically and foster strong relationships with Medicaid. Michigan also when a governor, legislator, Medicaid director, or other state funds a position for an Early Childhood Mental Health Co- official prioritizes early childhood or early childhood mental ordinator in the Department of Health and Human Services, health. Policymaker attention can come in many forms, such which began with federal funds from the U.S. Department as executive budget proposals, legislation, revised agency of Education Race to the Top grant and continued with rules, and/or dedicated agency staff. In these five leader state resources. State Medicaid agencies may also hire staff states, support from the highest levels of public leadership with expertise in IECMH who bring practice experience, at key points in time set the trajectory for IECMH policy knowledge of best practice, and relationships with the field. and program development. Medicaid directors in Colorado, In Washington State, philanthropic funding provided initial Michigan, and Washington State have championed young resources to create positions within the Medicaid agency children. But policymakers can't successfully advance to boost internal capacity to advance IECMH and early IECMH in isolation. Private sector leaders from philanthropy, relational health as part of larger health care transformation professional organizations (e.g., mental health, pediatrics), efforts. Key to hiring IECMH practitioners in Medicaid is the child advocacy, and family organizations are key to long support of senior agency leadership. Hiring staff with IECMH term success to sustain knowledge and momentum. As key practitioners expertise provides an important vantage point policy champions change over time, states risk losing insti- for Medicaid policy development. But new practice-oriented tutional knowledge and capacity, making partners outside of staff can also face a steep learning curve on the nuances of state government key to sustaining gains. Medicaid policy and identifying the most effective strategies Cultivating leadership and subject matter expertise within to leverage Medicaid to finance needed services and scale state agencies also aids strong policy development and best practices. Medicaid staff dedicated to IECMH change implementation. Colorado is considered the first state to need consistent support from Medicaid senior leadership to have a director of early childhood mental health who helps be successful in creating meaningful and sustained change. guide development of a strategic plan, sustain programs, CO Leadership in Colorado Colorado began the journey toward IECMH by funding a pilot program for Early Childhood Mental Health consultants in childcare out of the (then) Office of Behavior Health in 1997, which has since expanded and been sustained statewide. Additional IECMH efforts took off in 2001 with the founding of a new Colorado Association for Infant Mental Health, a cross-system Blue Ribbon policy council, and federal pilot projects that helped to evolve IECMH alongside other early childhood initiatives. For more than 20 years, the Colorado Department of Health Care Pol- icy and Financing, Colorado Medicaid, has been an active participant in the design and planning September 2023 CCF.GEORGETOWN.EDU MEDICAID SUPPORT FOR CHILDHOOD MENTAL HEALTH 3 CO of early childhood initiatives, not merely in the role of payer. Medicaid directors' leadership has been an essential component of success in combination with long-time Medicaid EPSDT program administrator, Gina Robinson, who helped ensure a consistent vision for the important role that Medicaid's EPSDT child benefit could play in improving children's mental health and well-being. But, a team of agency staff have been key to strong program implementation. Med- icaid staff person Alex Weichselbaum said: "Across the years, a culture of having the will to do what it takes to make things work has evolved." Colorado Medicaid has played a vital role in financing services along the continuum of care, including screening for mothers and young children, early interventions to address risks, and more intensive treatment when needed. To operationalize benefits and assure their effective use, Medicaid adopted billing codes, provider qualifications, and service definitions related to early childhood mental health. Innovation in benefit design has been a major contributor to change. In 2016-18, the state reimagined ways to improve access to mental health for beneficiaries through their medical home. New policy provided for Medicaid financing of six visits per member per year, without a diagnosis, for short-term behavioral/mental health services provided by qualified mental health providers in primary care settings. In addition, three maternal depression screen- ings can be financed at well-child visits during an infant's first year. In Colorado, Medicaid does not mandate use of specific IECMH models, therapies, or screening tools. The state instead relies on the expertise and competencies of the mental health and primary care professionals, combined with measurement and quality improvement systems, to address quality of care. Recently, behavioral health transformation efforts in the state have broadened focus to include the developmental needs of younger children, not just adolescents and adults. A Children's Behavioral Health Subcommittee was established within the Colorado Behavioral Health Task Force, with the task of improving outcomes by developing a plan to address delivery and man- agement of children's behavioral health (ages birth to 26 years). They conceptualized a financial map of the behavioral health system in 2020 and made recommendations for change in 2021. Colorado's philanthropic community, including an Early Childhood Mental Health funders group, has a long history of support for IECMH. One year into Colorado's federal HHS SAMHSA-funded Project LAUNCH grant, a collaborative of eight foundations invested $11.5 million to create the LAUNCH Together initiative. New funds supported five additional communities to implement the LAUNCH strategies in partnership with the Project LAUNCH local site. All six communities learned together and benefited from the tools, processes, experts, and champions made avail- able through the combined initiatives. Private funders also supported both staff positions inside government and child advocacy. Public-private partnerships helped to make the state a pioneer in IECMH. Colorado was the first state to have a director of early childhood mental health (a position that no longer exists), among the first to have an early childhood mental health strategic plan, and a leader in continually assessing unmet needs and taking steps to fill remaining service gaps. Angela Rothermel of Early Milestones Colorado emphasized: September 2023 CCF.GEORGETOWN.EDU MEDICAID SUPPORT FOR CHILDHOOD MENTAL HEALTH 4 CO Through public-private partnerships, we've done a remarkable job of embedding and expanding mental health supports at the state and local levels, beyond Medicaid. Looking ahead, Colorado leaders are hopeful about the positive impact of Medicaid coverage expansions for undocumented residents and the postpartum coverage extensions to support improved maternal and early childhood mental health. These aspirations are parallel to those of advocates for maternal and child health in other states. Key stakeholders in Colorado emphasized the importance of partnerships between leaders and champions inside and outside of government. Jordana Ash, former Director of Early Child- hood Mental Health in the Colorado Office of Early Childhood, Department of Human Services, reflects: At the end of the day, what's needed in systems change are champions with longevity. 2. STRATEGIC PARTNERSHIPS CAN SUSTAIN THE WORK THROUGH TRANSITIONS Interagency partnerships inside state government are foun- services work, and lived experience. They can also help hold dational components of effective policy and program imple- states accountable for centering the needs and voices of mentation. No one governmental agency can or is intended children and their families. to provide all of the resources needed to finance services, Philanthropy can accelerate progress by funding new ini- develop the workforce, and ensure support for the most tiatives to grow IECMH awareness and engagement. Pri- vulnerable children and families. Partnerships and shared vate foundations support embedded public agency staff, understanding among Medicaid, public health, mental health, demonstration projects, startup initiatives, and /or support early childhood, and social services agencies can provide a coalitions and work groups that can build consensus and more coordinated system, program, and policy responses inform policy decision-making in several states. In Colorado, to addressing the mental health needs of young children an early childhood mental health funders group played an and their families. Further, because low-income families may active role over a period of years in guiding, supporting, and rely on more than one state system to access services and sustaining programs and projects at local and state levels. supports, the lack of strong interagency collaboration can In Washington State, private dollars from the Perigee Fund exacerbate gaps in needed care, leaving more families to fall spurred IECMH by supporting dedicated Medicaid agency through the cracks. staff, policy advocacy, outreach to families, IECMH workforce Having an inside-outside government partnership can development, improved maternal mental health services, and further accelerate progress to advance program, provider, research studies (e.g. unrestricted cash transfer for pregnant and family success. In each of the five states, a balance of people, social media campaigns). partners inside and outside of government helped to drive Partnering with professional mental health or other health and sustain Medicaid program and policy change in support practitioner organizations can help to strengthen and inform of mental health services for children ages birth to 6. Private advocacy efforts. In addition, partnering with professional sector partners bring additional resources, knowledge of how organizations working in children's health and mental health, September 2023 CCF.GEORGETOWN.EDU MEDICAID SUPPORT FOR CHILDHOOD MENTAL HEALTH 5 care providers can increase understanding of system and receive the services they need for optimal development. For practice challenges, the potential impact of proposed chang- example, creating clear, structured relationships and commu- es, and the pace of policy implementation of new policies. nication processes between IDEA Part C Early Intervention, The Washington State Chapter of the American Academy IECMH consultation, and primary care providers, among oth- of Pediatrics (AAP) has played an active role in recent policy ers, are frequently identified as key to delivery of a continuum developments related to IECMH and early relational health, as of care for young children with social-emotional-mental health well as in workforce development. Michigan leaders empha- needs. Without consistent screening and effective referrals, sized the importance of simultaneously giving attention to children with both developmental and mental health needs policy and program implementation, along with workforce often fall through the cracks between these service delivery development, to maximize the impact of Medicaid financing systems. Integration of behavioral/mental health in pediatric by helping to generate critical buy-in among practitioners primary care also requires practice redesign and commu- early in the advocacy process. nity-level partnerships that require support well beyond Finally, strong and effective relationships among providers at Medicaid payment change. the community level are central to ensure that young children WA Partnerships in Washington State The Washington State Medicaid agency (Health Care Authority) has accelerated focus on IECMH in recent years in part thanks to strong agency leadership. Health Care Authority director Sue Birch is passionate about improving maternal and child health and population health. Washington was the second state in the nation to provide continuous Medicaid eligibility from birth to age six. Philanthropic funding from the Perigee Fund supported new positions in the agency to create internal capacity to advance IECMH and early relational health in Medicaid. Medicaid agency leadership and dedicated IECMH expertise on staff helped to create an environment that fosters a culture of change and administrative action for smoother implementation. This is seen as a tipping point for Medicaid policy and program development in IECMH. Christine Cole, Infant-Early Childhood Mental Health Program Manager in the Washington State Health Care Authority, believes that: The magic was in applying the principles of IECMH, grounding Medicaid policy decisions in what had been learned in practice. In 2021, the Washington State legislature adopted important changes to improve IECMH, requir- ing Medicaid to allow reimbursement for: up to five sessions for mental health professionals to conduct mental health assessments, mental health assessments in home and community-based settings, and use the DC:0-5 (Diagnostic Classification of Mental Health and Development in Infancy and Early Childhood, a developmentally based diagnostic approach). In response, the agency developed a DC:0-5 "crosswalk" with clinical and community input. In 2022, the legislature approved funding for a Medicaid pilot project designed to co-locate community health workers in primary care settings, including funds dedicated to the role of community health workers in September 2023 CCF.GEORGETOWN.EDU MEDICAID SUPPORT FOR CHILDHOOD MENTAL HEALTH 6 WA improving the early relational health and well-being of children birth to 3 and their caregivers. The Medicaid managed care reprocurement process in 2024, where the state will allow private insur- ance companies to bid for updated contracts with Medicaid, will provide opportunities for further refinements to maternal and infant health prevention and intervention efforts. Washington is also among the growing number of states that have implemented extension of Medicaid postpartum coverage from 60 days to one year, under a new state option. The Medicaid agency and its partners intend to focus implementation of the extended coverage period on ways to improve maternal-infant health and mental health with coverage and financing under the post- partum coverage expansion. Partnerships with child advocates, philanthropy, the Washington State Chapter of the AAP, Seattle Children's Hospital, other providers, and families have been essential to creating the conditions for change. Collaboration and partnerships also took the form of the Children and Behavioral Health Workgroup and participation by a cross-agency team that participated in the Zero to Three's Infant-Early Childhood Mental Health Finance and Policy Project. Washington has been fortunate to leverage strong health care sector leaders, notably both pediatricians and child psychiatrists have been active in shaping IECMH Medicaid changes. Kiki Fabian, Infant-Early Childhood Mental Health Analyst, Washington State Health Care Authority, commented: Partnering with other systems, providers, and parents is essential to ensure a continuum of services. Washington leaders recognize that getting the child-and family serving workforce ready for change is essential to the success of Medicaid investments. Many workforce development efforts are under- way. For example, the Barnard Center for IEMCH at University of Washington has partnered with Seattle Children's Hospital to build the skills of pediatric residents in promoting early relationships and strengths-based approaches in primary care. Sarah Rafton of the Washington State AAP said: Since COVID, clinics and primary care providers are overwhelmed. Getting the workforce ready for change is critical. 3. ADVOCACY CAN SHAPE THE AGENDA AND MAKE THE CASE Effective policy advocacy is essential for policy and program protect, and intervene for children's mental health. Working change, especially related to Medicaid financing. Advancing in coalition with other child advocates and policy leaders, IECMH in Medicaid requires both legislative (budget and including Children Now, First 5 Center for Children's Policy, program) and administrative advocacy. While multi-issue child and the AAP, this initiative was able to take advantage of a advocacy organizations were not the leading change agents new gubernatorial administration prioritizing early childhood for IECMH in every state profiled, they were a driving force with the added willingness to consider Medicaid changes. for change in states where their resources and partnership A clear vision, strategic plan, or agenda for change, report- allowed. For example, the California Children's Trust set out ed in all five states, makes a difference by focusing atten- a comprehensive agenda for change in Medicaid to promote, tion. Such a shared agenda, including near- and longer-term September 2023 CCF.GEORGETOWN.EDU MEDICAID SUPPORT FOR CHILDHOOD MENTAL HEALTH 7 action steps, should include the full continuum of IECMH health is not easy. Educating policy makers and state services and supports, with specific steps to address each agency leaders is an ongoing challenge. Helping policy- agenda priority over time. This may be a formally adopted makers understand opportunities to promote and intervene document or an advocacy agenda used as a roadmap for an for early childhood mental health, including parent-child organization or coalition. services, can challenge traditional views on what mental Policy entrepreneurs - experts on and advocates for an health care looks like. Real or perceived competition for issue who look for opportunities to insert their program and limited resources also makes strong and strategic advocacy policy priorities into the political process - can be impor- key. The COVID-exacerbated mental health crisis has rightly tant change agents within state advocacy efforts. Decades elevated concern for the mental health of school aged chil- of policy research has shown that policy entrepreneurs dren and youth. Effective advocacy can help policymakers help to sustain focus and guide change over time, educate understand the need for a continuum of services across the policymakers, and frame policy solutions in alignment with age span, and the heightened opportunity to prevent more policymakers' agendas and interests. costly unaddressed mental health challenges by investing in young children before a crisis intervention is necessary. Making the case for investment in young children's mental CA Advocacy in California In recent years, two major Medicaid policy initiatives in California - CalAIM (California Advanc- ing Innovation in Medi-Cal, the multi-year initiative to implement broad delivery system, program and payment reforms) and the re-procurement of Medi-Cal managed care contracts - present- ed opportunities for transforming coverage for children. With leadership from then California Sur- geon General Dr. Nadine Burke Harris and strong advocacy from the California Children's Trust and other organizations, AB133, was passed by the legislature and California's Medi-Cal agency (the Department of Health Care Services, DHCS) adopted new policies that permit children, along with their parents/caregivers, to receive promotion, prevention, and treatment related to so- cial-emotional-mental behavioral health. Alex Briscoe of the California Children's Trust believes: With the roll out this year of the dyadic behavioral health benefit, we should see a big bump in the ability of Medi-Cal to pay for the right services, to address social drivers of health and ACEs. Sarah Crow, Managing Director, First 5 Center for Children's Policy, pointed out that the: DHCS adopted bold goals that resulted in a real shift in focus toward the health and well-being of children and families. The work is moving upstream with greater focus on promotion and prevention, with greater emphasis on social drivers. Colleague Alexandra Parma, Senior Policy Research Associate at the First 5 Center for Children's Policy, described the advocacy in support of these policy changes as: a chorus of voices on early childhood mental health that pointed out what has not been working, elevated the issue on the radar, and brought greater visibility to policy solutions. September 2023 CCF.GEORGETOWN.EDU MEDICAID SUPPORT FOR CHILDHOOD MENTAL HEALTH 8 In January 2023, Medi-Cal began coverage of a range of dyadic (parent-child/family) behav- CA ioral health care to promote child and family well-being. The statutory change (Ca. Welf. and Inst. Code § 14132.755) calls for dyadic behavioral health care as a covered benefit under Medi-Cal. The dyadic services are family-focused and intended to address developmental and behavioral health conditions of children as soon as they are identified, and that fosters access to preventive care for children, care coordination, child social-emotional health and safety, developmentally appropriate parenting, and parental mental health. As described by Medi-Cal in a March 2023 letter to managed care plans, California's new "Dyadic Services" include Dyadic behavioral health (DHB) well-child visits, Dyadic Comprehensive Community Supports Services, Dyadic Psychoeducational Services, and Dyadic Family Training and Counseling for Child Development. New promotive and preventive dyadic services are anchored in DBH well-child visits, where the caregiver and child have the chance to experience more positive ways to interact with each other and to learn from providers about child development. This benefit will permit providers to bill for services delivered under evidence-based models in embedded primary care such as HealthySteps and DULCE, to support the parents in the well-child visit process and to provide care coordination as follow up to referrals to other services. Under EPSDT standards, a diag- nosis is not required to qualify for these preventive services. DBH well-child visits are intended to be universal and reflect the Bright Futures periodicity schedule and guidelines for behavioral/ social-emotional screening. Such visits do not need a specific recommendation or referral, but rather are part of well-child care. Managed care plans and their pediatric primary care providers may deliver DBH well-child visits as: a) part of the HealthySteps program, b) a different DBH pro- gram, or c) in a clinical setting without a certified DBH program as long as the core components are included (e.g., behavioral health history, developmental history, mental health assessment of parents/caregivers, screening for family needs and SDOH, related anticipatory guidance/educa- tion and needed referrals/connections via care coordination). Some services may be provided to a parent/caregiver during a well-child visit for the benefit of the child and may be billed using the child's beneficiary number. Services include: screening for depression and other mental/behavioral health conditions, tobacco and substance misuse, ACEs, and social determinants of health (e.g., food insecurity and housing instability), as well as health behavior interventions (e.g., tobacco cessation), family guidance on child development, care coor- dination, and referrals for appropriate follow-up care. Family therapy is a separately covered Medi-Cal benefit delivered to at least two family members together to improve parent/child or caregiver/child relationships, resolve conflicts, and create a positive home environment. Under federal law governing the Medicaid EPSDT child health benefit requires family therapy services (and other treatments) be provided if needed to correct or ameliorate a child's mental health condition. Children enrolled in Medi-Cal under age 21 may receive family therapy sessions before a mental health diagnosis is required. This benefit is intended to reach children: a) with a diagnosed mental health disorder, b) having symptoms September 2023 CCF.GEORGETOWN.EDU MEDICAID SUPPORT FOR CHILDHOOD MENTAL HEALTH 9 without a diagnosis, and c) with select social and psychological risk factors (e.g., NICU hospital- CA ization, parent separation or death, foster home placement, food or housing insecurity, maltreat- ment, bullying, and discrimination). Parental risks include: serious illness or disability, history of incarceration, depression/mood or psychotic disorder, PTSD, substance use disorder, job loss, interpersonal violence, and teen parenthood. Providers approved to deliver the family therapy benefit includes an array of mental health professionals, including but not limited to licensed clinical social workers, licensed psychologists, psychiatric nurse practitioners, and psychiatrists. Extension of postpartum coverage for pregnant women from 60 days to a full year will ensure uninterrupted coverage for mothers who had a Medicaid financed pregnancy/birth. As in other states, the extended postpartum coverage will enable mothers to receive their own mental health therapy and other health services that are beyond the scope of dyadic preventive or treatment services. California also has added new provider categories: community health workers, doulas, and behavioral health coaches. Adopting policies that permit Medi-Cal billing by these groups of providers will enhance and diversify the workforce available to serve families with young children in community and clinical settings. This creates an opportunity to embed these workers into primary care and help to implement promotion, prevention, and treatment models that focus on mental health for young children. Nonetheless, Karen Finello of WestEd believes: We still need more trained early childhood mental health specialists in order to provide consultation in child care and health care settings. In addition to changes in Medi-Cal, on July 2023, California announced $30.5 million in grants to 63 groups to support youth mental health through community and evidence-based practices, supporting parents, grandparents, and other family caregivers. The funded evidence-based practices and community-defined evidence practice models include: Positive Parenting Prac- tices (Triple P), Incredible Years, HealthySteps, Parent Child Interaction Therapy, Effective Black Parenting Program, Positive Indian Parenting, and a variety of other community-defined parent- ing support programs. Community based organizations receiving awards include: First 5 county sites, community health centers, mental health programs, schools, tribal organizations, and others. These grants are grounded in broad partner engagement and are part of the multi-year Children and Youth Behavioral Health Initiative, which seeks to reimagine the systems that sup- port behavioral health for California's children, youth, and their families, especially for those most at risk. As part of the announcement, DHCS Director Michelle Bass, said: DHCS is awarding grants to organizations seeking to strengthen families and improve youth behavioral health based on robust evidence for effectiveness for children and families, impact on racial equity, and sustainability. September 2023 CCF.GEORGETOWN.EDU MEDICAID SUPPORT FOR CHILDHOOD MENTAL HEALTH 10 4. INCREMENTAL ACTIONS SIGNAL PROGRESS, HELP BUILD MOMENTUM OVER TIME Advancing IECMH requires patience and persistence to workforce or start up new models of care, while Medicaid create shared knowledge across systems and consider or multi-year formula funds may be deployed to scale or the full constellation of supports needed to create mean- sustain services and supports where possible. ingful changes for families. State leaders pointed to the Building from national policy recommendations, federal importance of identifying incremental steps that will help to Medicaid guidance, and successful initial policy change in progress the long-range vision set out in a strategic plan or California, state agency leaders and advocates are seeking policy agenda. Long-time leaders in states such as Colora- to better use Medicaid to finance services that promote do and Michigan have been working to improve Medicaid and protect early childhood mental health and early rela- financing for IECMH for two decades or more. While major tional health before a more serious, diagnosed condition policy change can take years, incremental advances help emerges. While delivery of screening, diagnostic, and early maintain momentum among partners and create a shared intervention services in advance of a confirmed mental sense of progress. Change does not necessarily occur in a health diagnosis for young children are widely supported natural sequence or as a reflection of need. Some changes by research, it has long been a challenge to secure health occur because of political traction offering policy windows system recognition, including Medicaid financing, for mental in state legislatures or agencies. For example, initial policy health services without a diagnosed condition. Accelerated change might have been stimulated by a focus on so- progress could result in more support for evidence-based cial-emotional screening, maternal mental health, or family models of care, evidence-informed best practices, and (dyadic) therapy, as was true in California. Champions of effective interventions for generalized developmental and IECMH seized those opportunities and then returned to mental health concerns among the youngest children. seek funding for other services along the continuum of care. Seizing the moment, advocates also described the poten- Many states' efforts in early childhood mental health were tial they see for advancing maternal-infant-early childhood building upon related federal policy initiatives or grant funds, mental health and well-being through Medicaid postpartum including: 1) early childhood initiatives (e.g., Race to the coverage extensions. With more than half of states having Top, Early Childhood Comprehensive Systems), 2) early adopted the Medicaid postpartum extension option for childhood mental health grants in Project LAUNCH, or 3) coverage to one year following the end of pregnancy, the Medicaid innovations (e.g., State Innovation Models – SIM potential is great. In those states, mothers and infants have Initiative grants, Medicaid Section 1115 waivers, Integrated automatic and continuous Medicaid coverage for 12 full Care for Kids-InCK). Such initiatives may help to acceler- months. Many states, providers, and family advocates are ate change; the terms and structures of these initiatives exploring the best ways to do this, which might include may define or influence what is possible. For example, a dyadic services for promotion, prevention, and intervention time-limited federal grant might be best used to develop the related to mental health and well-being. September 2023 CCF.GEORGETOWN.EDU MEDICAID SUPPORT FOR CHILDHOOD MENTAL HEALTH 11 Action in Michigan MI Medicaid financing for maternal, infant, and early childhood mental health services has a long history in Michigan. In the 1980s, Michigan child behavioral health leaders began to focus on IECMH with prevention dollars. When mental health spending was expanding in the 1990s, they envisioned broadening access to an existing infant mental health services program developed by IECMH pioneer Selma Fraiberg. Funding for direct prevention services (behavioral health) under Medicaid evolved between 2005 and 2007. By 2010, the state's Infant Mental Health Home Visiting (IMH-HV) model was added to Medicaid home-based services as a Medicaid-covered prevention model to be delivered to at-risk parents and their young children by community mental health ser- vice providers across the state. In addition, while IECMH consultation is primarily funded by child care dollars (Child Care Development Fund quality set aside, Race to the Top, 2015-2019; and Preschool Development Grant, 2020-2023), a subset of eligible consultation services, considered to be prevention and early intervention, are financed in part by Medicaid and Community Mental Health Block Grant funds. Over the past decade, Medicaid's role has expanded to cover parent-child therapies up to age five and other evidence-based practices in IECMH. Michigan also has incorporated an infant mental health specialist into the teams delivering the Maternal Infant Health Program (MIHP), an evidence-based home visiting program for families in Medicaid. In 2018, the Medicaid provider manual was updated to include maternal depression screening as part of its guidance related to EPSDT well-child visits. Medicaid leader Mary Ludtke emphasized the importance of: being able to write specific Medicaid language and guidance to fund the right services to be included in the Michigan Medicaid specific provider manual. The commitment of leadership coupled with grants, partnerships, and system development efforts, has made Michigan a leader, said Kim Batsche-McKenzie of the Department of Health and Human Services. For example, with funds initially from a Race to the Top grant in partnership with the Michigan Department of Education and continuing with other state dollars, Michigan funds a position for a state-level early childhood mental health coordinator. Assuring that the IMH-HV would become designated as an evidence-based program has also been a priority. In addition, support and infrastructure for other parent-child interventions (e.g., Child-Parent Psychotherapy, Triple P, Incredible Years, Circle of Security) have grown. Thinking about the system of care, child health advocate Amy Zaagman, executive director of the Michigan Council on Maternal and Child Health, sees the potential to: better integrate and connect pediatric primary care and mental health services for children in Medicaid. While the need for workforce development remains high, the focus on professional guidelines (e.g., integrating infant mental health endorsement and reflective supervision/consultation), training in IECMH, and growing provider capacity statewide has yielded results. Tina Jones, Infant and Early September 2023 CCF.GEORGETOWN.EDU MEDICAID SUPPORT FOR CHILDHOOD MENTAL HEALTH 12 Childhood Development / Early Childhood Mental Health Coordinator in the Department of Health and Human Services reported that Michigan has developed a: MI cadre of services and aimed to improve diversity and equity, supported by experts dedicated to delivering a continuum of IECMH services to promote equity. The success of these efforts is grounded in partnerships among state Medicaid agency staff, mental health agency staff, child advocates, Michigan Association for Infant Mental Health, early care and education, and early childhood systems leadership (e.g., Office of Great Start). Meghan Schmelzer of Zero to Three, who has worked on IECMH in Michigan for years, believes it was important: to not just create a program but to infuse IECMH into every part of the early childhood system. 5. LEARN ABOUT APPLYING MEDICAID LEVERS In every state, understanding the primary Medicaid levers state Medicaid program. Generally, this begins by having for health care change and transformation is essential. a periodic well-child visit schedule that includes recom- Change in policy is the first step; however, successful mended screening for general development, social-emo- implementation of policy into practice changes requires tional development, and maternal depression. When further action. When it comes to Medicaid recognition screening identifies risks or needs, the process should of IECMH services, states often need to: adopt or clarify continue with permitting more than one visit for mental service definitions, establish billing codes, publish provider health diagnostic assessment and paying for multiple guidance, write clear and specific Medicaid managed care intervention visits for young children without requiring a di- contract language, and use measurement to assure quality agnosis, prior authorization, or medical necessity determi- and monitor progress. In some states, alternative payment nation. Among these five states, all have used the strength mechanisms or broader payment reform initiatives offer an and breadth of EPSDT to improve early childhood mental additional lever, such as pay-for-performance, incentive health services. For example, Colorado has used EPS- payments for screening, bundled payments, and so forth. DT as the anchor for such work for more than 20 years, In most every case, Medicaid levers to advance IECMH and California recently seized the opportunity to improve require attention to administrative policy and process EPSDT by adding coverage for certain services without a changes, not just legislative action. For example, leaders diagnosis. in California took advantage of state health reform efforts In these five states and elsewhere across the country, through a Medicaid waiver renewal engagement process to child health champions and decision makers often feel elevate IECMH priorities. pressure to show short-term cost savings. This is true Building upon the federal requirements, guarantees, and despite the fact that the return on investments for IECMH opportunities in Medicaid's comprehensive EPSDT benefit and developmental services, when limited to health system for children can help states anchor financing for a con- investments, primarily accrues over many years rather than tinuum of mental health services for children birth to age in one-to-three years or a legislative budget cycle. While six. As reflected in its name, Medicaid financing for early savings from Medicaid investments in health and mental screening, diagnosis, and treatment is required of every health services for young children may accrue in the state September 2023 CCF.GEORGETOWN.EDU MEDICAID SUPPORT FOR CHILDHOOD MENTAL HEALTH 13 budget for education or other agencies, such cross-sys- care organizations (CCOs) in delivering mental health and tems savings are rarely acknowledged or easily accounted IECMH services varies widely across states. These man- for in cost estimates or projections. Helping policymakers aged care or managed care-like entities are the primary consider a longer-range view on the benefit and return for health care delivery system for most Medicaid beneficiaries prevention and early intervention investments is important. in most states, and the wide state variation in such arrange- State and community-level structures responsible for behav- ments is hard to understate. For example, in some states ioral/mental health in each state may also influence the pace separate MCO-like entities may provide Medicaid mental of change. This includes the structure of behavioral/mental health services. Some interviewees in these five states health in state government overall (e.g., where does mental raised concerns that separate Medicaid contracts with health agency sit and does it include IECMH), as well as the behavioral/mental health organizations can leave the young- existence and role of publicly funded community mental est children excluded from mental health care or otherwise health entities. Linkages between mental health and Medic- falling through into cracks in the healthcare delivery system aid agencies are similarly important, as Medicaid pays for a that is not designed to address early risk factors that may large proportion of behavioral/mental care in states. prevent or mitigate later mental health conditions. The role of Medicaid managed care organizations (MCOs), accountable care organizations (ACOs), and/or community NC Medicaid Levers in North Carolina North Carolina has adopted a series of improvements designed to promote optimal child development and IECMH over the past two decades. Champions for IECMH and optimal child development have engaged in a long series of administrative and advocacy efforts. At the same time, the continuing redesign and evolution of the state's Medicaid program meant that IECMH efforts have been challenged to evolve evenly amidst large-scale delivery systems change. Most recently, North Carolina, by direction of the state legislature, has begun transi- tioning its entire Medicaid program to managed care. Based on the success of the Assuring Better Child Health and Development (ABCD) initiative, including Medicaid policy changes to require and incentivize developmental screening, North Carolina attained a developmental screening rate of 94 percent (including general develop- ment, maternal depression, and autism screening) by 2014 for infants and toddlers-far and away a top performer nationwide in Medicaid. The state also created a standardized referral system for IDEA Part C Early Intervention and Part B Exceptional Preschool, and used Title V Maternal and Child Health Services Block Grant dollars to fund public health nurses to con- duct screenings and make community referrals. Provider acceptance of the policy was high. Unfortunately, the quarterly screening data have not been collected and reported after 2019, so no up-to-date progress report is available. Since 2001, thanks to the leadership of pediatricians and other advocates, North Carolina Med- icaid policy has permitted Medicaid payment for up to 6 mental health visits without a diagnosis. September 2023 CCF.GEORGETOWN.EDU MEDICAID SUPPORT FOR CHILDHOOD MENTAL HEALTH 14 NC Originally as high as 26, now 16 "unmanaged" mental health intervention visits also are permitted. These changes allow young children and their families to be supported with needed services when developmental and mental health risks are identified. The state also provides a small payment incentive for completion of perinatal depression screens as part of infant well-child visits, a univer- sally recommended screening for a major risk factor in a child's development. The NC Medicaid Transformation process to adopt Medicaid managed care has been rolled out across different regions of North Carolina and launched July 1, 2021 with changes to the system of care. If implemented, the next phase of so-called "tailored plans" will be aimed at providing whole-person care for people with serious developmental disabilities and mental health conditions. Child health advocates remain concerned that creation of new structures for managed care plans and contracts holds the potential to disrupt children's connection to the medical home and create arbitrary barriers in care for children with social-emotional risks and needs but without diagnoses. While some states' early childhood system efforts did not initially include health or health care providers, pediatrician Marian Earls has been a force within North Carolina and across the nation driving change in pediatric practice, particularly screening and prompt interventions to improve young children's development, mental health, and well-being. She is part of a wider group of pediatricians, child psychiatrists, IECMH consultants, and other mental health pro- viders focused on improving policy and practice. Together these champions paved the way for the North Carolina's Institute of Medicine's Task Force on the Mental Health, Social, and Emo- tional Needs of Young Children and Their Families, created at the request of the North Carolina General Assembly in 2010. The panel made strong recommendations based on research and best practices for the unique health practitioner audience. Dr. Earls sees the potential to con- tinue progress toward implementing the AAP recommendations. In addition, the EarlyWell Initiative (formerly known as the North Carolina Initiative for Young Children's Social-Emotional Health) is designed to strengthen and enhance the IECMH system across North Carolina. With input from NC families and other stakeholders, EarlyWell is developing a comprehensive action plan and policy agenda aimed at having family-driven, equitable systems that serve children in the context of their families and communities and offer access to high-qual- ity primary care and mental health services to support social-emotional development. EarlyWell Initiative Director Morgan Forrester Ray affirmed: We have developed a consensus on recommendations and are rowing in the same direction to support family voice and equity. Chameka Jackson, Child and Adolescent Services Coordinator for Medicaid, sees the potential to do more. In particular, she envisions: the opportunity to improve outcomes for children through active listening and partnership with families, providers, and advocates. Together we will be able to identify and fill gaps in the continuum of care – in short, to modernize care and enhance the narrative about children's health and well-being. September 2023 CCF.GEORGETOWN.EDU MEDICAID SUPPORT FOR CHILDHOOD MENTAL HEALTH 15 6. WORK ACROSS THE FULL CONTINUUM OF CARE: PROMOTION AND PREVENTION TO INTERVENTIONS AND TREATMENT The leaders interviewed in five states all pointed to the childhood systems design, particularly because these servic- importance of working to assure a continuum of services es and the providers who deliver them occur across multiple to promote social-emotional development, screen for risks, systems of care. Closing gaps among systems was a consist- use appropriate diagnostic methods, and intervene for men- ent theme, especially gaps between primary care and other tal health conditions. The diagram below offers a group of delivery systems such as mental health services, IDEA Part successful state strategies for state Medicaid programs to C Early Intervention, and early care and education. Engaging finance care across the continuum of mental health services a wide array of diverse stakeholders-including families with for children 0 – 6 years to ensure that children and families varied experience, providers with different qualifications, and receive support they need to achieve optimal mental health public sector decision makers - to guide system design and and well-being. As states identify IECMH service gaps, implementation was seen as a high priority. inequities in services across the continuum may become For decades states have received small grants related more apparent. For example, while most states pay for to early childhood comprehensive system development. maternal depression screenings in well child visits, a smaller Recent federal investments include a new round of grants set of states reimburse for family therapy, one key interven- for state and community action to advance early childhood tion for a child whose parent is experiencing depression. comprehensive systems. In addition, more federal grants are While Medicaid only finances care for a share of children, focused on child health transformation, which might include the program's reach can help to drive toward greater access promotion and prevention for IECMH (e.g., Health Care to a continuum of high quality and age-appropriate mental Resources and Services Administration funding opportuni- health services for all young children. ties for Transforming Pediatrics for Early Childhood; Early State leaders also described the importance of working Childhood Developmental Health Systems-Evidence to within the larger child health care system, beginning with the Impact; Early Childhood Comprehensive Systems; and Early primary care medical home, as well as in the context of early Childhood Development for Community Health Centers). FINANCING SERVICES ACROSS THE CONTINUUM OF NEED AND RISK Medical home Promotion of Screening and Prevention and Early intervention structure health & well-being response support and treatment September 2023 CCF.GEORGETOWN.EDU MEDICAID SUPPORT FOR CHILDHOOD MENTAL HEALTH 16 Conclusion and Key Takeaways States seeking to make progress on Medicaid financing for related to early childhood mental health. Each state also has IECMH services can learn from states highlighted throughout an opportunity to recommend screening tools, use age-ap- as they start or continue their journeys. Takeaways from state propriate diagnostic codes, and avoid requirements for diag- successes to advance policies, program structures, and sys- noses or determinations of medical necessity for diagnostic tems include the following. and early intervention services related to IECMH. • Cultivate leadership at all levels. Seize the moment when • Infuse IECMH into broader early childhood reforms. An the governor, another elected official, or agency director sees early childhood system includes health, early care and edu- early childhood health and/or IECMH as a priority. In some cation, family support, and other providers that serve young cases, educating leadership is the path to change; however, children and their families. IECMH services and the providers it may equally be an unexpected change due to an appoint- who deliver them are working across multiple systems of ment or election. Be a policy entrepreneur who is ready to care. They may work in primary care, mental health, IDEA make proposals and take action when the time is ripe. Part C Early Intervention, early care and education, child • Engage a wide array of partners. Effective advocacy welfare, nutrition, or other sectors. Closing the gaps in the requires a strong partnership among those working inside system of systems is critical for supporting families in reach- and outside of government. Even if advocates are success- ing their goals for optimal health and well-being. System ful in getting legislation passed or increasing funding, policy level data can help monitor progress. and program implementation will rely on the knowledge • Advance equity by engaging families. A focus on equity in and support of state agency staff. These five states also access and outcomes should drive efforts to improve system exemplify how partnerships with philanthropy, families, connections for families who have been historically marginal- professional organizations, and others created the basis for ized or underrepresented. As affirmed by the AAP, racism is moving IECMH ahead. a determinant of health for children. Authentic engagement • Create a strategic plan and priorities for action. In each of families who use the services and have experience in the of these states, a long-range plan for action was set out. systems of care is essential, including not only those whose Sometimes this was a formally adopted, statewide plan. In children have special health or mental health needs, but also other states, the priorities for action were set by an advocacy those from historically marginalized and minoritized groups. organization in partnership with key stakeholders. Moreover, Families should be engaged and directly involved not only in advocates recognized that adopting services across the the health care system but also in co-design of early child- continuum of IECMH risk and need would be an incremental hood systems. process, taking years not months. As the federal Medicaid agency describes it: • Understand state Medicaid policy levers. In most states, The goal of the EPSDT benefit is to ensure that individual the most powerful lever is the Medicaid managed care children get the health care they need in the right place contract, which should set specific, concrete, and actionable when they need it. expectations for health plans and their network providers. Many states are taking action and most could do more Whether or not the state uses managed care or similar to finance high-performing systems and services that arrangements, measurement for quality and performance im- promote the social-emotional-mental health and well- provement is key. Also, operationalizing benefits by adopting being of children, starting in the earliest years. billing codes, provider qualifications, and service definitions September 2023 CCF.GEORGETOWN.EDU MEDICAID SUPPORT FOR CHILDHOOD MENTAL HEALTH 17 Appendix A. Individuals Interviewed CALIFORNIA MICHIGAN Alex Briscoe, Principal, California Children's Trust Kim Batsche-McKenzie, Division Director, Division of Sarah Crow, Managing Director, First 5 Center for Children's Program and Grant Development and Quality Monitoring, Policy Bureau of Children's Coordinated Health Policy and Sup- ports, Michigan Department of Health and Human Services Karen Moran Finello, Project Director, WestEd Mary Ludtke, Evidence Based Practice and Grant Devel- Alexandra Parma, Senior Policy Research Associate, First 5 opment Section Manager, Division of Program and Grant Center for Children's Policy Development and Quality Monitoring, Michigan Department Pamela Riley, MD, MPH, Chief Equity Officer & Assistant of Health and Human Services Deputy Director, Quality and Population Health Manage- Tina Jones, Infant and Early Childhood Development / Early ment, California Department of Health Care Services Childhood Mental Health Coordinator, Bureau of Children's Coordinated Health Policy and Supports, Division of Pro- COLORADO gram and Grant Development and Quality Monitoring, Jordana Ash, Senior Clinical Instructor, Department of Evidence Based Practice and Grant Development Section, Psychiatry; and Co-Director Harris Community Fellowship Michigan Department of Health and Human Services in Child Development & Infant Mental Health, University of Meghan Schmelzer, Senior Manager, Infant Early Childhood Colorado School of Medicine Mental Health Policy Center, Zero to Three John Laukkanen, Behavioral Health Policy and Benefit Amy Zaagman, Executive Director, Michigan Council for Operations Unit Supervisor, Behavioral Health Initiatives Maternal and Child Health and Coverage Office, Colorado Department of Health Care Policy and Financing NORTH CAROLINA Erin Miller, Vice President of Health Initiatives, Colorado Marian Earls, Independent Consultant; and Clinical Profes- Children's Campaign sor of Pediatrics for UNC Medical School Gina Robinson, Senior Policy Advisor/EPSDT Program Morgan Forrester Ray, Director, EarlyWell Initiative, NC Child Administrator, Health Policy Office, Colorado Department of Health Care Policy and Financing Chameka Jackson, Child and Adolescent Services Coordi- nator, North Carolina Medicaid, Department of Health and Angela Rothermel, Deputy Director, Early Milestones Human Services Colorado Kaylan Szafranski, Health Program Director, NC Child Alex Weichselbaum, Primary / Rehabilitative Care and Analytics Section Manager, Colorado Department of Health WASHINGTON STATE Care Policy and Financing Christine Cole, Infant-Early Childhood Mental Health Pro- Tanya Weinberg, Portfolio Director for Health & Well-Being, gram Manager, Washington State Health Care Authority Early Milestones Colorado Kimberly "Kiki" Fabian, Infant-Early Childhood Mental Health Analyst, Washington State Health Care Authority Monica Oxford, Executive Director, Barnard Center for Infant Mental Health and Development, University of Washington Sarah Rafton, Executive Director, Washington Chapter of the American Academy of Pediatrics Beth Tinker, Maternal and Child Health Consultant, Wash- ington State Health Care Authority September 2023 CCF.GEORGETOWN.EDU MEDICAID SUPPORT FOR CHILDHOOD MENTAL HEALTH 18 Appendix B. Questions for Interviews 1. Your state has gained attention as one using Medicaid to finance mental services for children 0-6, tell me more about the forces that led to policy change? a. To what extent the Medicaid agency play a key leadership role? b. To what extent did the mental health agency play a key leadership role? c. To what extent did providers and advocates play a role in driving change in Medicaid policy? 2. Your state is reported to have Medicaid policies that finance and support access to a continuum of early childhood mental health services. We'd like to learn more about support for various components along the continuum of care. a. How would you describe your state's Medicaid financing and support for mental health promotion and prevention services for children 0-6? i. We are particularly interested in examples of an array of child or parent screening for social-emo- tional-mental health ii. This might also include promotion and preventions models such as HealthySteps or DULCE. b. How would you describe your state's Medicaid financing and supports for mental health interventions and treatments for children 0-6? i. This might include therapy models such as Parent-Child Interaction Therapy (PCIT) or Child-Parent Psychotherapy (CPP). ii. We are particularly interested in examples of financing parent-child dyadic or family treatment, in which a clinician treats a parent and infant/young child together to reduce mental health and behavior difficulties. 3. If your state is using Medicaid managed care to serve a large majority of children in Medicaid, what role to do MCOs play in delivery of mental health services for children 0-6? 4. What do you see as the most important Medicaid policy or process innovation you state has put into place in order to finance and ensure access to a continuum of mental health services for children 0-6? 5. What do you see as the key next steps in your state's work to improve access to mental health services for young children in Medicaid? Prior to the interview, we will confirm whether or not your state has returned the survey. If possible, in addition to this interview, we would like to have your state's survey information to complement this interview and be part of the baseline for our national report. September 2023 CCF.GEORGETOWN.EDU MEDICAID SUPPORT FOR CHILDHOOD MENTAL HEALTH 19 Resources and References Alker, J. & Osario A. (2023). Child Uninsured Rate Could Johnson, K. & Knitzer, J. (2005). Spending Smarter: A Funding Rise Sharply if States Don't Take Care. Washington, DC: Guide for Policymakers to Promote Social and Emotional Health Georgetown University Center for Children and Families. and School Readiness. New York, NY: National Center for Children Retrieved from: https://ccf.georgetown.edu/2023/02/01/ in Poverty, Columbia University. 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Optimizing Medicaid Extend- moting the Emotional Well-being of Children and Families Policy ed Postpartum Coverage to Drive Health Care System Change. Paper 4). New York, NY: National Center for Children in Poverty, Women's Health Issues, 32(6), 536–539. https://doi.org/10.1016/j. Columbia University. Retrieved from: https://academiccommons. whi.2022.08.008 columbia.edu/doi/10.7916/D88P6874 September 2023 CCF.GEORGETOWN.EDU MEDICAID SUPPORT FOR CHILDHOOD MENTAL HEALTH 20