Using Medicaid to Ensure the Healthy Social and Emotional Development of Infants and Toddlers by Elisabeth Wright Burak and Kelly Rolfes-Haase Executive Summary Each child’s social and emotional development underpins Medicaid provides health insurance to nearly half of all overall development and greatly influences his or her lifelong infants and young children.3 While Medicaid alone cannot trajectory. Infants and toddlers experience a period of solve broader system challenges, such as stigma or the rapid brain development marked by great possibility and need for more qualified mental health providers, it can be vulnerability, depending on their family and community a leader for improvements across payers and systems. contexts. The first years of life are particularly crucial to a The program’s comprehensive pediatric benefit, known as child’s development of a sense of security and attachment Early and Periodic Screening, Diagnostic, and Treatment with others, foundational activities that undergird subsequent services (EPSDT), is designed to meet the preventive care social and emotional development. Prolonged stress brought and treatment needs of young children, including their on by trauma—parental substance abuse, poverty, and other mental health. EPSDT is not well understood or consistently family, social, and/or environmental factors—places healthy applied, but it holds much potential to strengthen access to development at great risk. Nurturing relationships with parents IECMH services. The opportunity to reach young children, and caregivers can mitigate these risks, especially with early along with their parents and caregivers, as early as possible identification and support for young children’s mental health can prevent conditions from escalating and requiring more needs along with those of their parents. But when such stress complex, expensive interventions. To ensure the youngest gets in the way of consistent caring and responsive parent- children and their families in Medicaid receive the support child relationships, it can lead to a host of health, behavioral, they need to ensure strong mental health, states can: social, and emotional difficulties for the child throughout his or 1. Improve preventive screenings based on expert- her life. recommended schedules and guidelines. Young children’s social and emotional development, also 2. Adopt diagnosis guidelines specific to young called infant and early childhood mental health (IECMH), lays children’s mental health. the foundation for lifelong success.1 Many interventions to 3. Update or clarify payment policies and processes for prevent and treat young children’s emotional health, often needed IECMH services. focused on relationships with their parents or caregivers, 4. Consider new settings or provider types appropriate are available and effective. Yet federal and state health care, for IECMH services. mental health and early childhood policies do not reflect the 5. Include IECMH in broader Medicaid improvements evidence base for IECMH.2 and reforms. November 2018 1 Using Medicaid to Ensure the Healthy Social and Emotional Development of Infants and Toddlers Introduction A baby’s brain forms more than 1 million new neural This paper outlines state opportunities to address children’s connections every second.4 This extraordinary rate of mental health earlier and more effectively through Medicaid. development allows infants to process new stimuli and to A variety of factors influence this work, including social begin to master languages, social behaviors, and cultural determinants of health and broader promotion and norms within their first few years of life. At the same time, prevention efforts. This paper does not address these areas the ever-expanding neural networks that enable children’s comprehensively, as many of the resources referenced brains to take in vast amounts of information also make throughout provide a more comprehensive take on these them especially vulnerable. Stressful family experiences— topics.10 Instead, it offers a starting place to inform Medicaid such as illness or family death, parent mental health (e.g., discussions that will require additional attention to the full maternal depression) or substance abuse, abuse, neglect, range of family and environmental factors that influence a parental absence, discrimination, or exposure to other child’s development. trauma—can impede children’s healthy development. The greater number of adverse childhood experiences (ACEs) children encounter, the higher their risk for physical and Audience Matters: Talking About Healthy mental health problems (heart disease, depression, suicide Social and Emotional Development in risk) as adults. ACEs are also linked with poorer school readiness and educational outcomes and involvement with Young Children the juvenile justice system.5 These poor outcomes not only Advocates and other stakeholders should be mindful cost families and communities, they cost taxpayers: Poor of their audience when selecting terms and crafting health outcomes associated with ACEs cost the nation messages about IECMH. A number of terms are nearly $100 billion annually in expenses for cardiovascular used to describe this concept: social and emotional care and more than $85 billion in mental health disorders.6 development, emotional health and wellbeing, and others. States, and even specific sectors or Many who need mental health treatment do not receive it. agencies within states, use varying terminology Research suggests that as many as one in five U.S. children based on their roles. For example, health or mental suffers from some kind of emotional impairment or disorder, health stakeholders may use terms such as “early including an estimated 10 to 14 percent of children under childhood mental health” or “behavioral health,” age 6.7 Yet between half and two-thirds of those identified while early learning and education stakeholders may as needing mental health services do not receive timely use “social emotional development.” treatment.8 Treatment gaps tend to be larger among those who develop a mental health condition at a very young age Research suggests that while mental health or who come from rural and/or minority backgrounds.9 experts and providers may prefer IECMH, parents, pediatricians, and the general public may be more Medicaid support to strengthen IECMH services can go comfortable with terms like social and emotional a long way to improving children’s long-term success. development.11 In this paper, “IECMH” is used most Medicaid serves most low-income young children and often to specifically call attention to screening, includes a robust pediatric health benefit designed to diagnosis, and treatment services that may be ensure that children’s developmental needs are met and supported in Medicaid. “Social and emotional that diseases or delays are addressed as early as possible. health” or “emotional development” refer more In the earliest years, there is a tremendous opportunity to broadly to promotion and prevention activities. respond much earlier and more proactively to children at risk of or showing signs of emotional, social, and developmental needs and delays. November 2018 2 Using Medicaid to Ensure the Healthy Social and Emotional Development of Infants and Toddlers What is Infant and Early Childhood Mental Health (IECMH) and Why is it Important? Infant and early childhood mental health (IECMH) is a young An explicit focus on children’s social and emotional child’s ability to experience, express, and regulate emotions; development may prevent or minimize more costly, complex form close, secure interpersonal relationships; and explore his and/or overutilized services. Expanding the availability of or her environment and learn, within the context of family and IECMH services offers new intervention pathways to meet each cultural expectations.12 The expanding evidence base of brain child’s unique needs and prevent more costly and complex science and child development suggests the following: treatments down the line. It also has the potential to limit use of available, overutilized strategies that raise risks or concerns Young children’s mental health needs can be successfully (see box). addressed early on, but must be more broadly embraced. IECMH is not as widely understood and does not look the same as mental health challenges for older children or adults.13 Extending access to IECMH in Medicaid Warning signs among young children include excessive crying, could support state efforts to limit developmental delays, failure to seek comfort from caregivers, or lack of curiosity.14 Left untreated, these early signals can psychotropic use in young children escalate into more serious mental health disorders (e.g. Many states are taking a closer look at medication Depressive Disorder of Early Childhood, Anxiety Disorders, prescribing practices for children or sub-groups in Posttraumatic Stress Disorder, Attention Deficit Hyperactivity Medicaid, especially for psychotropic medications. Medication, in conjunction with psychotherapy, may be Disorder, etc.) that can upend lifelong health, as well as appropriate for some conditions if other interventions have educational and economic success.15 The good news is that not helped, particularly for older children. Experts warn, effective, evidence-informed, and promising interventions to however, that the practice of medicating young children support infant and toddlers’ mental health are available. should be reserved for those with severe conditions and only after careful consideration of alternative Parents and caregivers influence babies’ brain approaches. Yet studies have shown an upward trend in development from the start. Babies who feel loved, the prescription of psychotropic medications in recent comforted, and have the freedom to play form more years, with an estimated 1 to 2 percent of Medicaid- brain connections, which increases their ability to covered children under age 4 receiving prescriptions for at least one psychotropic drug, and higher rates for children trust, relate, communicate, and learn. diagnosed with specific mental or behavioral conditions such as ADHD or autism. Research is lacking on how these drugs may affect children’s long-term neurological and behavioral development, making the increased use of Parent/caregiver well-being is key to their children’s social psychotropic medications for young children a concern. In and emotional development. Parents and caregivers influence addition, many young children who take these medications babies’ brain development from the start. Babies who feel do so without having received complete mental health loved, comforted, and have the freedom to play form more assessments or oversight from a psychiatrist. Providers brain connections, which increases their ability to trust, relate, may be responding to a lack of availability or awareness of communicate, and learn. Strong, nurturing relationships between alternative treatment options, such as child psychotherapy. children and their parents and caregivers can protect children The increasing prevalence and potential risks of from adversity and help them recover. Added stressors on psychopharmacological treatment in children underscores parents (financial, mental health or substance abuse, health the need for broader efforts to promote healthy emotional conditions or others) get in the way of their ability to fully respond development and prevent and treat mental health problems to their own mental health needs and their children’s needs, in young children. Extending access to IECMH treatment which can impede their children’s development. Interventions to can offer a broader range of options for providers seeking support IECMH necessarily must also support and engage their to help children and their families. primary caregiver to protect and nurture these relationships. November 2018 3 Using Medicaid to Ensure the Healthy Social and Emotional Development of Infants and Toddlers Young Children’s Mental Health is Often Overlooked in Policy and Practice Despite the important role that mental health plays in XXAccounting children’s long-term development, federal and state policies If a child is referred to a mental health clinician for could do more to promote IECMH.24 Federal law, most treatment, the provider may encounter challenges recently under the Affordable Care Act (ACA), requires health in obtaining reimbursement. Although all “medically payers, including Medicaid,25 to ensure that access to mental necessary” services, including mental health, must be health care is equal to that of physical health.26 However, the provided under EPSDT for Medicaid children, state move to a fully responsive and integrated mental health care definition and application of the medical necessity system—while growing—is still nascent.27 Even within mental standard varies. In addition, lack of specific codes or health policy and systems, IECMH is often overlooked.28 clearly-defined billing procedures for a needed service Attention to young children’s social and emotional health is creates confusion and administrative barriers for growing, but the following obstacles, many related to broader providers seeking reimbursement. health and mental health system challenges across public and private coverage sources, remain: These challenges are not unique to young children but there is additional urgency to address their mental health needs. XXAwareness Expanding awareness and availability of IECMH services Some caregivers and primary healthcare providers may in the broader health and mental health systems offers an not be trained to recognize mental health disorders for important opportunity to reduce or mitigate more complex young children, feel reticent to diagnose young children and costly challenges later in life. Policymakers can promote with mental health issues due to lack of familiarity with healthy social and emotional development and improve developmentally-appropriate diagnostic approaches or IECMH promotion, prevention and treatment services for the perceived stigma, and/or be unaware of the effective young children and families who need them today.31 treatment options that are available (described below).29 They may also be reticent to identify early warning signs for compromised healthy development because they do not feel equipped to offer any positive actions or response. XXAccess Even when pediatricians or other providers are able and willing to diagnose or refer for IECMH disorders, they may encounter challenges finding pediatric mental health professionals. A Substance Abuse and Mental Health Services Administration (SAMHSA) report highlights the lack of sufficient child and adolescent psychiatrists to meet the projected need for these services, especially in rural and low-income communities.30 This shortage extends across disciplines to psychologists and other clinicians with specialized IECMH training. November 2018 4 Using Medicaid to Ensure the Healthy Social and Emotional Development of Infants and Toddlers Medicaid is Well-Positioned to Advance Infant and Early Childhood Mental Health (IECMH) As the primary health insurance source for young, low-income children, Medicaid is the logical system Figure 1. Sources of Health Coverage for to reach them with their families before they enter Children Under Age 6, 2016 school.32 More than one-third of all children rely on Medicaid and CHIP for health coverage, and the programs play an even greater role for the nation’s youngest children (See Figure 1). One in Medicaid/CHIP five parents of children aged 3 and younger were 44.1% Direct purchase 4.8% enrolled in Medicaid in 2016, a rate that will likely increase as more states take up the ACA option to Other expand Medicaid to low-income adults.33 Medicaid’s 3.7% purchasing power, along with state flexibility in ESI program administration, provide an opportunity to 43.6% lead broader health and mental health reforms that Uninsured include attention on young children’s emotional 3.8% development.34 Source: Georgetown University Center for Children and Families Medicaid’s Pediatric Benefit (EPSDT): A tabulations of the 2016 U.S. Census ACS data from IPUMS. Pathway to Improved IECMH Services Note: “Medicaid/CHIP” includes children covered by Medicaid or CHIP alone or in combination with other coverage sources. Medicaid’s pediatric benefit, called Early and Periodic Screening, Diagnostic, and Treatment services (EPSDT), guarantees a comprehensive array of services for all children under age 21.35 Each The Building Blocks of EPSDT Medicaid-eligible child is entitled to recommended preventive screens, follow-up diagnostic Identify problems early, assessments and, in turn, any resulting services a Early starting at birth. medical professional considers essential to prevent, Check children’s health at periodic, treat, or improve the diagnosed condition.36 This Periodic age-appropriate intervals and whenever a problem appears. includes services considered “optional” for adults Provide physical, mental, developmental, in Medicaid.37 While the Medicaid statute itself does hearing, vision, and other screening tests to not specify mental health on the list of required S creening detect potential problems or affirm healthy development. Screenings start with a services, it may be captured under a number of comprehensive health and development history, benefits categories, including physician services, an unclothed physical exam, appropriate immunizations and laboratory tests, as well as clinic services, services provided by a licensed health education for the parent and child. mental health or related professional, rehabilitation services, case management, and/or others (see Diagnosis Perform diagnostic tests to follow up when a risk is identified. Appendix A).38 Statutory clarifications, federal guidance, and legal decisions against state Medicaid Treatment Address any problems that are found. programs have clarified the inclusion of mental Adapted from EPSDT - A Guide for States: Coverage in the Medicaid Benefit for health services under EPSDT.39 Children and Adolescents (Centers for Medicare and Medicaid Services, 2014). November 2018 5 Using Medicaid to Ensure the Healthy Social and Emotional Development of Infants and Toddlers State Levers for Change States have wide flexibility in Medicaid program administration, Medicaid Managed Care: above federal minimum requirements. Core state Medicaid The Role of Managed Care functions include eligibility and enrollment, delivery system, Organizations (MCOs) payment, and quality improvement.40 Functions most directly In most states, some or all Medicaid related to IECMH include: beneficiaries are enrolled in Medicaid XXDelivery system managed care organizations (MCOs), private States determine how Medicaid services are provided, and health plans that contract with the state under have a variety of system design options. Most states contract a capitated, or fixed, rate.46 The majority of with managed care organizations (MCOs) to ensure enrolled children in Medicaid are enrolled in MCOs, Medicaid beneficiaries receive needed care (see box).41 In and the number is increasing as more states these cases, the MCO, not the state, pays providers for shift to managed care.47 Medicaid MCOs often services. Some states use fee-for-service arrangements (FFS) have latitude over decisions such as payment for some or all Medicaid beneficiaries, where the Medicaid rates to network providers, utilization controls agency reimburses providers directly. Certain services, such (e.g. prior authorization or service limits), and as mental health, may be carved out of managed care and provider networks.48 provided by FFS or a separate MCO plan as a “wraparound” States have ultimate responsibility benefit.42 Beyond the movement toward managed care, many states are actively engaged in delivery system reforms, such for ensuring Medicaid beneficiaries as integration of primary care and behavioral health, an area receive the care they need and are key ripe for IECMH.43 to lasting systems-level change. XXPayment and reimbursement States set payment standards (e.g. rate ceilings or floors) for MCOs can be important change partners for MCOs and providers. MCO and provider manuals often outline stakeholders, child health advocates, and EPSDT requirements, including pediatric medical necessity, others seeking to increase access to IECMH. services, payment and approval processes. States can also MCOs, for example, can pilot new projects designate additional types of professionals that may provide or initiate changes that can impact access to and bill for certain services, under specific circumstances, care for children they enroll. But states have either through FFS or managed care. ultimate responsibility for ensuring Medicaid beneficiaries receive the care they need and XXQuality and Performance Improvement are key to lasting systems-level change. State States oversee or conduct quality measurement and requests for proposals (RFPs) and contracts performance improvement activities and have the option to play a key role in ensuring MCOs adhere prioritize specific services or outcome measures.44 States to EPSDT requirements. State contracts must require MCOs to have information systems that meet with MCOs, and MCO sub-contracts federal minimum standards and have the option to determine with providers, should clearly specify the if additional data must be collected. State MCO contracts responsibilities of each actor under EPSDT, must specify data reporting and quality improvement including outreach to families, ensuring requirements, including the establishment of a Quality preventive screens and medically necessary Assessment and Performance Improvement Plan (QAPI) that services, and data reporting and performance includes performance improvement projects (PIP) and External requirements.49 Quality Review (EQR) activities.45 November 2018 6 Using Medicaid to Ensure the Healthy Social and Emotional Development of Infants and Toddlers The Medical Necessity Standard for Children provides research-based diagnostic criteria specific to young children. Its adoption and use can improve accuracy Under EPSDT states must ensure each child receives any of age-appropriate diagnoses and allow for a common medically necessary treatment that results from screenings language for child-serving professionals.57 and/or diagnoses to “correct or ameliorate” a condition (See Appendix A).50 Medical necessity is defined and applied A growing base of evidence also outlines the effectiveness inconsistently across Medicaid and private plans, and is of specific services. Dyadic interventions (i.e., involving often intended to be generalizable across populations the parent and the child together) are particularly effective served, which could miss addressing children’s unique in addressing mental health of infants and young children, developmental needs.51 While states and/or Medicaid MCOs especially when the child or family has experienced serious define the scope and process for pediatric medical necessity trauma.58 Several common evidence-based interventions59 determinations in Medicaid, states must use the following include: Parent-Child Interaction Therapy (PCIT),60 Child- parameters:52 Parent Psychotherapy (CPP),61 Attachment Biobehavioral zz Decisions must be made on a case-by-case basis. Catch-up (ABC),62 and Trauma-Focused Cognitive Behavioral Therapy (TF-CBT).63 For billing purposes, states zz States may not impose hard limits on pediatric may classify such treatments as individual and family services. therapy (Florida 64), family psychotherapy (Minnesota 65) or zz States or plans may impose tentative “soft” limits similar descriptions. on services (e.g. frequency or cap on treatments) pending an individualized medical necessity determination. zz Medicaid MCOs must not use a definition of medical necessity for children that is more restrictive than that used by the state.53 State officials or MCOs may hesitate to approve a particular service due to a perceived or real lack of evidence on improved health outcomes.54 Examples of services related to IECMH that may require additional justification for medical necessity include: behavioral health services, early intervention for developmental disabilities or other “educational” programs, rehabilitative services, and psychological testing.55 What IECMH Services May Be Considered Medically Necessary? Research supports specific IECMH diagnostic tools and interventions that can help to prevent or treat mental health disorders in infants and young children. Common diagnosis tools and systems used in the health system, such as the Diagnostic and Statistical Manual of Mental Disorders (DSM), are geared toward older children and adults and do not reflect what is known about mental health disorders that may be first diagnosed in infancy and early childhood.56 The DC:0-5TM: Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood November 2018 7 Using Medicaid to Ensure the Healthy Social and Emotional Development of Infants and Toddlers Recommendations Without clear guidance or intentional effort to incorporate children under age 4.71 At least six states do not specify the unique developmental needs of young children, health or require universal screening for maternal depression in and mental health systems often apply practices tailored a well-child visit (Alabama, Massachusetts, Minnesota, for adults that may be inappropriate in pediatric care. And Rhode Island, Utah, Wisconsin).72 At least two states as knowledge and evidence about IECMH has grown, it has (Alabama and Arizona) do not require universal not fully translated to widespread system change. Medicaid psychosocial/behavioral assessments.73 Alabama does agencies can ensure policies and practices match the latest not require universal developmental screenings.74 (Note: evidence and meet the promise of EPSDT to not only ensure Whether a state requires a particular assessment or the right treatment but also catch problems early and prevent screening is separate from how or whether the specific conditions from escalating. Recommendations below offer a service is reimbursed. States may reimburse for a starting place, but each state’s beneficiaries and their families, service that is not universally required, for example.) providers, and others serving families in need will have the zz Adopt clear guidelines and processes for referrals strongest sense of the opportunities and barriers in the and follow-up services. When a screen shows Medicaid system. (Also see “Getting Started” on page 12.) a need for further evaluation, a uniform tracking system from screening to diagnosis and any resulting 1. Improve preventive screenings based treatment could help ensure consistency across on expert-recommended schedules and providers and the potential for better data. States can guidelines. streamline referral processes that indicate clear cross- States determine their own policies and guidelines for sector responsibilities and feedback loops can aid preventive care in Medicaid, including a periodicity understanding of whether children receive necessary schedule, or the state’s reimbursement timetable for referrals and follow-up care when a screen identifies preventive screens. The AAP Bright Futures Guidelines for a need. Thirty-three states promote standardized Health Supervision of Infants, Children, and Adolescents66 referral processes in at least one system to connect sets the standard for preventive care, providing an children or families to follow-up services such as early evidence-based template for well-child visits. Medicaid intervention.75 States must set network adequacy programs in 40 states and the District of Columbia use standards to assure timely access to care. Validation Bright Futures as the preventive care standard or use a of network adequacy is a required component of an similar standard.67 Policies in 11 states do not align with External Quality Review (EQR) process.76 Bright Futures, because their policies specify fewer well- child visits for young children and/or do not fully reflect 2. Adopt diagnosis guidelines specific to young preventive screening guidance.68 Even among states children’s mental health. with recommendations similar to Bright Futures, specific Mental health disorders present differently in very young screening schedules and reimbursement policies vary.69 children and must be understood in the context of their relationships. To better ensure assessments and any Bright Futures recommends developmental screenings, resulting diagnoses most accurately reflect research maternal depression screenings, and social-emotional and best practices with regard to young children’s assessments for all young children. The most recent developmental stages, states can: addition of expanded emphasis on identifying and responding to social determinants of health.70 Actions zz Encourage or require providers to use infant and early states may consider specific to IECMH include: childhood mental health and developmental disorders (DC:0-5TM). Specific diagnoses, when appropriate, zz Require Bright Futures-recommended IECMH- may be necessary to access the right type or amount related screenings or assessments. Most states of needed treatment. Adopting DC:0-5TM in Medicaid adhere to Bright Futures universal screening/ policy is an important, tangible step to improve assessment recommendations in their preventive assessment and diagnosis consistency across care guidelines with a few exceptions noted below for November 2018 8 Using Medicaid to Ensure the Healthy Social and Emotional Development of Infants and Toddlers providers and MCOs.77 Seven states (Arkansas, Virginia worked with state mental health and Medicaid Arizona, Colorado, Michigan, Minnesota, Nevada, agencies to map out current Medicaid reimbursable and Oregon) require or recommend use the DC:0-5TM services and billing codes for young children to inform to diagnose and refer for services to support young changes to MCO and provider billing manuals.84 children’s mental health.78 Other states, like New zz Support two-generation services that aid young Mexico, help build the state provider knowledge children’s mental health. Policymakers at all levels are base by providing training on DC:0-5 to a range of increasingly identifying ways to promote approaches health and early childhood professionals.79 that nurture parent- or caregiver-child relationships zz Allow multiple sessions for assessment or central to children’s emotional health.85 Recent federal prevention services before making a diagnosis. guidance in outlines the ways states can use Medicaid States should also allow sufficient time for preventive to support services that aim to support a child’s healthy care and evaluation before a diagnosis is necessary. development through the quality of the parent-child DC:0-5TM recommends a minimum of three to five relationship (see Appendix B).86 sessions of at least 45 minutes for a full evaluation.80 States may also use a parent diagnosis to trigger Colorado recently started allowing all Medicaid eligibility for other supports or reimbursement for beneficiaries to receive mental health treatment in parent-child treatment. New York is developing the primary care setting for up to six visits without a additional guidance to clarify reimbursement for diagnosis.81 Other states, including North Carolina parent-child therapy under a child’s Medicaid eligibility and Oregon, use pre-diagnosis billng codes to when the parent or caregiver is diagnosed with a reimburse interventions for young children at risk mood, anxiety, or substance abuse disorder. Michigan of mental health disorders.82 This approach allows and Minnesota take a similar approach.87 the needed time for mental health professionals to observe parent-child interactions over multiple visits, ideally in a range of settings including the home, to No. of States IECMH Approach make the most accurate diagnosis. Reimbursing in or Service Medicaid 3. Update or clarify payment policies and Child social-emotional processes for needed IECMH services. screenings 88 with a specific 43 screening tool New and/or underutilized services may require explicit Maternal or caregiver depression billing policy or guidance for providers from state screening 89 under child’s 32 Medicaid agencies or MCOs. State or MCO policy and Medicaid enrollment during a well-child visit procedure manuals or other resources for providers Home visiting 90 for pregnant/ should explicitly signal an ability to bill for certain postpartum women and/or young 33 services. As they seek to clarify or update payment and children* billing processes, states should consider the following: Dyadic/Parent-child treatment91 zz Add or adapt billing codes to aid tracking of (e.g. parent-child therapy) under 42 service needs and use. Sometimes states require child’s Medicaid enrollment billing codes for services, such as developmental Parent programs 92 designed to help parents/caregivers promote screenings or psychotherapy, that do not capture their young children’s emotional 16 the exact interventions specific to young children or development and address child their mental health. States or plans wanting to track mental health needs. IECMH-specific services may need to create new * Note: While it may include IECMH, home visiting encompasses services billing codes both to create financial incentives and and supports that are broader than mental health. Sources: S. Smith et al., “How States Use Medicaid to Cover Key Infant and provide for more accurate utilization.83 At a minimum, Early Childhood Mental Health Services: 2018 update of a 50-state Survey,” states can provide detailed guidance to MCOs and (New York: National Center for Children in Poverty, 2018), and K. Gifford et al., “Medicaid Coverage of Pregnancy and Perinatal Benefits: Results from a provider about which codes should be used for certain State Survey” (Washington: Kaiser Family Foundation, April 2017). IECMH interventions. For example, child advocates in November 2018 9 Using Medicaid to Ensure the Healthy Social and Emotional Development of Infants and Toddlers zz Review the state definition and application while parents work. Thirty-five states allow of pediatric “medical necessity” to identify individualized IECMH services to be provided by a opportunities for improvement. Understanding qualified mental health specialist in early care and how the state’s pediatric medical necessity process education settings, specific to treatment for an works at the state, MCO, and provider levels individual child and their family.97 In thirteen of these may offer insight into possible treatment barriers. states, mental health specialists may be reimbursed States set their own definitions and processes to for consultations with early childhood teachers determine pediatric medical necessity. For example, about specific interventions or supports to aid an an AAP review of state pediatric medical necessity individual child’s mental health needs.98 definitions found that forty states and Washington, zz Expand the range of qualified providers for D.C. incorporate a preventive care purpose into IECMH. States may consider new ways to expand the definition they use, nine states do not, and one the availability of trained providers to serve young state does not have a pediatric medical necessity children. In 2011, Minnesota began allowing definition.93 doctoral- and masters-level clinical trainees, with The AAP’s recommended definition of pediatric adequate supervision, to provide IECMH services in medical necessity offers an important standard that Medicaid.99 may guide states and MCOs: 94 "Health care interventions that are evidence based, State agreements with managed care evidence informed, or based on consensus advisory opinion and that are recommended by recognized health organizations (MCOs) can promote care professionals, such as the AAP, to promote optimal and prioritize IECMH growth and development in a child and to prevent, States use MCO request for proposals (RFPs) detect, diagnose, treat, ameliorate, or palliate the effects of and contracts with individual plans to promote physical, genetic, congenital, developmental, behavioral, priorities. Increasingly states are using MCO or mental conditions, injuries, or disabilities." RFPs and agreements to reflect and better 4. Consider new settings or provider types for track the young children’s social and emotional IECMH services to aid workforce challenges. development. For example: States have wide discretion, under federal parameters, Virginia’s Medicaid agency included IECMH to decide who is able to be reimbursed and where a language in a request for proposals for plans service may be provided, especially under EPSDT.95 competing to become Medicaid MCOs as well as While Medicaid alone can’t solve mental health the state’s model MCO contract.100 workforce challenges, states can use their flexibility to broaden the range of trained and qualified mental As part of a statewide move to Medicaid health professionals or paraprofessionals as initial managed care starting in 2019, North Carolina points for screening and early identification of possible has worked to elevate support for young needs. States could also require IECMH training or children through Medicaid MCO RFP language credentialing as a condition for reimbursement. States and supporting concept papers that will inform should consider the following settings or provider types contracts. In the area of quality improvement, for IECMH: MCOs will be required to adopt three performance improvement projects based on a zz Improve access to IECMH services in early care list of priority areas for the state, one of which is and education settings. Most states allow for early childhood health and development.101 IECMH services in home- and community-based settings and pediatric primary care practices.96 States are also seeing the opportunity to connect to children and families in early care and education settings, where many children spend their days November 2018 10 Using Medicaid to Ensure the Healthy Social and Emotional Development of Infants and Toddlers 5. Include IECMH in broader Medicaid systems.103 States should adopt cross-system improvements and reforms. goals, with accompanying measures to track Medicaid delivery and payment reforms are happening improvements, that include an explicit emphasis on at the local, state and national levels. IECMH-trained the social-emotional and behavioral health needs of professionals, child development experts, and other young children as they craft and implement cross- stakeholders should be invited to reform tables and system action plans.104 consulted regularly to keep the mental health needs of zz Elevate IECMH in broader reforms. Medicaid can young children front and center. help to spread and sustain practice changes that zz Address IECMH in Medicaid quality improvement both elevate the mental health of young children efforts. A focus on young children’s social- and address conditions before they become emotional health in Medicaid should seek costlier down the road.105 Popular Medicaid and to improve data collection and reporting. A health system reforms in states, such as alternative comprehensive effort on young children’s health payment models or behavioral health integration in quality improvement can help determine where gaps primary care, should explicitly address the needs exist or where additional or revised data may be of young children.106 Many promising pediatric necessary—this is especially important for IECMH. primary care models, for example, seek to support The Child Core Set, federal Medicaid measures parents in nurturing their children’s healthy standardized for consistent reporting across states, development.107 On such model, HealthySteps for and other data sets based on health payment data Young Children, integrates IECMH promotion and have few measures specific to young children’s prevention support for parents into well-child visits, social and emotional health.102 But states or MCOs demonstrating a number of positive outcomes may aim to develop and test quality measures for children and their families. Research on the related to IECMH. States, for example, could require model in Colorado suggests savings in avoidable or encourage MCOs to have an explicit focus on costs, particularly related to parent interventions.108 IECMH through a performance improvement project Strong care coordination is one key element of or related initiative (See box above). successful behavioral health-pediatric primary Medicaid quality improvement efforts require close care integration.109 Most states (44) allow case engagement with other child-serving systems— management in Medicaid for IECMH.110 Medicaid all of which rely on a strong foundation of young reforms can also advance enhanced pediatric children’s mental health. For example, in Oregon primary models that seek to address the social and New York, Medicaid and education agencies determinants of health through strengthened have committed to use the shared goal of school linkages between primary care, mental health, and readiness to inform improvements and move social services at the community level.111 toward shared accountability across child-serving Conclusion Medicaid can do more to promote, prioritize, and ensure require strong partnerships between Medicaid and the support for services that address young children’s mental many systems that serve children: mental and behavioral health. While Medicaid alone cannot solve broader system health, early childhood, public health, child welfare, and challenges, such as the stigma attached to mental health others. Medicaid is an essential player to helping to ensure issues or the need for more qualified providers, it can be a children’s social and emotional development is addressed leader for improvements across payers and systems. The early and in the context of their families and communities. structural changes necessary to improve access to IECMH November 2018 11 Using Medicaid to Ensure the Healthy Social and Emotional Development of Infants and Toddlers Getting Started: What Can Medicaid Do in Your State to Promote Young Children’s Emotional Development? There are many places to begin to assess a state’s potential to do more for Infant Early Childhood Mental Health (IECMH) in Medicaid. The following questions may help to uncover possible opportunities for action. XX state or MCO policies, guidance, and/or practice suggest that mental health services Do and/or a specific service are not allowable for young children? Are providers under the impression that they would not be reimbursed for mental health services to children under 6? XXDoes the state have a medical necessity definition for children that is comprehensive, prevention oriented, and inclusive of mental health (e.g. AAP recommended)? What is the process for establishing medical necessity at the state and/or MCO levels? Are there problems with approval of a specific service that seemingly meets medical necessity criteria for children with a specific diagnosis? Does the state or MCO deny additional services beyond a specified limit, even if the provider deems them medically necessary? XXDoes Medicaid require or allow use of DC:0-5 for diagnosis? If so, is it detailed in Medicaid provider and MCO plan manuals? Is the policy clear for children in both fee-for-service and managed care arrangements (as applicable)? Does the state offer training for Medicaid providers on its use? XX IECMH-related services explicitly included in EPSDT MCO plan and/or provider Are manuals? XX the provider billing, referral, and treatment processes explicit and well-understood Are for IECMH services? XXDoes the state support dyadic/parent-child treatment under the child’s Medicaid eligibility? XX the state’s managed care plans incorporating IECMH in their promotion or quality Are improvement efforts (e.g. performance improvement plan, or PIP)? Would the state consider encouraging MCOs to develop PIPs with key measures to track improved access to IECMH for children/families in need? XX new provider types or settings need to be recognized in state Medicaid policy to Do strengthen access to IECMH services? XX what ways are young children’s mental health needs addressed in broader Medicaid In reforms (e.g. payment reforms such as value-based purchasing, or delivery system reforms such as primary care-behavioral health integration or health homes)? November 2018 12 Using Medicaid to Ensure the Healthy Social and Emotional Development of Infants and Toddlers For More Information From Georgetown University Center for Children and Families: Promoting Young Children’s Healthy Development in Medicaid and CHIP (October 2018). EPSDT: A Primer on Medicaid’s Pediatric Benefit (Georgetown University Center for Children and Families, March 2017) EPSDT Webinar Series (with the American Academy of Pediatrics) zz EPSDT Education for Providers and Advocates (July 2018) zz Medical Necessity and EPSDT: Tools for Providers and Advocates (September 2018) zz When to Engage the Legal Community (October 2018) From ZERO TO THREE: Infant and Early Childhood Mental Health (IECMH) Policy Series Planting Seeds in Fertile Ground: Steps Every Policymaker Should Take to Advance Infant and Early Childhood Mental Health (May 2016). Advancing Infant and Early Childhood Mental Health: The Integration of DC:0-5™ Into State Policy and Systems (July 2018) Expanding Infant and Early Childhood Mental Health Supports and Services: A Planning Tool for States and Communities (February 2018). Additional Resources: How States use Medicaid to Cover Key Infant and Early Childhood Mental Health Services: 2018 update of a 50-state Survey (National Center for Children in Poverty, November 2018) A Sourcebook on Medicaid’s Role in Early Childhood: Advancing High Performing Medical Homes and Improving Lifelong Health (Child and Family Policy Center, October 2018) Acknowledgements This brief was written by Elisabeth Wright Burak, Senior Fellow, and Kelly Rolfes-Haase, Graduate Research Associate, of Georgetown University Center for Children and Families (CCF). Cindy Oser and Lindsay Usry from ZERO TO THREE helped to conceptualize this paper and provided critical reviews and several stages in the process. The authors also thank the following individuals for their thoughtful reviews and contributions: Joan Alker, Maggie Clark, Phyllis Jordan, and Andy Schneider from CCF; Sheila Smith and Maribel Granja from the National Center on Children and Poverty; Elena Rivera of the Children’s Institute (OR); and Charles Bruner. The final paper and its conclusions are solely those of the authors and do not necessarily represent those of each reviewer. The authors also thank Allie Gardner and Kyrstin Racine for analysis support and edits. Design and layout provided by Nancy Magill. The Georgetown University Center for Children and Families (CCF) is an independent, nonpartisan policy and research center founded in 2005 with a mission to expand and improve high-quality, affordable health coverage for America’s children and families. CCF is based in the McCourt School of Public Policy’s Health Policy Institute. ZERO TO THREE created the Think Babies™ campaign to make the potential of every baby a national priority. Funding partners for Think Babies™ include the Robert Wood Johnson Foundation, which supports the campaign’s public education aspects, and the Perigee Fund, which supports the campaign’s public education and advocacy aspects. Learn more at www.thinkbabies.org. November 2018 13 Using Medicaid to Ensure the Healthy Social and Emotional Development of Infants and Toddlers APPENDIX A: What Services Must Medicaid Provide to Children Under EPSDT? Mandatory Services √√ Family planning services and supplies √√ Non-emergency medical transportation √√ Federally Qualified Health Clinics and Rural √√ Nurse midwife services Health Clinics √√ Pediatric and family nurse practitioner √√ Home health services services √√ Inpatient and outpatient hospital services √√ Physician services √√ Laboratory and X-Rays √√ Pregnancy-related services √√ Medical supplies and durable medical √√ Tobacco cessation counseling and equipment pharmacotherapy for pregnant women √√ Medication-assisted treatment* Other Services – Required under EPSDT (Optional for adults, but required for children if deemed medically necessary based on a screening) √√ Chiropractic services √√ Other diagnostic, screening, preventive and rehabilitative services √√ Clinic services √√ Other licensed practitioners’ services √√ Critical access hospital services √√ Physical therapy services √√ Dental services √√ Prescribed drugs √√ Dentures √√ Primary care case management services √√ Emergency hospital services (in a hospital not meeting certain federal requirements) √√ Private duty nursing services √√ Eyeglasses √√ Prosthetic devices √√ Home and Community Based Services √√ Respiratory care for ventilator dependent individuals √√ Inpatient psychiatric services for individuals under age 21 √√ Speech, hearing and language disorder services √√ Intermediate care facility services for individuals with intellectual disabilities √√ Targeted case management √√ Optometry services √√ Tuberculosis-related services * Time-limited (January 1, 2020 – September 30, 2025). Sources: Social Security Act § 1905(a), 1905(r), Section 1006 (b) of P.L. 115-271. November 2018 14 Using Medicaid to Ensure the Healthy Social and Emotional Development of Infants and Toddlers APPENDIX B: Federal Medicaid Guidance and Opportunities Related to Children’s Social and Emotional Health Tri-Agency Letter on Trauma-Informed Treatment (Department of Health and Human Services, July 11, 2013). Prevention and Early Identification of Mental Health and Substance Use Conditions (Centers for Medicaid and CHIP Services, Informational Bulletin, March 27, 2013). EPSDT - A Guide for States: Coverage in the Medicaid Benefit for Children and Adolescents (Centers for Medicare and Medicaid Services, June 2014). Clarification of Medicaid Coverage of Services to Children with Autism (Centers for Medicaid and CHIP Services, Informational Bulletin, July 7,2014). Coverage of Maternal, Infant, and Early Childhood Home Visiting Services (Centers for Medicaid and CHIP Services and Health Resources and Services Administration, Joint Informational Bulletin, March 2, 2016). Maternal Depression Screening and Treatment: A Critical Role for Medicaid in the Care of Mothers and Children (Centers for Medicaid and CHIP Services, Informational Bulletin, May 11, 2016). The Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit for children and youth in managed care (Centers for Medicaid and CHIP Services, Informational Bulletin, January 5, 2017). Neonatal Abstinence Syndrome: A Critical Role for Medicaid in the Care of Infants (Centers for Medicaid and CHIP Services, Informational Bulletin, June 11, 2018). Integrated Care for Kids (InCK) Model (Centers for Medicare and Medicaid Services, August 2018). Maternal Opioid Misuse (MOM) Model (Centers for Medicare and Medicaid Services, October 2018). November 2018 15 Using Medicaid to Ensure the Healthy Social and Emotional Development of Infants and Toddlers Endnotes Replication,” Archives of General Psychiatry, 62(2005):629-640; A. Angold et al.. “Psychiatric Disorder, Impairment, and Service Use in 1 ZERO TO THREE, “Frequently Asked Questions about Brain Rural African American and White Youth,” Archive of General Psychiatry, Development” (Washington: Author); P.F. Cronholm et al., “Adverse 59 (2002): 893–901; E.J. Costello et al.., “Services for Adolescents with Childhood Experiences: Expanding the Concept of Adversity,” American Psychiatric Disorders: 12-Month Data From the National Comorbidity Journal of Preventive Medicine, 49(3): 354–361; V. J. Felitti et al.., Survey–Adolescent,” Psychiatric Services, 65(3)(2005): 359-366; K.R. “Relationship of Childhood Abuse and Household Dysfunction to Many Merikangas et al.., “Service Utilization for Lifetime Mental Disorders of the Leading Causes of Death in Adults: The Adverse Childhood in U.S. Adolescents: Results of the National Comorbidity Survey- Experiences (ACE) Study,” American Journal of Preventative Medicine Adolescent Supplement (NCS-A),” Journal of the American Academy of 14, no. 4 (May 1998): 245-258. Child & Adolescent Psychiatry, 50(1)(2011):32-45. 2 J. Cohen et al.., “Making it Happen: Overcoming Barriers to Providing 10 For further reading, see K. Johnson and C. Bruner, A Sourcebook on Infant and Early Childhood Mental Health” (Washington: ZERO TO Medicaid’s Role in Early Childhood: Advancing High Performing Medical THREE, 2012). Homes and Improving Lifelong Health (Child and Family Policy Center, 2018); ZERO TO THREE, “Planting Seeds in Fertile Ground: Steps 3 E. Burak, “Promoting Young Children’s Healthy Development in Every Policymaker Should Take to Advance Infant and Early Childhood Medicaid and CHIP” (Washington: Georgetown University Center for Mental Health” (Washington: ZERO TO THREE and Manatt Health, Children and Families, October 2018). May 2016); T. McGinnis et al.., “Implementing Social Determinants 4 Center on the Developing Child, Harvard University, “Five Numbers of Health Interventions in Medicaid Managed Care: How to Leverage to Remember About Early Childhood Development” (Cambridge, MA; Existing Authorities and Shift to Value Based Purchasing” (Academy Author, 2009). Health, Nemours, Robert Wood Johnson Foundation, February 2018); D. 5 Center on the Developing Child, Harvard University, “Toxic Stress” Bachrach and J. Guyer, “Medicaid Coverage of Social Interventions: A (Cambridge, MA; Author); Center on the Developing Child, Harvard Road Map for States” (Washington: Manatt Health, July 2016). University, “The Impact of Early Adversity on Child Development ZERO TO THREE et al.., “Public Perceptions of Baby Brain 11 (In Brief)” (Cambridge, MA; Author, 2007); ZERO TO THREE,” The Development: A National Survey of Voters” (Washington: Author, 2017). Basics of Infant and Early Childhood Mental Health: A Briefing Paper” 12 Definition for IECMH taken from ZERO TO THREE, “Planting Seeds in (Washington: Author, 2017); G.S. Petit et al.., “Supportive parenting, Fertile Ground: Steps Every Policymaker Should Take to Advance Infant ecological context, and children’s adjustment: a seven-year longitudinal and Early Childhood Mental Health” (Washington: ZERO TO THREE and study,” Child Development, 68 (1997): 908-23; C.D. Bethell et al.., Manatt Health, May 2016). “Adverse Childhood Experiences: Assessing the Impact on Health and School Engagement And the Mitigating Role Of Resilience,” Health 13 Center for Law and Social Policy and ZERO TO THREE “Mental Affairs, 33(12)(2014): 2106–2115; V. J. Felitti et al.., “Relationship of Health Services: Critical Supports for Infants, Toddlers and Families” Childhood Abuse and Household Dysfunction to Many of the Leading (Washington: CLASP, 2017). Causes of Death in Adults: The Adverse Childhood Experiences (ACE) ZERO TO THREE, “Planting Seeds in Fertile Ground: Steps Every 14 Study,” American Journal of Preventative Medicine 14, no. 4 (May 1998): Policymaker Should Take to Advance Infant and Early Childhood Mental 245-258; A. Giovanelli et al.., “Adverse Childhood Experiences and Health” (Washington: ZERO TO THREE and Manatt Health, May 2016). Adult Well-Being in a Low-income, Urban Cohort,” Pediatrics, 137(4) 15 Ibid. (2016); P.J. Mersky et al.., “Impacts of adverse childhood experiences 16 For example, see the Center for Health Care Strategies, Improving the on health, mental health, and substance use in early adulthood: A Appropriate Use of Psychotropic Medication for Children in Foster Care: cohort study of an urban, minority sample in the U.S.,” Child Abuse & A Resource Center. Neglect, 37 (2013):917–925. 17 W.J. Barbaresi, “Use of Psychotropic Medications in Young, 6 Agency for Healthcare Research and Quality (2016) in Center on Preschool Children: Primum Non Nocere.” Archives of Pediatrics the Developing Child at Harvard University “From Best Practices to & Adolescent Medicine, 157 (2003): 121-123; M.M. Gleason et al.,, Breakthrough Impacts: A Science-based Approach to Building a More “Psychopharmacological treatment for very young children: Contexts Promising Future for Young Children and Families,” (working paper, and guidelines,” Journal of the American Academy of Child Adolescent Cambridge, MA, 2016), p. 4. Psychiatry, 46 (2007): 1532–1572. 7 C.B. Brauner et al.., “Estimating the prevalence of early 18 L.D. Garfield et al.,, “Psychotropic Drug Use Among Preschool childhood serious emotional/behavioral disorders: Challenges and Children in the Medicaid Program From 36 States,” American Journal recommendations,” Public Health Reports, 121(3)(2006), 303–310; of Public Health, 105(3)(2015): 524–529; J.N. Harrison, “Antipsychotic Centers for Disease Control and Prevention, “Mental Health Surveillance Medication Prescribing Trends in Children and Adolescents,” Journal Among Children - United States, 2005–2011” CDC Morbidity and of Pediatric Health Care, 26(2)(2012): 139–145; J.M. Zito et al., “Trends Mortality Weekly Report, Supplement 62(2)(2013). in the Prescribing of Psychotropic Medications to Preschoolers,” 8 U.S. Department of Health and Human Services, Mental Health: A JAMA, 283(8)(2000): 1025–1030; J.M. Zito et al.,, “Psychotherapeutic Report of the Surgeon General (Rockville, M.D., Author, 1999), pp. medication prevalence in Medicaid-insured preschoolers,” Journal of 75-77; K.R. Merikangas et al.., “Service Utilization for Lifetime Mental Child and Adolescent Psychopharmacology, 17(2)(2007): 195-203. Disorders in U.S. Adolescents: Results of the National Comorbidity 19 M. Matone et al.,, “The Relationship between Mental Health Diagnosis Survey-Adolescent Supplement (NCS-A),” Journal of the American and Treatment with Second-Generation Antipsychotics over Time: A Academy of Child & Adolescent Psychiatry, 50(1)(2011):32-45. National Study of U.S. Medicaid-Enrolled Children” Health Services 9 P.S. Wang et al.., “Twelve-Month Use of Mental Health Services in Research, 47(5)(2012): 1836–1860; M.D. Rappley et al.,, “Diagnosis the United States: Results From the National Comorbidity Survey November 2018 16 Using Medicaid to Ensure the Healthy Social and Emotional Development of Infants and Toddlers of Attention-Deficit/Hyperactivity Disorder and Use of Psychotropic 30 American Hospital Association, “The State of the Behavioral Health Medication in Very Young Children” Archives of Pediatrics & Adolescent Workforce: A Literature Review,” (Chicago, IL: Author, 2016); R.W. Medicine, 153(10)(1999): 1039–1045. Manderscheid et al., “An Action Plan for Behavioral Health Workforce 20 L.D. Garfield et al., “Psychotropic Drug Use Among Preschool Development,” (Rockville, MD; Substance Abuse and Mental Health Children in the Medicaid Program From 36 States,” American Journal Services Administration, 2007). of Public Health, 105(3)(2015): 524–529 and J.M. Zito et al., “Trends in 31 J. Cohen et al., “Making it Happen: Overcoming Barriers to Providing the Prescribing of Psychotropic Medications to Preschoolers,” JAMA, Infant and Early Childhood Mental Health” (Washington: ZERO TO 283(8)(2000): 1025–1030. THREE, 2012). 21 M. Olfson et al., “Trends in antipsychotic drug use by very young, E. Burak, “Promoting Young Children’s Healthy Development in 32 privately insured children,” Journal of the American Academy of Child Medicaid and CHIP” (Washington: Georgetown University Center for Adolescent Psychiatry, 49 (2010): 13–23. Children and Families, October 2018). 22 L.D. Garfield et al.,, “Psychotropic Drug Use Among Preschool 33 J. Haley et al., “Health Insurance Coverage among Children Ages 3 Children in the Medicaid Program From 36 States,” American Journal and Younger and Their Parents in 2016” (Washington: Urban Institute, of Public Health, 105(3)(2015): 524–529; J.N. Harrison, “Antipsychotic January 2018). As cited in E. Burak, “Promoting Young Children’s Medication Prescribing Trends in Children and Adolescents," Journal Healthy Development in Medicaid and CHIP” (Washington: Georgetown of Pediatric Health Care, 26(2)(2012): 139–145; and J.M. Zito et al., University Center for Children and Families, October 2018). “Psychotropic medication patterns among youth in foster care,” E. Burak, “Promoting Young Children’s Healthy Development in 34 Pediatrics,121 (2008): 157–163. Medicaid and CHIP” (Washington: Georgetown University Center for 23 M.D. Rappley et al., “Diagnosis of Attention-Deficit/Hyperactivity Children and Families, October 2018). Disorder and Use of Psychotropic Medication in Very Young Children,” 35 K. Whitener, “EPSDT: A Primer on Medicaid’s Pediatric Benefit” Archives of Pediatrics & Adolescent Medicine, 153(10)(1999): 1039– (Washington: Georgetown University Center for Children and Families, 1045 and J.N. Harrison, “Antipsychotic Medication Prescribing Trends March 2017). in Children and Adolescents," Journal of Pediatric Health Care, 26(2) 36 Ibid. (2012): 139–145. 37 Centers for Medicare and Medicaid Services, “EPSDT - A Guide for 24 Center for Law and Social Policy and ZERO TO THREE, “Mental States: Coverage in the Medicaid Benefit for Children and Adolescents” Health Services: Critical Supports for Infants, Toddlers and Families” (Washington: Centers for Medicare and Medicaid Services, June 2014). (Washington: CLASP and ZERO TO THREE, 2017). 38 Ibid, p. 10 -11. 25 42 CFR § 438.900 (2016). Mental health parity rules require parity in Medicaid managed care and Alternative Benefits Packages. The 39 The Omnibus Reconciliation Act of 1989 clarified services for children rule encourages, but does not require, states to also apply the rule to with mental health and developmental disabilities under EPSDT. KATIE Medicaid fee-for-service. A. v. BONTA (CA) and Rosie D vs Patrick (MA), for example, affirmed Medicaid EPSDT mental health coverage and have laid a foundation 26 The Mental Health Parity and Addiction Equity Act (MHPAEA) of 2008 for improvements to Medicaid-eligible children’s access to necessary (P.L. 110-343) requires health insurers and group health plans to provide mental health services. Also see Centers for Medicare and Medicaid the same level of benefits for mental and/or substance use treatment Services, “EPSDT - A Guide for States: Coverage in the Medicaid and services that they do for medical/surgical care. The Affordable Benefit for Children and Adolescents” (Washington: Centers for Care Act further expands the MHPAEA’s requirements by ensuring that Medicare and Medicaid Services, June 2014). marketplace plans apply these changes to CHIP and most Medicaid populations. 40 Medicaid and CHIP Payment and Access Commission, “Federal Medicaid Requirements and State Options: How states exercise 27 For example, an analysis of state statute 10 years after the 2008 flexibility under a state plan,” (Washington: MACPAC, August 2018). Mental Health Parity and Addiction Equity Act found most states do not protect parity in law. See M. Douglas et al., “Evaluating State Mental 41 Kaiser Family Foundation, “State Health Facts: Total Medicaid MCO Health and Addiction Parity Statutes,” (Well Being Trust, The Kennedy Enrollment,” (Washington: Author, March 2018). Forum, Kennedy-Satcher Center for Mental Health Equity at the 42 R. Garfield et al., “Medicaid Manage Care Plans and Access to Care,” Morehouse School of Medicine, and The Carter Center, 2018). (Washington: Kaiser Family Foundation, March 2018). 28 Center for Law and Social Policy and ZERO TO THREE, “Mental 43 Ibid. Also see M.H. Soper, “Integrating Mental Health Into Medicaid Health Services: Critical Supports for Infants, Toddlers and Families” Managed Care: Lessons from State Innovators” (Hamilton, NJ: Center (Washington: CLASP and ZERO TO THREE, 2017), and ZERO TO for Health Care Strategies, Inc., April 2016). THREE, “Planting Seeds in Fertile Ground: Steps Every Policymaker 44 T. Brooks, “Measuring and Improving Health Care Quality for Children Should Take to Advance Infant and Early Childhood Mental Health” in Medicaid and CHIP: A Primer for Child Health Stakeholders” (Washington: ZERO TO THREE and Manatt Health, May 2016). (Washington: Georgetown University Center for Children and Families, 29 C.B. Brauner et al., “Estimating the prevalence of early March 2016), and A. Schneider, “How Can We Tell Whether Medicaid childhood serious emotional/behavioral disorders: Challenges and MCOs are Doing a Good Job for Kids?” (Washington: Georgetown recommendations,” Public Health Reports, 121(3)(2006), 303–310, University Center for Children and Families, February 2018). and ZERO TO THREE, “Planting Seeds in Fertile Ground: Steps Every 45 D. Machledt and T. Brooks, “Medicaid/CHIP Managed Care Policymaker Should Take to Advance Infant and Early Childhood Mental Regulations: Assuring Quality,” (Washington: Georgetown University Health” (Washington: ZERO TO THREE and Manatt Health, May 2016). Center for Children and Families and National Health Law Program, September 2016). Note: A rule proposed in late 2018 may roll back some requirements finalized in 2016. November 2018 17 Using Medicaid to Ensure the Healthy Social and Emotional Development of Infants and Toddlers 46 For more detail see K. Gifford et al., “States Focus on Quality and 6 J. Hagan, J. Shaw, and P. Duncan, eds., Bright Futures Guidelines for Outcomes Amid Waiver Changes, Managed Care Initiatives: Results Health Supervision of Infants, Children, and Adolescents, 4th Ed. (Elk from a 50-state Medicaid Budget Survey for State Fiscal Years 2018 and Grove, IL: American Academy of Pediatrics, 2017). Periodicity schedule 2019,” (Washington: Kaiser Family Foundation, October 2018). available at American Academy of Pediatrics and Bright Futures, K. Gifford et al., “States Focus on Quality and Outcomes Amid Waiver 47 “Recommendations for Preventative Pediatric Health” (Elk Grove, IL: Changes, Managed Care Initiatives: Results from a 50-state Medicaid American Academy of Pediatrics, February 2017). Budget Survey for State Fiscal Years 2018 and 2019,” (Washington: 67 Georgetown University Center for Children and Families analysis of Kaiser Family Foundation, October 2018). American Academy of Pediatrics, “Children’s Health Care Coverage 48 R. Garfield et al., “Medicaid Manage Care Plans and Access to Care,” Fact Sheets” (Elk Grove, IL: American Academy of Pediatrics). As cited (Washington: Kaiser Family Foundation, March 2018). in E. Burak, “Promoting Young Children’s Healthy Development in Medicaid and CHIP” (Washington: Georgetown University Center for 49 K. Whitener, “Three Ways to Make EPSDT Work in Managed Care,” Children and Families, October 2018). (Washington: Georgetown University Center for Children and Families, September 2017). Also see J. Perkins, “Thirty Questions to Ask About 68 Ibid. Managed Care and EPSDT” (Washington: National Health Law Program, American Academy of Pediatrics, “2015 Medicaid Reimbursement 69 2007), and J. Perkins, “Behavioral Health: Medicaid, Managed Care and Reports,” (Elks Grove: American Academy of Pediatrics, 2015). Children More Questions to Ask” (NHeLP, April 2012). 70 The most recent edition, updated in 2017, added universal maternal 50 Social Security Act § 1905(r)(5). Also see K. Whitener, “EPSDT: A depression screening and new guidance related to psychosocial/ Primer on Medicaid’s Pediatric Benefit” (Washington: Georgetown behavioral assessments, noting that they should be “should be family- University Center for Children and Families, March 2017). centered and may include may include an assessment of child social- T.F. Long et al., “Essential Contractual Language for Medical 51 emotional health, caregiver depression, and social determinants of Necessity in Children,” Pediatrics, 132(2)(2013). health.” See Footnote 13 at https://www.aap.org/en-us/Documents/ periodicity_schedule.pdf. Also see “Promoting Optimal Development: 52 Centers for Medicare and Medicaid Services, “EPSDT - A Guide for Screening for Behavioral and Emotional Problems” and “Poverty and States: Coverage in the Medicaid Benefit for Children and Adolescents” Child Health in the United States.” (Washington: Centers for Medicare and Medicaid Services, June 2014), pp. 23- 24. 71 Georgetown University Center for Children and Families analysis of American Academy of Pediatrics, “Children’s Health Care Coverage 53 Ibid, p. 30. Fact Sheets: EPSDT State Profiles” (Elk Grove, IL: American Academy 54 A. Clary and B. Worth, “State Strategies for Defining Medical of Pediatrics). Necessity for Children and Youth with Special Health Care Needs” 72 Ibid. (Portland, ME: National Academy for State Health Policy, October 2015), p. 5. 73 Ibid. 55 Ibid, p. 5. 74 Ibid. 56 A. Szekely et al.,“Advancing Infant and Early Childhood Mental 75 Note: State promotion of standardized referrals are not necessarily Health: The Integration of DC: 0-5 Into State Policy and Systems” in the state Medicaid agency. See National Academy for State Health (Washington: ZERO TO THREE, July 2018), p. 2. Policy, “Referral and Care Coordination” (Portland, ME: National Academy for State Health Policy). For more information, see N. 57 Ibid. Kaye and J. Rosenthal, “Improving the Delivery of Health Care that 58 J.R. Weisz et al., “Evidence-based youth psychotherapies versus Supports Young Children’s Healthy Mental Development: Update usual clinical care: a meta-analysis of direct comparisons” American on Accomplishments and Lessons from a Five-State Consortium,” Psychologist (61)(7)(2006): 671-689. (Portland, ME: National Academy for State Health Policy, February 2008) 59 For additional evidence-based psychotherapy treatments, go to and “Part Three: High Performing Medical Homes: Care Coordination https://knowledge.samhsa.gov/ta-centers/national-registry-evidence- and Case Management” in K. Johnson and C. Bruner, A Sourcebook on based-programs-and-practices. Medicaid’s Role in Early Childhood: Advancing High Performing Medical Homes and Improving Lifelong Health (Child and Family Policy Center, 60 See PCIT International at http://www.pcit.org/what-is-pcit.html. 2018). 61 See The National Child Traumatic Stress Network on Child-Parent 76 D. Machledt and T. Brooks, “Medicaid/CHIP Managed Care Psychotherapy at https://www.nctsn.org/interventions/child-parent- Regulations: Assuring Quality” (Washington: Georgetown University psychotherapy. Center for Children and Families and National Health Law Program, 62 See Attachment and Biobehavioral Catch-up at http://www. September 2016). abcintervention.org/about/. 77 A. Szekely et al.,“Advancing Infant and Early Childhood Mental See Trauma-Focused Cognitive Behavioral Therapy Therapist 63 Health: The Integration of DC: 0-5 Into State Policy and Systems” Certification Program at https://tfcbt.org/. (Washington: ZERO TO THREE, July 2018). 64 J. Cohen et al., “Nurturing Change: State Strategies for Improving 78 Ibid; and S. Smith et al., “How States use Medicaid to Cover Key Infant and Early Childhood Mental Health” (Washington: ZERO TO Infant and Early Childhood Mental Health Services: 2018 update of a THREE, April 2013). 50-state Survey,” (New York: National Center for Children in Poverty, 65 A. Szekely et al., “Advancing Infant and Early Childhood Mental 2018). Health: The Integration of DC: 0-5 Into State Policy and Systems” (Washington: ZERO TO THREE, July 2018), p. 4. November 2018 18 Using Medicaid to Ensure the Healthy Social and Emotional Development of Infants and Toddlers 79 A. Szekely et al.,“Advancing Infant and Early Childhood Mental 94 T.F. Long et al., “Essential Contractual Language for Medical Health: The Integration of DC: 0-5 Into State Policy and Systems” Necessity in Children,” Pediatrics, 132(2)(2013).Note: AAP is in the (Washington: ZERO TO THREE, July 2018). process of updating its recommendation on pediatric medical necessity. 80 ZERO TO THREE, DC:0–5™: Diagnostic classification of mental See American Academy of Pediatrics/Georgetown University Center for health and developmental disorders of infancy and early childhood. Children and Families webinar, Medical Necessity and EPSDT: Tools for (Washington: ZERO TO THREE, 2016) as cited in A. Szekely et Providers and Advocates (September 2018). al.,“Advancing Infant and Early Childhood Mental Health: The 95 S. Rosenbaum et al., “Room to Grow: Promoting Child Development Integration of DC: 0-5 Into State Policy and Systems” (Washington: Through Medicaid and CHIP” (Washington: The Commonwealth Fund, ZERO TO THREE, July 2018), page 4. June 2001). 81 Colorado Department of Health Care Policy and Financing, “Short- 96 S. Smith et al., “How States use Medicaid to Cover Key Infant and term Behavioral Health Services in the Primary Care Setting” (Denver, Early Childhood Mental Health Services: 2018 update of a 50-state CO: Colorado Department of Health Policy and Financing, July 2018). Survey,” (New York: National Center for Children in Poverty, 2018). 82 ZERO TO THREE, “Zero to Three Infant and Early Childhood Mental 97 Ibid. Health Policy Convening” (Washington: ZERO TO THREE, February 98 Ibid. 2017). 99 ZERO TO THREE, “ZERO TO THREE Infant and Early Childhood 83 S. Smith et al., “Using Medicaid to Help Young Children and Parents Mental Health Policy Convening” (Washington: ZERO TO THREE, Access Mental Health Services: Results of a 50-State Survey” (New February 2017), p. 14. York: National Center for Children in Poverty, 2016), p. 18. 100 ZERO TO THREE, “States Advance Infant Early Childhood Mental 84 Email correspondence with Ashely Everette, Voices for Virginia’s Health (IECMH) Policy and Practice,” Washington: ZERO TO THREE, Children 11/14/18 and ZERO TO THREE, “States Advance Infant Early November 2017); Email correspondence with Ashely Everette, Voices for Childhood Mental Health (IECMH) Policy and Practice” (Washington: Virginia’s Children 11/14/18. ZERO TO THREE, November 2017). 101 Each MCO will be required to undertake at least three performance 85 A. Mosle, N. Patel, and J. Stedron, “Top Ten for 2Gen” (Washington: improvement projects (PIPs) as part of the annual quality review and First Focus, 2015); Ascend at the Aspen Institute, “What is 2Gen?” improvement efforts, as approved by the Medicaid agency. MCOs shall (Washington: Ascend at the Aspen Institute). conduct at least one (1) non-clinical PIP will also be required to conduct E. Burak, “Promoting Young Children’s Healthy Development in 86 two (2) clinical PIPs annually related to the following areas: a) Pregnancy Medicaid and CHIP” (Washington: Georgetown University Center for Intendedness; b) Tobacco Cessation; c) Diabetes Prevention; d) Birth Children and Families, October 2018), p. 11. outcomes; e) Early childhood health and development; f) Hypertension; 87 Proposal 18: New York State Department of Public Health, “First and g) Behavioral Health Integration. See p. 173 ”Addendum 1 - RFP 1,000 Days on Medicaid: Parent/Caregiver Diagnosis as Eligibility 30-19029-DHB Section V. Scope of Services “Requests for Proposals Criteria for Dyadic Therapy,” New York State Department of Public (RFPs) and Requests for Information (RFIs),” (NC Department of Health Health (proposal, Albany, December 2017). and Human Services, 2018). 88 S. Smith et al., “How States use Medicaid to Cover Key Infant and ZERO TO THREE, “ZERO TO THREE Infant and Early Childhood 102 Early Childhood Mental Health Services: 2018 Update of a 50-state Mental Health Policy Convening” (Washington: ZERO TO THREE, Survey,” (New York: National Center for Children in Poverty, 2018). February 2017), p. 5. 89 Ibid. C. Howard et al., “School Readiness: The Next Essential Quality 103 Metric For Children,” Health Affairs Blog, July 18, 2018. 90 K. Gifford et al., “Medicaid Coverage of Pregnancy and Perinatal Benefits: Results from a State Survey” (Washington: Kaiser Family 104 K. Johnson and C. Bruner (2018), A Sourcebook on Medicaid’s Role Foundation, April 2017); B. Normile, K. VanLandeghem, and A. King, in Early Childhood: Advancing High Performing Medical Homes and “Medicaid Financing of Home Visiting Services for Women, Children, Improving Lifelong Health. Child and Family Policy Center. See Table 7, and Their Families” (Portland, ME: National Academy for State Health p. 104 for examples in shared early childhood measures across national Policy, August 2017); and National Academy for State Health Policy, data sets. Also see U.S. Department of Health and Human Services “Using Medicaid to Finance Home Visiting Services: a Checklist for and U.S. Department of Education, Policy Statement to Support the State Decision Makers” (Portland, ME: National Academy for State Alignment of Health and Early Learning Systems. Health Policy, December 2016). 105 See, for example: C. Bruner and N. Counts, “CMMI RFI Responses: 91 S. Smith et al., “How States use Medicaid to Cover Key Infant and Some Common Themes” (Child and Family Policy Center and Mental Early Childhood Mental Health Services: 2018 Update of a 50-state Health America, June 2017); C. Bruner, N. Counts, and P. Dworkin, Survey,” (New York: National Center for Children in Poverty, 2018). “Alternative Payment Models for Pediatrics: Operationalizing Value- Based Care Over the Life Course” (Hartford, CT: Connecticut Children’s 92 Ibid. Office for Community Child Health, August 2018). 93 Georgetown University Center for Children and Families analysis of C. Wong, J. Perrin, and M. McClellan, “Making the Case for Value- 106 American Academy of Pediatrics, “Children’s Health Care Coverage Based Payment Reform in Children’s Health Care,” JAMA Pediatrics Fact Sheets: EPSDT State Profiles” (Elk Grove, IL: American Academy 172, no. 6 (June 2018): 513-514. of Pediatrics). November 2018 19 Using Medicaid to Ensure the Healthy Social and Emotional Development of Infants and Toddlers 107 K. Johnson and C. Bruner, A Sourcebook on Medicaid’s Role in Early Childhood: Advancing High Performing Medical Homes and Improving Lifelong Health  (Child and Family Policy Center, 2018). 108 Buchholz et al., “Early Childhood Behavioral Health Integration Activities and Healthy Steps: Sustaining Practice, Averting Cost,” APA Clinical Practice in Pediatric Psychology, Vol 6, No. 2 (2018), 140-151. 109 E.T. Tyler et al., “Behavioral Health Integration in Pediatric Primary Care: Considerations and Opportunities for Policymakers, Planners, and Providers” (New York: Milbank Memorial Fund, March 2017). Smith, S. et al., “How States use Medicaid to Cover Key Infant and 110 Early Childhood Mental Health Services: 2018 update of a 50-state Survey,” (New York: National Center for Children in Poverty, 2018). 111 K. Johnson and C. Bruner, A Sourcebook on Medicaid’s Role in Early Childhood: Advancing High Performing Medical Homes and Improving Lifelong Health (Child and Family Policy Center, 2018). November 2018 20