Financing School-Based Mental Health Services in Medicaid Managed Care Adam S. Wilk, Ph.D. Rollins School of Public Health, Emory University August 7, 2019
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Financing School-Based Mental Health Services in Medicaid Managed Care
Adam S Wilk PhD
Rollins School of Public Health Emory University
August 7 2019
DisclosureDisclaimer
Receive funding support through role with the Southeast
Mental Health Technology Transfer Center (MHTTC)
Administrative Supplement funded by Substance Abuse and
Mental Health Services Administration (SAMHSA)
The opinions expressed herein are the views of the
presenters and do not reflect the official position of the
Department of Health and Human Services (DHHS)
SAMHSA No official support or endorsement of DHHS
SAMHSA for the opinions described in this document is
intended or should be inferred
Learning Objectives
1 Integrate the historical context of the ldquofree care rulerdquo into understanding of the role of Medicaid in financing school-based health services today
2 Identify four key criteria that determine whether Medicaid will pay for a service
3 Discuss how benefit administration by Medicaid managed care plans can complicate local education authoritiesrsquo efforts to finance school-based mental health services and programs
A little about mehellip
Health economist health policy researcher
Medicaid consulting technical assistance and research for 13 years
Now at Rollins School of Public Health Emory University
Areas of focus
o Access to care for low-income and medically vulnerable populations
o Medicaid Managed Care and cost containment strategies
o Impacts of state policy decisions on providersrsquo operations and care
o Determinants of Medicaid coverage and continuity of enrollment
Mental Health Technology Transfer
Center Network
Funded by SAMHSA
Focus on SBMH Financing
Literature Document Review
Interview Series (in process)bull State and local (ie district) leaders all 8 states in
the SE regionbull Sources Medicaid Department of Education
budgetgrants non-for-profit organizations philanthropies
bull Barriers and facilitators to effectively leveraging funding sources
Survey (planning)
Medicaid is Key in School-based
Mental Health (SBMH) Financing
- Medicaid pays for Tier 2 (screening) and Tier 3
(treatment) SBMH services principally
As of 2016 nationwide nearly 93 of Medicaid-
enrolled children are enrolled in a Medicaid
Managed Care plan (and rising)
Medicaid is the largest payer for behavioral health
services in the US including SBMH services
Why The ldquoFree Care rulerdquo
changed in December 2014
Previously ldquoIf you bill Medicaid you have to bill
patients andor other payers toordquo
Many SBMH programs could not operate
New example starting August 2015 APEX program in
Georgia now in over 400 schools
States may need to file a State Plan Amendment or
pass legislation to leverage
When will Medicaid pay
for a service
SBMH services will be reimbursable through
Medicaid if the following criteria are met
1) Child is enrolled in Medicaid
2) Service is a covered service
3) Provider is an eligible provider
4) Setting is an accepted setting
1 Is the child enrolled in
Medicaid
Many children are not eligible for Medicaid
Many Medicaid-eligible children are not enrolled
Enrollment can fluctuate over time due to fluctuating eligibility or difficulty meeting administrative requirements
Medicaid allows for administrative billing including payment for outreach and enrollment support activities
PR
ES
SU
RE
PO
INT
S
A child must be enrolled in Medicaid in order for Medicaid to pay for the childrsquos SBMH care35 of kids age 6-18 are enrolled in Medicaid
Variation in Jan 2019 Income Eligibility
Levels in MedicaidCHIP of FPL
Note on eligibility redetermination indicates that beneficiaries in these states must
recertify every 6 months or more frequently (vs 12 months)
KY
TN
GA
SC
FL
MS AL
NC
200
255
199
196
225
199
201
146
Pregnant Women
KY
TN
GA
FL
MS AL
NC
218
255
214
215
252
213
216
317
SC
Children
MedicaidCHIP Child Participation Rates
StateParticipation Rate
2013
Participation Rate
2016
Alabama 916 963
Florida 850 930
Georgia 855 906
Kentucky 903 956
Mississippi 892 948
North Carolina 919 950
South Carolina 899 955
Tennessee 911 955
Participation Rate = ratio of MedicaidCHIP-eligible enrolled children
to MedicaidCHIP-eligible enrolled children plus MedicaidCHIP-
eligible uninsured children
Continuity of Coverage in Medicaid
StateContinuity Ratio
(All)
Continuity Ratio
(Children)
Alabama 840 852
Florida 743 797
Georgia 763 792
Kentucky 792 830
Mississippi 814 830
North Carolina 802 855
South Carolina 819 821
Tennessee 831 872
The Continuity Ratio measures the portion of a year that an average
beneficiary is enrolled in Medicaid It is the ratio of the average of
Medicaid enrollees in a fiscal year divided by the unduplicated of
annual enrollees
2 Is the service
covered by Medicaid
While all Medicaid programs cover mental health services in general different Medicaid programs make different decisions about which specific services will be covered and under what circumstances
Mandatory benefits inpatient and outpatient hospital care physician visits rural health clinic services etc
Optional benefits prescription drugs targeted case management licensed clinical social work services etc
PR
ES
SU
RE
PO
INT
Pressure Point Medicaid Managed
Care (MMC) Plans Cover Services
on Their Own Terms
Across plans variation in terms of coverage for key SBMH services
Examples psychotherapy services and assessment
1 Initial services may be covered with referral sometimes requiring prior authorization
2 Covered up until a fixed benefit ldquocaprdquo
3 Coverage may be extended above the cap if the provider obtains re-authorization
Plans may give little notice before making changes to coverage terms
Example Preferred Drug List
Pressure Point Multiple Medicaid
Managed Care (MMC) Plans To
Work With
Typically multiple MMC plans serve the same
(child) population
SE region (8 states) 2-17 plans statewide
Some states (eg FL MI TX) contract with MMC plans
separately for distinct geographic service areas
o SE region 20 ndash 57 plans per service area
Multiple sets of MMC plan
coverage terms to manage
Pressure Point Multiple Medicaid
Managed Care (MMC) Plans To
Work With (Part 2)
1 MMC plans may subcontract with specialized BH managed care companies
o 30-50 of MMC plans (esp larger)
2 State-level BH (andor Rx) ldquocarve-outsrdquo
o 11 statesrsquo Medicaid programs with a BH carve-out as of 2017
ldquoLeadrdquo MMC Plans may not administer behavioral health (BH) benefits directly ndash two main reasons
ldquoEXTRArdquo sets of MMC plan
coverage terms to manage
3 Is the provider an eligible
provider +Providers must be credentialed (ie determined to be in good
professional standing) and approved by Medicaid before their claims
will be reimbursable
Major shortages of all behavioral health providers
o Compounded by misallocation of staff
o Therapist shortage has upstream impact on screening
providers report currently accepting any Medicaid patients
Some services may only be covered when provided by certain provider types (eg licensed clinical social worker vs non-clinical)P
RE
SS
UR
E P
OIN
TS
EPSDT is
underleveraged
Pressure Point Medicaid Managed
Care (MMC) Plans Form Provider
Networks
MMC plans (like commercial insurers)hellip
bull Negotiate fee schedules
Do not use standard Medicaid fee schedule
bull Make determinations on network inclusion (or exclusion)
Not all providers who ldquoaccept Medicaid patientsrdquo are in-network for a given MMC plan
Plansrsquo member handbooks (including lists of in-network providers) may be out of date
Pressure Point Multiple Medicaid
Managed Care (MMC) Plans To
Work With (Part 3)
Typically multiple MMC plans serve the same
(child) population
May complicate
bull Rate negotiations (if employing or
contracting with providers)
bull Provider network management
(eg for referrals)
ldquoLeadrdquo MMC Plans may not administer behavioral health (BH) benefits directly
4 Is the care setting
acceptable
Medicaid programs set rules that govern whether a covered service will be reimbursable only if provided in a program-approved setting
Outpatient (non-school-based) clinics generally an acceptable setting
School mental health programs often facilitate transportation tofrom outpatient clinics
Schools may be an accepted care setting for some services in some states but not others
IDEA ndash Schools may submit claims to Medicaid for Medicaid-covered school-based treatment management services listed in the IEP
North Carolina
Medicaid Services
Provided in Schools
Early and Periodic Screening Diagnostic and Treatment (EPSDT) services
Evaluation services (with required written report)cognitive emotional personality adaptive behavior behavior and
perceptual or visual motor
Treatment services may include one or more of the following therapies cognitive-behavioral therapy rational-emotive therapy family
therapy individual interactive psychotherapy using play equipment (et al) sensory integrative therapy
As of January 2019 State Plan Amendment approval
Medicaid Managed Care
Administrative Burden
Anecdotally only the most well-resourced school districts may have the bandwidth to manage this effectively
May be easier to partner with a community provider
District duties
Perform outreach to potentially
Medicaid-eligible students
Assist students with applying for
Medicaid coverage
Assist with re-certifying eligibility
Administrative billing
Know statersquos benefit package (incl
optional benefits)
Track MMC plansrsquo coverage terms
Manage MMC plansrsquo cost containment
tools (eg prior authorization)
Negotiate rates with MMC plans
Monitor MMC plansrsquo provider networks
Avoid confusing rulesprocesses
across multiple MMC plans in area
Track which services are reimbursable
when delivered on school grounds
If Medicaid will pay for SBMH services the following
criteria must be met
Key Takeaways
1) Child is enrolled in Medicaid
2) Service is a covered service
3) Provider is an eligible provider
4) Setting is an accepted setting
Medicaid Managed Care can complicate these matters
in some key ways
Prior authorization other cost containment tools
Provider network management
Separate administration of behavioral health benefits
Identify measure and act on key ldquopressure pointsrdquo in
your states
Key Takeaways ctd
Interviews and survey data collection (state and local)
Barriers and facilitators to leveraging Medicaid to finance
SBMH services and programs
Similar issues for other funding sources particularly
Dept of Education
Relative importance of funding sources
Forthcoming webinars to present findings (stay tuned)
Ongoing Activities at the
SE MHTTC
Thank you
Please contact me with questions
E-mail adamswilkemoryedu
Twitter adamswilk
httpsmhttcnetworkorgcenterssoutheast-mhttchome
References pt 1
Brooks T Roygardner L amp Artiga S 2019 Medicaid and CHIP Eligibility Enrollment and Cost Sharing Policies as of January 2019 Findings from a 50-State Survey Henry J Kaiser Family Foundation
CMS (Centers for Medicare amp Medicaid Services) 2014 Letter from Cindy Mann to state Medicaid directors regarding Medicaid payment for services provided without charge (free care)rdquo December 15 2014 Baltimore MD CMS httpswwwmedicaidgovfederal-policy-guidancedownloadssmd-medicaid-payment-forservices-provided-without-charge-free-carepdf
CMS ldquoManaged Carerdquo httpswwwmedicaidgovmedicaidmanaged-careindexhtml
Chester A and Wright Burak E Fact Sheet Medicaidrsquos Role for Young Children Georgetown University Health Policy Institute Center for Children and Families 13 Dec 2016 httpsccfgeorgetownedu20161213fact-sheet-medicaids-role-for-young-children
Florida Agency for Health Care Administration httpsahcamyfloridacomMedicaidstatewide_mcpdfSMMC_Region_mappdf
Kaiser Family Foundation httpswwwkfforgmedicaidstate-indicatortotal-medicaid-mcoscurrentTimeframe=0ampsortModel=7B22colId2222Location2222sort2222asc227D
Kentucky Cabinet for Family Health and Family Services httpschfskygovagenciesdmsdpqomco-cmbPagesmco-optionsaspx
Ku L Steinmetz E and Bysshe T (2015) Continuity of Medicaid Coverage in an Era of Transition (Working Paper) Milken Institute of Public Health George Washington University
References pt 2
MACPAC (Medicaid and CHIP Payment and Access Commission) Behavioral Health Benefits httpswwwmacpacgovsubtopicbehavioral-health-benefits
MACPAC Issue Brief Medicaid in Schools Washington DC April 2018
MACPAC Section 3 Program enrollment and spendingmdashMedicaid managed care Washington DC December 2016
Mississippi Division of Medicaid httpsmedicaidmsgovprogramsmanaged-care SAMHSA (Substance Abuse and Mental Health Services Administration) Mental Health
Technology Transfer Center Network httpsmhttcnetworkorg
Tuck K amp Smith E ldquoBehavioral Health Coverage in Medicaid Managed Carerdquo Institute for Medicaid Innovation April 2019 httpswwwmedicaidinnovationorg_imagescontent2019-IMI-Behavioral_Health_in_Medicaid-Reportpdf
Urban Institute tabulations of 20132016 American Community Survey (ACS) data from the Integrated Public Use Microdata Series (IPUMS) from Jennifer Haley Genevieve Kenney Robin Wang Victoria Lynch and Matthew Buettgens MedicaidCHIP Participation Reached 937 Percent Among Eligible Children In 2016 The Urban Institute Washington DC August 2018
Wen H Wilk A S Druss B G amp Cummings J R 2019 Medicaid Acceptance by Psychiatrists Implications for Medicaid Expansion JAMA Psychiatry epub 5 Jun 2019
DisclosureDisclaimer
Receive funding support through role with the Southeast
Mental Health Technology Transfer Center (MHTTC)
Administrative Supplement funded by Substance Abuse and
Mental Health Services Administration (SAMHSA)
The opinions expressed herein are the views of the
presenters and do not reflect the official position of the
Department of Health and Human Services (DHHS)
SAMHSA No official support or endorsement of DHHS
SAMHSA for the opinions described in this document is
intended or should be inferred
Learning Objectives
1 Integrate the historical context of the ldquofree care rulerdquo into understanding of the role of Medicaid in financing school-based health services today
2 Identify four key criteria that determine whether Medicaid will pay for a service
3 Discuss how benefit administration by Medicaid managed care plans can complicate local education authoritiesrsquo efforts to finance school-based mental health services and programs
A little about mehellip
Health economist health policy researcher
Medicaid consulting technical assistance and research for 13 years
Now at Rollins School of Public Health Emory University
Areas of focus
o Access to care for low-income and medically vulnerable populations
o Medicaid Managed Care and cost containment strategies
o Impacts of state policy decisions on providersrsquo operations and care
o Determinants of Medicaid coverage and continuity of enrollment
Mental Health Technology Transfer
Center Network
Funded by SAMHSA
Focus on SBMH Financing
Literature Document Review
Interview Series (in process)bull State and local (ie district) leaders all 8 states in
the SE regionbull Sources Medicaid Department of Education
budgetgrants non-for-profit organizations philanthropies
bull Barriers and facilitators to effectively leveraging funding sources
Survey (planning)
Medicaid is Key in School-based
Mental Health (SBMH) Financing
- Medicaid pays for Tier 2 (screening) and Tier 3
(treatment) SBMH services principally
As of 2016 nationwide nearly 93 of Medicaid-
enrolled children are enrolled in a Medicaid
Managed Care plan (and rising)
Medicaid is the largest payer for behavioral health
services in the US including SBMH services
Why The ldquoFree Care rulerdquo
changed in December 2014
Previously ldquoIf you bill Medicaid you have to bill
patients andor other payers toordquo
Many SBMH programs could not operate
New example starting August 2015 APEX program in
Georgia now in over 400 schools
States may need to file a State Plan Amendment or
pass legislation to leverage
When will Medicaid pay
for a service
SBMH services will be reimbursable through
Medicaid if the following criteria are met
1) Child is enrolled in Medicaid
2) Service is a covered service
3) Provider is an eligible provider
4) Setting is an accepted setting
1 Is the child enrolled in
Medicaid
Many children are not eligible for Medicaid
Many Medicaid-eligible children are not enrolled
Enrollment can fluctuate over time due to fluctuating eligibility or difficulty meeting administrative requirements
Medicaid allows for administrative billing including payment for outreach and enrollment support activities
PR
ES
SU
RE
PO
INT
S
A child must be enrolled in Medicaid in order for Medicaid to pay for the childrsquos SBMH care35 of kids age 6-18 are enrolled in Medicaid
Variation in Jan 2019 Income Eligibility
Levels in MedicaidCHIP of FPL
Note on eligibility redetermination indicates that beneficiaries in these states must
recertify every 6 months or more frequently (vs 12 months)
KY
TN
GA
SC
FL
MS AL
NC
200
255
199
196
225
199
201
146
Pregnant Women
KY
TN
GA
FL
MS AL
NC
218
255
214
215
252
213
216
317
SC
Children
MedicaidCHIP Child Participation Rates
StateParticipation Rate
2013
Participation Rate
2016
Alabama 916 963
Florida 850 930
Georgia 855 906
Kentucky 903 956
Mississippi 892 948
North Carolina 919 950
South Carolina 899 955
Tennessee 911 955
Participation Rate = ratio of MedicaidCHIP-eligible enrolled children
to MedicaidCHIP-eligible enrolled children plus MedicaidCHIP-
eligible uninsured children
Continuity of Coverage in Medicaid
StateContinuity Ratio
(All)
Continuity Ratio
(Children)
Alabama 840 852
Florida 743 797
Georgia 763 792
Kentucky 792 830
Mississippi 814 830
North Carolina 802 855
South Carolina 819 821
Tennessee 831 872
The Continuity Ratio measures the portion of a year that an average
beneficiary is enrolled in Medicaid It is the ratio of the average of
Medicaid enrollees in a fiscal year divided by the unduplicated of
annual enrollees
2 Is the service
covered by Medicaid
While all Medicaid programs cover mental health services in general different Medicaid programs make different decisions about which specific services will be covered and under what circumstances
Mandatory benefits inpatient and outpatient hospital care physician visits rural health clinic services etc
Optional benefits prescription drugs targeted case management licensed clinical social work services etc
PR
ES
SU
RE
PO
INT
Pressure Point Medicaid Managed
Care (MMC) Plans Cover Services
on Their Own Terms
Across plans variation in terms of coverage for key SBMH services
Examples psychotherapy services and assessment
1 Initial services may be covered with referral sometimes requiring prior authorization
2 Covered up until a fixed benefit ldquocaprdquo
3 Coverage may be extended above the cap if the provider obtains re-authorization
Plans may give little notice before making changes to coverage terms
Example Preferred Drug List
Pressure Point Multiple Medicaid
Managed Care (MMC) Plans To
Work With
Typically multiple MMC plans serve the same
(child) population
SE region (8 states) 2-17 plans statewide
Some states (eg FL MI TX) contract with MMC plans
separately for distinct geographic service areas
o SE region 20 ndash 57 plans per service area
Multiple sets of MMC plan
coverage terms to manage
Pressure Point Multiple Medicaid
Managed Care (MMC) Plans To
Work With (Part 2)
1 MMC plans may subcontract with specialized BH managed care companies
o 30-50 of MMC plans (esp larger)
2 State-level BH (andor Rx) ldquocarve-outsrdquo
o 11 statesrsquo Medicaid programs with a BH carve-out as of 2017
ldquoLeadrdquo MMC Plans may not administer behavioral health (BH) benefits directly ndash two main reasons
ldquoEXTRArdquo sets of MMC plan
coverage terms to manage
3 Is the provider an eligible
provider +Providers must be credentialed (ie determined to be in good
professional standing) and approved by Medicaid before their claims
will be reimbursable
Major shortages of all behavioral health providers
o Compounded by misallocation of staff
o Therapist shortage has upstream impact on screening
providers report currently accepting any Medicaid patients
Some services may only be covered when provided by certain provider types (eg licensed clinical social worker vs non-clinical)P
RE
SS
UR
E P
OIN
TS
EPSDT is
underleveraged
Pressure Point Medicaid Managed
Care (MMC) Plans Form Provider
Networks
MMC plans (like commercial insurers)hellip
bull Negotiate fee schedules
Do not use standard Medicaid fee schedule
bull Make determinations on network inclusion (or exclusion)
Not all providers who ldquoaccept Medicaid patientsrdquo are in-network for a given MMC plan
Plansrsquo member handbooks (including lists of in-network providers) may be out of date
Pressure Point Multiple Medicaid
Managed Care (MMC) Plans To
Work With (Part 3)
Typically multiple MMC plans serve the same
(child) population
May complicate
bull Rate negotiations (if employing or
contracting with providers)
bull Provider network management
(eg for referrals)
ldquoLeadrdquo MMC Plans may not administer behavioral health (BH) benefits directly
4 Is the care setting
acceptable
Medicaid programs set rules that govern whether a covered service will be reimbursable only if provided in a program-approved setting
Outpatient (non-school-based) clinics generally an acceptable setting
School mental health programs often facilitate transportation tofrom outpatient clinics
Schools may be an accepted care setting for some services in some states but not others
IDEA ndash Schools may submit claims to Medicaid for Medicaid-covered school-based treatment management services listed in the IEP
North Carolina
Medicaid Services
Provided in Schools
Early and Periodic Screening Diagnostic and Treatment (EPSDT) services
Evaluation services (with required written report)cognitive emotional personality adaptive behavior behavior and
perceptual or visual motor
Treatment services may include one or more of the following therapies cognitive-behavioral therapy rational-emotive therapy family
therapy individual interactive psychotherapy using play equipment (et al) sensory integrative therapy
As of January 2019 State Plan Amendment approval
Medicaid Managed Care
Administrative Burden
Anecdotally only the most well-resourced school districts may have the bandwidth to manage this effectively
May be easier to partner with a community provider
District duties
Perform outreach to potentially
Medicaid-eligible students
Assist students with applying for
Medicaid coverage
Assist with re-certifying eligibility
Administrative billing
Know statersquos benefit package (incl
optional benefits)
Track MMC plansrsquo coverage terms
Manage MMC plansrsquo cost containment
tools (eg prior authorization)
Negotiate rates with MMC plans
Monitor MMC plansrsquo provider networks
Avoid confusing rulesprocesses
across multiple MMC plans in area
Track which services are reimbursable
when delivered on school grounds
If Medicaid will pay for SBMH services the following
criteria must be met
Key Takeaways
1) Child is enrolled in Medicaid
2) Service is a covered service
3) Provider is an eligible provider
4) Setting is an accepted setting
Medicaid Managed Care can complicate these matters
in some key ways
Prior authorization other cost containment tools
Provider network management
Separate administration of behavioral health benefits
Identify measure and act on key ldquopressure pointsrdquo in
your states
Key Takeaways ctd
Interviews and survey data collection (state and local)
Barriers and facilitators to leveraging Medicaid to finance
SBMH services and programs
Similar issues for other funding sources particularly
Dept of Education
Relative importance of funding sources
Forthcoming webinars to present findings (stay tuned)
Ongoing Activities at the
SE MHTTC
Thank you
Please contact me with questions
E-mail adamswilkemoryedu
Twitter adamswilk
httpsmhttcnetworkorgcenterssoutheast-mhttchome
References pt 1
Brooks T Roygardner L amp Artiga S 2019 Medicaid and CHIP Eligibility Enrollment and Cost Sharing Policies as of January 2019 Findings from a 50-State Survey Henry J Kaiser Family Foundation
CMS (Centers for Medicare amp Medicaid Services) 2014 Letter from Cindy Mann to state Medicaid directors regarding Medicaid payment for services provided without charge (free care)rdquo December 15 2014 Baltimore MD CMS httpswwwmedicaidgovfederal-policy-guidancedownloadssmd-medicaid-payment-forservices-provided-without-charge-free-carepdf
CMS ldquoManaged Carerdquo httpswwwmedicaidgovmedicaidmanaged-careindexhtml
Chester A and Wright Burak E Fact Sheet Medicaidrsquos Role for Young Children Georgetown University Health Policy Institute Center for Children and Families 13 Dec 2016 httpsccfgeorgetownedu20161213fact-sheet-medicaids-role-for-young-children
Florida Agency for Health Care Administration httpsahcamyfloridacomMedicaidstatewide_mcpdfSMMC_Region_mappdf
Kaiser Family Foundation httpswwwkfforgmedicaidstate-indicatortotal-medicaid-mcoscurrentTimeframe=0ampsortModel=7B22colId2222Location2222sort2222asc227D
Kentucky Cabinet for Family Health and Family Services httpschfskygovagenciesdmsdpqomco-cmbPagesmco-optionsaspx
Ku L Steinmetz E and Bysshe T (2015) Continuity of Medicaid Coverage in an Era of Transition (Working Paper) Milken Institute of Public Health George Washington University
References pt 2
MACPAC (Medicaid and CHIP Payment and Access Commission) Behavioral Health Benefits httpswwwmacpacgovsubtopicbehavioral-health-benefits
MACPAC Issue Brief Medicaid in Schools Washington DC April 2018
MACPAC Section 3 Program enrollment and spendingmdashMedicaid managed care Washington DC December 2016
Mississippi Division of Medicaid httpsmedicaidmsgovprogramsmanaged-care SAMHSA (Substance Abuse and Mental Health Services Administration) Mental Health
Technology Transfer Center Network httpsmhttcnetworkorg
Tuck K amp Smith E ldquoBehavioral Health Coverage in Medicaid Managed Carerdquo Institute for Medicaid Innovation April 2019 httpswwwmedicaidinnovationorg_imagescontent2019-IMI-Behavioral_Health_in_Medicaid-Reportpdf
Urban Institute tabulations of 20132016 American Community Survey (ACS) data from the Integrated Public Use Microdata Series (IPUMS) from Jennifer Haley Genevieve Kenney Robin Wang Victoria Lynch and Matthew Buettgens MedicaidCHIP Participation Reached 937 Percent Among Eligible Children In 2016 The Urban Institute Washington DC August 2018
Wen H Wilk A S Druss B G amp Cummings J R 2019 Medicaid Acceptance by Psychiatrists Implications for Medicaid Expansion JAMA Psychiatry epub 5 Jun 2019
Learning Objectives
1 Integrate the historical context of the ldquofree care rulerdquo into understanding of the role of Medicaid in financing school-based health services today
2 Identify four key criteria that determine whether Medicaid will pay for a service
3 Discuss how benefit administration by Medicaid managed care plans can complicate local education authoritiesrsquo efforts to finance school-based mental health services and programs
A little about mehellip
Health economist health policy researcher
Medicaid consulting technical assistance and research for 13 years
Now at Rollins School of Public Health Emory University
Areas of focus
o Access to care for low-income and medically vulnerable populations
o Medicaid Managed Care and cost containment strategies
o Impacts of state policy decisions on providersrsquo operations and care
o Determinants of Medicaid coverage and continuity of enrollment
Mental Health Technology Transfer
Center Network
Funded by SAMHSA
Focus on SBMH Financing
Literature Document Review
Interview Series (in process)bull State and local (ie district) leaders all 8 states in
the SE regionbull Sources Medicaid Department of Education
budgetgrants non-for-profit organizations philanthropies
bull Barriers and facilitators to effectively leveraging funding sources
Survey (planning)
Medicaid is Key in School-based
Mental Health (SBMH) Financing
- Medicaid pays for Tier 2 (screening) and Tier 3
(treatment) SBMH services principally
As of 2016 nationwide nearly 93 of Medicaid-
enrolled children are enrolled in a Medicaid
Managed Care plan (and rising)
Medicaid is the largest payer for behavioral health
services in the US including SBMH services
Why The ldquoFree Care rulerdquo
changed in December 2014
Previously ldquoIf you bill Medicaid you have to bill
patients andor other payers toordquo
Many SBMH programs could not operate
New example starting August 2015 APEX program in
Georgia now in over 400 schools
States may need to file a State Plan Amendment or
pass legislation to leverage
When will Medicaid pay
for a service
SBMH services will be reimbursable through
Medicaid if the following criteria are met
1) Child is enrolled in Medicaid
2) Service is a covered service
3) Provider is an eligible provider
4) Setting is an accepted setting
1 Is the child enrolled in
Medicaid
Many children are not eligible for Medicaid
Many Medicaid-eligible children are not enrolled
Enrollment can fluctuate over time due to fluctuating eligibility or difficulty meeting administrative requirements
Medicaid allows for administrative billing including payment for outreach and enrollment support activities
PR
ES
SU
RE
PO
INT
S
A child must be enrolled in Medicaid in order for Medicaid to pay for the childrsquos SBMH care35 of kids age 6-18 are enrolled in Medicaid
Variation in Jan 2019 Income Eligibility
Levels in MedicaidCHIP of FPL
Note on eligibility redetermination indicates that beneficiaries in these states must
recertify every 6 months or more frequently (vs 12 months)
KY
TN
GA
SC
FL
MS AL
NC
200
255
199
196
225
199
201
146
Pregnant Women
KY
TN
GA
FL
MS AL
NC
218
255
214
215
252
213
216
317
SC
Children
MedicaidCHIP Child Participation Rates
StateParticipation Rate
2013
Participation Rate
2016
Alabama 916 963
Florida 850 930
Georgia 855 906
Kentucky 903 956
Mississippi 892 948
North Carolina 919 950
South Carolina 899 955
Tennessee 911 955
Participation Rate = ratio of MedicaidCHIP-eligible enrolled children
to MedicaidCHIP-eligible enrolled children plus MedicaidCHIP-
eligible uninsured children
Continuity of Coverage in Medicaid
StateContinuity Ratio
(All)
Continuity Ratio
(Children)
Alabama 840 852
Florida 743 797
Georgia 763 792
Kentucky 792 830
Mississippi 814 830
North Carolina 802 855
South Carolina 819 821
Tennessee 831 872
The Continuity Ratio measures the portion of a year that an average
beneficiary is enrolled in Medicaid It is the ratio of the average of
Medicaid enrollees in a fiscal year divided by the unduplicated of
annual enrollees
2 Is the service
covered by Medicaid
While all Medicaid programs cover mental health services in general different Medicaid programs make different decisions about which specific services will be covered and under what circumstances
Mandatory benefits inpatient and outpatient hospital care physician visits rural health clinic services etc
Optional benefits prescription drugs targeted case management licensed clinical social work services etc
PR
ES
SU
RE
PO
INT
Pressure Point Medicaid Managed
Care (MMC) Plans Cover Services
on Their Own Terms
Across plans variation in terms of coverage for key SBMH services
Examples psychotherapy services and assessment
1 Initial services may be covered with referral sometimes requiring prior authorization
2 Covered up until a fixed benefit ldquocaprdquo
3 Coverage may be extended above the cap if the provider obtains re-authorization
Plans may give little notice before making changes to coverage terms
Example Preferred Drug List
Pressure Point Multiple Medicaid
Managed Care (MMC) Plans To
Work With
Typically multiple MMC plans serve the same
(child) population
SE region (8 states) 2-17 plans statewide
Some states (eg FL MI TX) contract with MMC plans
separately for distinct geographic service areas
o SE region 20 ndash 57 plans per service area
Multiple sets of MMC plan
coverage terms to manage
Pressure Point Multiple Medicaid
Managed Care (MMC) Plans To
Work With (Part 2)
1 MMC plans may subcontract with specialized BH managed care companies
o 30-50 of MMC plans (esp larger)
2 State-level BH (andor Rx) ldquocarve-outsrdquo
o 11 statesrsquo Medicaid programs with a BH carve-out as of 2017
ldquoLeadrdquo MMC Plans may not administer behavioral health (BH) benefits directly ndash two main reasons
ldquoEXTRArdquo sets of MMC plan
coverage terms to manage
3 Is the provider an eligible
provider +Providers must be credentialed (ie determined to be in good
professional standing) and approved by Medicaid before their claims
will be reimbursable
Major shortages of all behavioral health providers
o Compounded by misallocation of staff
o Therapist shortage has upstream impact on screening
providers report currently accepting any Medicaid patients
Some services may only be covered when provided by certain provider types (eg licensed clinical social worker vs non-clinical)P
RE
SS
UR
E P
OIN
TS
EPSDT is
underleveraged
Pressure Point Medicaid Managed
Care (MMC) Plans Form Provider
Networks
MMC plans (like commercial insurers)hellip
bull Negotiate fee schedules
Do not use standard Medicaid fee schedule
bull Make determinations on network inclusion (or exclusion)
Not all providers who ldquoaccept Medicaid patientsrdquo are in-network for a given MMC plan
Plansrsquo member handbooks (including lists of in-network providers) may be out of date
Pressure Point Multiple Medicaid
Managed Care (MMC) Plans To
Work With (Part 3)
Typically multiple MMC plans serve the same
(child) population
May complicate
bull Rate negotiations (if employing or
contracting with providers)
bull Provider network management
(eg for referrals)
ldquoLeadrdquo MMC Plans may not administer behavioral health (BH) benefits directly
4 Is the care setting
acceptable
Medicaid programs set rules that govern whether a covered service will be reimbursable only if provided in a program-approved setting
Outpatient (non-school-based) clinics generally an acceptable setting
School mental health programs often facilitate transportation tofrom outpatient clinics
Schools may be an accepted care setting for some services in some states but not others
IDEA ndash Schools may submit claims to Medicaid for Medicaid-covered school-based treatment management services listed in the IEP
North Carolina
Medicaid Services
Provided in Schools
Early and Periodic Screening Diagnostic and Treatment (EPSDT) services
Evaluation services (with required written report)cognitive emotional personality adaptive behavior behavior and
perceptual or visual motor
Treatment services may include one or more of the following therapies cognitive-behavioral therapy rational-emotive therapy family
therapy individual interactive psychotherapy using play equipment (et al) sensory integrative therapy
As of January 2019 State Plan Amendment approval
Medicaid Managed Care
Administrative Burden
Anecdotally only the most well-resourced school districts may have the bandwidth to manage this effectively
May be easier to partner with a community provider
District duties
Perform outreach to potentially
Medicaid-eligible students
Assist students with applying for
Medicaid coverage
Assist with re-certifying eligibility
Administrative billing
Know statersquos benefit package (incl
optional benefits)
Track MMC plansrsquo coverage terms
Manage MMC plansrsquo cost containment
tools (eg prior authorization)
Negotiate rates with MMC plans
Monitor MMC plansrsquo provider networks
Avoid confusing rulesprocesses
across multiple MMC plans in area
Track which services are reimbursable
when delivered on school grounds
If Medicaid will pay for SBMH services the following
criteria must be met
Key Takeaways
1) Child is enrolled in Medicaid
2) Service is a covered service
3) Provider is an eligible provider
4) Setting is an accepted setting
Medicaid Managed Care can complicate these matters
in some key ways
Prior authorization other cost containment tools
Provider network management
Separate administration of behavioral health benefits
Identify measure and act on key ldquopressure pointsrdquo in
your states
Key Takeaways ctd
Interviews and survey data collection (state and local)
Barriers and facilitators to leveraging Medicaid to finance
SBMH services and programs
Similar issues for other funding sources particularly
Dept of Education
Relative importance of funding sources
Forthcoming webinars to present findings (stay tuned)
Ongoing Activities at the
SE MHTTC
Thank you
Please contact me with questions
E-mail adamswilkemoryedu
Twitter adamswilk
httpsmhttcnetworkorgcenterssoutheast-mhttchome
References pt 1
Brooks T Roygardner L amp Artiga S 2019 Medicaid and CHIP Eligibility Enrollment and Cost Sharing Policies as of January 2019 Findings from a 50-State Survey Henry J Kaiser Family Foundation
CMS (Centers for Medicare amp Medicaid Services) 2014 Letter from Cindy Mann to state Medicaid directors regarding Medicaid payment for services provided without charge (free care)rdquo December 15 2014 Baltimore MD CMS httpswwwmedicaidgovfederal-policy-guidancedownloadssmd-medicaid-payment-forservices-provided-without-charge-free-carepdf
CMS ldquoManaged Carerdquo httpswwwmedicaidgovmedicaidmanaged-careindexhtml
Chester A and Wright Burak E Fact Sheet Medicaidrsquos Role for Young Children Georgetown University Health Policy Institute Center for Children and Families 13 Dec 2016 httpsccfgeorgetownedu20161213fact-sheet-medicaids-role-for-young-children
Florida Agency for Health Care Administration httpsahcamyfloridacomMedicaidstatewide_mcpdfSMMC_Region_mappdf
Kaiser Family Foundation httpswwwkfforgmedicaidstate-indicatortotal-medicaid-mcoscurrentTimeframe=0ampsortModel=7B22colId2222Location2222sort2222asc227D
Kentucky Cabinet for Family Health and Family Services httpschfskygovagenciesdmsdpqomco-cmbPagesmco-optionsaspx
Ku L Steinmetz E and Bysshe T (2015) Continuity of Medicaid Coverage in an Era of Transition (Working Paper) Milken Institute of Public Health George Washington University
References pt 2
MACPAC (Medicaid and CHIP Payment and Access Commission) Behavioral Health Benefits httpswwwmacpacgovsubtopicbehavioral-health-benefits
MACPAC Issue Brief Medicaid in Schools Washington DC April 2018
MACPAC Section 3 Program enrollment and spendingmdashMedicaid managed care Washington DC December 2016
Mississippi Division of Medicaid httpsmedicaidmsgovprogramsmanaged-care SAMHSA (Substance Abuse and Mental Health Services Administration) Mental Health
Technology Transfer Center Network httpsmhttcnetworkorg
Tuck K amp Smith E ldquoBehavioral Health Coverage in Medicaid Managed Carerdquo Institute for Medicaid Innovation April 2019 httpswwwmedicaidinnovationorg_imagescontent2019-IMI-Behavioral_Health_in_Medicaid-Reportpdf
Urban Institute tabulations of 20132016 American Community Survey (ACS) data from the Integrated Public Use Microdata Series (IPUMS) from Jennifer Haley Genevieve Kenney Robin Wang Victoria Lynch and Matthew Buettgens MedicaidCHIP Participation Reached 937 Percent Among Eligible Children In 2016 The Urban Institute Washington DC August 2018
Wen H Wilk A S Druss B G amp Cummings J R 2019 Medicaid Acceptance by Psychiatrists Implications for Medicaid Expansion JAMA Psychiatry epub 5 Jun 2019
A little about mehellip
Health economist health policy researcher
Medicaid consulting technical assistance and research for 13 years
Now at Rollins School of Public Health Emory University
Areas of focus
o Access to care for low-income and medically vulnerable populations
o Medicaid Managed Care and cost containment strategies
o Impacts of state policy decisions on providersrsquo operations and care
o Determinants of Medicaid coverage and continuity of enrollment
Mental Health Technology Transfer
Center Network
Funded by SAMHSA
Focus on SBMH Financing
Literature Document Review
Interview Series (in process)bull State and local (ie district) leaders all 8 states in
the SE regionbull Sources Medicaid Department of Education
budgetgrants non-for-profit organizations philanthropies
bull Barriers and facilitators to effectively leveraging funding sources
Survey (planning)
Medicaid is Key in School-based
Mental Health (SBMH) Financing
- Medicaid pays for Tier 2 (screening) and Tier 3
(treatment) SBMH services principally
As of 2016 nationwide nearly 93 of Medicaid-
enrolled children are enrolled in a Medicaid
Managed Care plan (and rising)
Medicaid is the largest payer for behavioral health
services in the US including SBMH services
Why The ldquoFree Care rulerdquo
changed in December 2014
Previously ldquoIf you bill Medicaid you have to bill
patients andor other payers toordquo
Many SBMH programs could not operate
New example starting August 2015 APEX program in
Georgia now in over 400 schools
States may need to file a State Plan Amendment or
pass legislation to leverage
When will Medicaid pay
for a service
SBMH services will be reimbursable through
Medicaid if the following criteria are met
1) Child is enrolled in Medicaid
2) Service is a covered service
3) Provider is an eligible provider
4) Setting is an accepted setting
1 Is the child enrolled in
Medicaid
Many children are not eligible for Medicaid
Many Medicaid-eligible children are not enrolled
Enrollment can fluctuate over time due to fluctuating eligibility or difficulty meeting administrative requirements
Medicaid allows for administrative billing including payment for outreach and enrollment support activities
PR
ES
SU
RE
PO
INT
S
A child must be enrolled in Medicaid in order for Medicaid to pay for the childrsquos SBMH care35 of kids age 6-18 are enrolled in Medicaid
Variation in Jan 2019 Income Eligibility
Levels in MedicaidCHIP of FPL
Note on eligibility redetermination indicates that beneficiaries in these states must
recertify every 6 months or more frequently (vs 12 months)
KY
TN
GA
SC
FL
MS AL
NC
200
255
199
196
225
199
201
146
Pregnant Women
KY
TN
GA
FL
MS AL
NC
218
255
214
215
252
213
216
317
SC
Children
MedicaidCHIP Child Participation Rates
StateParticipation Rate
2013
Participation Rate
2016
Alabama 916 963
Florida 850 930
Georgia 855 906
Kentucky 903 956
Mississippi 892 948
North Carolina 919 950
South Carolina 899 955
Tennessee 911 955
Participation Rate = ratio of MedicaidCHIP-eligible enrolled children
to MedicaidCHIP-eligible enrolled children plus MedicaidCHIP-
eligible uninsured children
Continuity of Coverage in Medicaid
StateContinuity Ratio
(All)
Continuity Ratio
(Children)
Alabama 840 852
Florida 743 797
Georgia 763 792
Kentucky 792 830
Mississippi 814 830
North Carolina 802 855
South Carolina 819 821
Tennessee 831 872
The Continuity Ratio measures the portion of a year that an average
beneficiary is enrolled in Medicaid It is the ratio of the average of
Medicaid enrollees in a fiscal year divided by the unduplicated of
annual enrollees
2 Is the service
covered by Medicaid
While all Medicaid programs cover mental health services in general different Medicaid programs make different decisions about which specific services will be covered and under what circumstances
Mandatory benefits inpatient and outpatient hospital care physician visits rural health clinic services etc
Optional benefits prescription drugs targeted case management licensed clinical social work services etc
PR
ES
SU
RE
PO
INT
Pressure Point Medicaid Managed
Care (MMC) Plans Cover Services
on Their Own Terms
Across plans variation in terms of coverage for key SBMH services
Examples psychotherapy services and assessment
1 Initial services may be covered with referral sometimes requiring prior authorization
2 Covered up until a fixed benefit ldquocaprdquo
3 Coverage may be extended above the cap if the provider obtains re-authorization
Plans may give little notice before making changes to coverage terms
Example Preferred Drug List
Pressure Point Multiple Medicaid
Managed Care (MMC) Plans To
Work With
Typically multiple MMC plans serve the same
(child) population
SE region (8 states) 2-17 plans statewide
Some states (eg FL MI TX) contract with MMC plans
separately for distinct geographic service areas
o SE region 20 ndash 57 plans per service area
Multiple sets of MMC plan
coverage terms to manage
Pressure Point Multiple Medicaid
Managed Care (MMC) Plans To
Work With (Part 2)
1 MMC plans may subcontract with specialized BH managed care companies
o 30-50 of MMC plans (esp larger)
2 State-level BH (andor Rx) ldquocarve-outsrdquo
o 11 statesrsquo Medicaid programs with a BH carve-out as of 2017
ldquoLeadrdquo MMC Plans may not administer behavioral health (BH) benefits directly ndash two main reasons
ldquoEXTRArdquo sets of MMC plan
coverage terms to manage
3 Is the provider an eligible
provider +Providers must be credentialed (ie determined to be in good
professional standing) and approved by Medicaid before their claims
will be reimbursable
Major shortages of all behavioral health providers
o Compounded by misallocation of staff
o Therapist shortage has upstream impact on screening
providers report currently accepting any Medicaid patients
Some services may only be covered when provided by certain provider types (eg licensed clinical social worker vs non-clinical)P
RE
SS
UR
E P
OIN
TS
EPSDT is
underleveraged
Pressure Point Medicaid Managed
Care (MMC) Plans Form Provider
Networks
MMC plans (like commercial insurers)hellip
bull Negotiate fee schedules
Do not use standard Medicaid fee schedule
bull Make determinations on network inclusion (or exclusion)
Not all providers who ldquoaccept Medicaid patientsrdquo are in-network for a given MMC plan
Plansrsquo member handbooks (including lists of in-network providers) may be out of date
Pressure Point Multiple Medicaid
Managed Care (MMC) Plans To
Work With (Part 3)
Typically multiple MMC plans serve the same
(child) population
May complicate
bull Rate negotiations (if employing or
contracting with providers)
bull Provider network management
(eg for referrals)
ldquoLeadrdquo MMC Plans may not administer behavioral health (BH) benefits directly
4 Is the care setting
acceptable
Medicaid programs set rules that govern whether a covered service will be reimbursable only if provided in a program-approved setting
Outpatient (non-school-based) clinics generally an acceptable setting
School mental health programs often facilitate transportation tofrom outpatient clinics
Schools may be an accepted care setting for some services in some states but not others
IDEA ndash Schools may submit claims to Medicaid for Medicaid-covered school-based treatment management services listed in the IEP
North Carolina
Medicaid Services
Provided in Schools
Early and Periodic Screening Diagnostic and Treatment (EPSDT) services
Evaluation services (with required written report)cognitive emotional personality adaptive behavior behavior and
perceptual or visual motor
Treatment services may include one or more of the following therapies cognitive-behavioral therapy rational-emotive therapy family
therapy individual interactive psychotherapy using play equipment (et al) sensory integrative therapy
As of January 2019 State Plan Amendment approval
Medicaid Managed Care
Administrative Burden
Anecdotally only the most well-resourced school districts may have the bandwidth to manage this effectively
May be easier to partner with a community provider
District duties
Perform outreach to potentially
Medicaid-eligible students
Assist students with applying for
Medicaid coverage
Assist with re-certifying eligibility
Administrative billing
Know statersquos benefit package (incl
optional benefits)
Track MMC plansrsquo coverage terms
Manage MMC plansrsquo cost containment
tools (eg prior authorization)
Negotiate rates with MMC plans
Monitor MMC plansrsquo provider networks
Avoid confusing rulesprocesses
across multiple MMC plans in area
Track which services are reimbursable
when delivered on school grounds
If Medicaid will pay for SBMH services the following
criteria must be met
Key Takeaways
1) Child is enrolled in Medicaid
2) Service is a covered service
3) Provider is an eligible provider
4) Setting is an accepted setting
Medicaid Managed Care can complicate these matters
in some key ways
Prior authorization other cost containment tools
Provider network management
Separate administration of behavioral health benefits
Identify measure and act on key ldquopressure pointsrdquo in
your states
Key Takeaways ctd
Interviews and survey data collection (state and local)
Barriers and facilitators to leveraging Medicaid to finance
SBMH services and programs
Similar issues for other funding sources particularly
Dept of Education
Relative importance of funding sources
Forthcoming webinars to present findings (stay tuned)
Ongoing Activities at the
SE MHTTC
Thank you
Please contact me with questions
E-mail adamswilkemoryedu
Twitter adamswilk
httpsmhttcnetworkorgcenterssoutheast-mhttchome
References pt 1
Brooks T Roygardner L amp Artiga S 2019 Medicaid and CHIP Eligibility Enrollment and Cost Sharing Policies as of January 2019 Findings from a 50-State Survey Henry J Kaiser Family Foundation
CMS (Centers for Medicare amp Medicaid Services) 2014 Letter from Cindy Mann to state Medicaid directors regarding Medicaid payment for services provided without charge (free care)rdquo December 15 2014 Baltimore MD CMS httpswwwmedicaidgovfederal-policy-guidancedownloadssmd-medicaid-payment-forservices-provided-without-charge-free-carepdf
CMS ldquoManaged Carerdquo httpswwwmedicaidgovmedicaidmanaged-careindexhtml
Chester A and Wright Burak E Fact Sheet Medicaidrsquos Role for Young Children Georgetown University Health Policy Institute Center for Children and Families 13 Dec 2016 httpsccfgeorgetownedu20161213fact-sheet-medicaids-role-for-young-children
Florida Agency for Health Care Administration httpsahcamyfloridacomMedicaidstatewide_mcpdfSMMC_Region_mappdf
Kaiser Family Foundation httpswwwkfforgmedicaidstate-indicatortotal-medicaid-mcoscurrentTimeframe=0ampsortModel=7B22colId2222Location2222sort2222asc227D
Kentucky Cabinet for Family Health and Family Services httpschfskygovagenciesdmsdpqomco-cmbPagesmco-optionsaspx
Ku L Steinmetz E and Bysshe T (2015) Continuity of Medicaid Coverage in an Era of Transition (Working Paper) Milken Institute of Public Health George Washington University
References pt 2
MACPAC (Medicaid and CHIP Payment and Access Commission) Behavioral Health Benefits httpswwwmacpacgovsubtopicbehavioral-health-benefits
MACPAC Issue Brief Medicaid in Schools Washington DC April 2018
MACPAC Section 3 Program enrollment and spendingmdashMedicaid managed care Washington DC December 2016
Mississippi Division of Medicaid httpsmedicaidmsgovprogramsmanaged-care SAMHSA (Substance Abuse and Mental Health Services Administration) Mental Health
Technology Transfer Center Network httpsmhttcnetworkorg
Tuck K amp Smith E ldquoBehavioral Health Coverage in Medicaid Managed Carerdquo Institute for Medicaid Innovation April 2019 httpswwwmedicaidinnovationorg_imagescontent2019-IMI-Behavioral_Health_in_Medicaid-Reportpdf
Urban Institute tabulations of 20132016 American Community Survey (ACS) data from the Integrated Public Use Microdata Series (IPUMS) from Jennifer Haley Genevieve Kenney Robin Wang Victoria Lynch and Matthew Buettgens MedicaidCHIP Participation Reached 937 Percent Among Eligible Children In 2016 The Urban Institute Washington DC August 2018
Wen H Wilk A S Druss B G amp Cummings J R 2019 Medicaid Acceptance by Psychiatrists Implications for Medicaid Expansion JAMA Psychiatry epub 5 Jun 2019
Mental Health Technology Transfer
Center Network
Funded by SAMHSA
Focus on SBMH Financing
Literature Document Review
Interview Series (in process)bull State and local (ie district) leaders all 8 states in
the SE regionbull Sources Medicaid Department of Education
budgetgrants non-for-profit organizations philanthropies
bull Barriers and facilitators to effectively leveraging funding sources
Survey (planning)
Medicaid is Key in School-based
Mental Health (SBMH) Financing
- Medicaid pays for Tier 2 (screening) and Tier 3
(treatment) SBMH services principally
As of 2016 nationwide nearly 93 of Medicaid-
enrolled children are enrolled in a Medicaid
Managed Care plan (and rising)
Medicaid is the largest payer for behavioral health
services in the US including SBMH services
Why The ldquoFree Care rulerdquo
changed in December 2014
Previously ldquoIf you bill Medicaid you have to bill
patients andor other payers toordquo
Many SBMH programs could not operate
New example starting August 2015 APEX program in
Georgia now in over 400 schools
States may need to file a State Plan Amendment or
pass legislation to leverage
When will Medicaid pay
for a service
SBMH services will be reimbursable through
Medicaid if the following criteria are met
1) Child is enrolled in Medicaid
2) Service is a covered service
3) Provider is an eligible provider
4) Setting is an accepted setting
1 Is the child enrolled in
Medicaid
Many children are not eligible for Medicaid
Many Medicaid-eligible children are not enrolled
Enrollment can fluctuate over time due to fluctuating eligibility or difficulty meeting administrative requirements
Medicaid allows for administrative billing including payment for outreach and enrollment support activities
PR
ES
SU
RE
PO
INT
S
A child must be enrolled in Medicaid in order for Medicaid to pay for the childrsquos SBMH care35 of kids age 6-18 are enrolled in Medicaid
Variation in Jan 2019 Income Eligibility
Levels in MedicaidCHIP of FPL
Note on eligibility redetermination indicates that beneficiaries in these states must
recertify every 6 months or more frequently (vs 12 months)
KY
TN
GA
SC
FL
MS AL
NC
200
255
199
196
225
199
201
146
Pregnant Women
KY
TN
GA
FL
MS AL
NC
218
255
214
215
252
213
216
317
SC
Children
MedicaidCHIP Child Participation Rates
StateParticipation Rate
2013
Participation Rate
2016
Alabama 916 963
Florida 850 930
Georgia 855 906
Kentucky 903 956
Mississippi 892 948
North Carolina 919 950
South Carolina 899 955
Tennessee 911 955
Participation Rate = ratio of MedicaidCHIP-eligible enrolled children
to MedicaidCHIP-eligible enrolled children plus MedicaidCHIP-
eligible uninsured children
Continuity of Coverage in Medicaid
StateContinuity Ratio
(All)
Continuity Ratio
(Children)
Alabama 840 852
Florida 743 797
Georgia 763 792
Kentucky 792 830
Mississippi 814 830
North Carolina 802 855
South Carolina 819 821
Tennessee 831 872
The Continuity Ratio measures the portion of a year that an average
beneficiary is enrolled in Medicaid It is the ratio of the average of
Medicaid enrollees in a fiscal year divided by the unduplicated of
annual enrollees
2 Is the service
covered by Medicaid
While all Medicaid programs cover mental health services in general different Medicaid programs make different decisions about which specific services will be covered and under what circumstances
Mandatory benefits inpatient and outpatient hospital care physician visits rural health clinic services etc
Optional benefits prescription drugs targeted case management licensed clinical social work services etc
PR
ES
SU
RE
PO
INT
Pressure Point Medicaid Managed
Care (MMC) Plans Cover Services
on Their Own Terms
Across plans variation in terms of coverage for key SBMH services
Examples psychotherapy services and assessment
1 Initial services may be covered with referral sometimes requiring prior authorization
2 Covered up until a fixed benefit ldquocaprdquo
3 Coverage may be extended above the cap if the provider obtains re-authorization
Plans may give little notice before making changes to coverage terms
Example Preferred Drug List
Pressure Point Multiple Medicaid
Managed Care (MMC) Plans To
Work With
Typically multiple MMC plans serve the same
(child) population
SE region (8 states) 2-17 plans statewide
Some states (eg FL MI TX) contract with MMC plans
separately for distinct geographic service areas
o SE region 20 ndash 57 plans per service area
Multiple sets of MMC plan
coverage terms to manage
Pressure Point Multiple Medicaid
Managed Care (MMC) Plans To
Work With (Part 2)
1 MMC plans may subcontract with specialized BH managed care companies
o 30-50 of MMC plans (esp larger)
2 State-level BH (andor Rx) ldquocarve-outsrdquo
o 11 statesrsquo Medicaid programs with a BH carve-out as of 2017
ldquoLeadrdquo MMC Plans may not administer behavioral health (BH) benefits directly ndash two main reasons
ldquoEXTRArdquo sets of MMC plan
coverage terms to manage
3 Is the provider an eligible
provider +Providers must be credentialed (ie determined to be in good
professional standing) and approved by Medicaid before their claims
will be reimbursable
Major shortages of all behavioral health providers
o Compounded by misallocation of staff
o Therapist shortage has upstream impact on screening
providers report currently accepting any Medicaid patients
Some services may only be covered when provided by certain provider types (eg licensed clinical social worker vs non-clinical)P
RE
SS
UR
E P
OIN
TS
EPSDT is
underleveraged
Pressure Point Medicaid Managed
Care (MMC) Plans Form Provider
Networks
MMC plans (like commercial insurers)hellip
bull Negotiate fee schedules
Do not use standard Medicaid fee schedule
bull Make determinations on network inclusion (or exclusion)
Not all providers who ldquoaccept Medicaid patientsrdquo are in-network for a given MMC plan
Plansrsquo member handbooks (including lists of in-network providers) may be out of date
Pressure Point Multiple Medicaid
Managed Care (MMC) Plans To
Work With (Part 3)
Typically multiple MMC plans serve the same
(child) population
May complicate
bull Rate negotiations (if employing or
contracting with providers)
bull Provider network management
(eg for referrals)
ldquoLeadrdquo MMC Plans may not administer behavioral health (BH) benefits directly
4 Is the care setting
acceptable
Medicaid programs set rules that govern whether a covered service will be reimbursable only if provided in a program-approved setting
Outpatient (non-school-based) clinics generally an acceptable setting
School mental health programs often facilitate transportation tofrom outpatient clinics
Schools may be an accepted care setting for some services in some states but not others
IDEA ndash Schools may submit claims to Medicaid for Medicaid-covered school-based treatment management services listed in the IEP
North Carolina
Medicaid Services
Provided in Schools
Early and Periodic Screening Diagnostic and Treatment (EPSDT) services
Evaluation services (with required written report)cognitive emotional personality adaptive behavior behavior and
perceptual or visual motor
Treatment services may include one or more of the following therapies cognitive-behavioral therapy rational-emotive therapy family
therapy individual interactive psychotherapy using play equipment (et al) sensory integrative therapy
As of January 2019 State Plan Amendment approval
Medicaid Managed Care
Administrative Burden
Anecdotally only the most well-resourced school districts may have the bandwidth to manage this effectively
May be easier to partner with a community provider
District duties
Perform outreach to potentially
Medicaid-eligible students
Assist students with applying for
Medicaid coverage
Assist with re-certifying eligibility
Administrative billing
Know statersquos benefit package (incl
optional benefits)
Track MMC plansrsquo coverage terms
Manage MMC plansrsquo cost containment
tools (eg prior authorization)
Negotiate rates with MMC plans
Monitor MMC plansrsquo provider networks
Avoid confusing rulesprocesses
across multiple MMC plans in area
Track which services are reimbursable
when delivered on school grounds
If Medicaid will pay for SBMH services the following
criteria must be met
Key Takeaways
1) Child is enrolled in Medicaid
2) Service is a covered service
3) Provider is an eligible provider
4) Setting is an accepted setting
Medicaid Managed Care can complicate these matters
in some key ways
Prior authorization other cost containment tools
Provider network management
Separate administration of behavioral health benefits
Identify measure and act on key ldquopressure pointsrdquo in
your states
Key Takeaways ctd
Interviews and survey data collection (state and local)
Barriers and facilitators to leveraging Medicaid to finance
SBMH services and programs
Similar issues for other funding sources particularly
Dept of Education
Relative importance of funding sources
Forthcoming webinars to present findings (stay tuned)
Ongoing Activities at the
SE MHTTC
Thank you
Please contact me with questions
E-mail adamswilkemoryedu
Twitter adamswilk
httpsmhttcnetworkorgcenterssoutheast-mhttchome
References pt 1
Brooks T Roygardner L amp Artiga S 2019 Medicaid and CHIP Eligibility Enrollment and Cost Sharing Policies as of January 2019 Findings from a 50-State Survey Henry J Kaiser Family Foundation
CMS (Centers for Medicare amp Medicaid Services) 2014 Letter from Cindy Mann to state Medicaid directors regarding Medicaid payment for services provided without charge (free care)rdquo December 15 2014 Baltimore MD CMS httpswwwmedicaidgovfederal-policy-guidancedownloadssmd-medicaid-payment-forservices-provided-without-charge-free-carepdf
CMS ldquoManaged Carerdquo httpswwwmedicaidgovmedicaidmanaged-careindexhtml
Chester A and Wright Burak E Fact Sheet Medicaidrsquos Role for Young Children Georgetown University Health Policy Institute Center for Children and Families 13 Dec 2016 httpsccfgeorgetownedu20161213fact-sheet-medicaids-role-for-young-children
Florida Agency for Health Care Administration httpsahcamyfloridacomMedicaidstatewide_mcpdfSMMC_Region_mappdf
Kaiser Family Foundation httpswwwkfforgmedicaidstate-indicatortotal-medicaid-mcoscurrentTimeframe=0ampsortModel=7B22colId2222Location2222sort2222asc227D
Kentucky Cabinet for Family Health and Family Services httpschfskygovagenciesdmsdpqomco-cmbPagesmco-optionsaspx
Ku L Steinmetz E and Bysshe T (2015) Continuity of Medicaid Coverage in an Era of Transition (Working Paper) Milken Institute of Public Health George Washington University
References pt 2
MACPAC (Medicaid and CHIP Payment and Access Commission) Behavioral Health Benefits httpswwwmacpacgovsubtopicbehavioral-health-benefits
MACPAC Issue Brief Medicaid in Schools Washington DC April 2018
MACPAC Section 3 Program enrollment and spendingmdashMedicaid managed care Washington DC December 2016
Mississippi Division of Medicaid httpsmedicaidmsgovprogramsmanaged-care SAMHSA (Substance Abuse and Mental Health Services Administration) Mental Health
Technology Transfer Center Network httpsmhttcnetworkorg
Tuck K amp Smith E ldquoBehavioral Health Coverage in Medicaid Managed Carerdquo Institute for Medicaid Innovation April 2019 httpswwwmedicaidinnovationorg_imagescontent2019-IMI-Behavioral_Health_in_Medicaid-Reportpdf
Urban Institute tabulations of 20132016 American Community Survey (ACS) data from the Integrated Public Use Microdata Series (IPUMS) from Jennifer Haley Genevieve Kenney Robin Wang Victoria Lynch and Matthew Buettgens MedicaidCHIP Participation Reached 937 Percent Among Eligible Children In 2016 The Urban Institute Washington DC August 2018
Wen H Wilk A S Druss B G amp Cummings J R 2019 Medicaid Acceptance by Psychiatrists Implications for Medicaid Expansion JAMA Psychiatry epub 5 Jun 2019
Focus on SBMH Financing
Literature Document Review
Interview Series (in process)bull State and local (ie district) leaders all 8 states in
the SE regionbull Sources Medicaid Department of Education
budgetgrants non-for-profit organizations philanthropies
bull Barriers and facilitators to effectively leveraging funding sources
Survey (planning)
Medicaid is Key in School-based
Mental Health (SBMH) Financing
- Medicaid pays for Tier 2 (screening) and Tier 3
(treatment) SBMH services principally
As of 2016 nationwide nearly 93 of Medicaid-
enrolled children are enrolled in a Medicaid
Managed Care plan (and rising)
Medicaid is the largest payer for behavioral health
services in the US including SBMH services
Why The ldquoFree Care rulerdquo
changed in December 2014
Previously ldquoIf you bill Medicaid you have to bill
patients andor other payers toordquo
Many SBMH programs could not operate
New example starting August 2015 APEX program in
Georgia now in over 400 schools
States may need to file a State Plan Amendment or
pass legislation to leverage
When will Medicaid pay
for a service
SBMH services will be reimbursable through
Medicaid if the following criteria are met
1) Child is enrolled in Medicaid
2) Service is a covered service
3) Provider is an eligible provider
4) Setting is an accepted setting
1 Is the child enrolled in
Medicaid
Many children are not eligible for Medicaid
Many Medicaid-eligible children are not enrolled
Enrollment can fluctuate over time due to fluctuating eligibility or difficulty meeting administrative requirements
Medicaid allows for administrative billing including payment for outreach and enrollment support activities
PR
ES
SU
RE
PO
INT
S
A child must be enrolled in Medicaid in order for Medicaid to pay for the childrsquos SBMH care35 of kids age 6-18 are enrolled in Medicaid
Variation in Jan 2019 Income Eligibility
Levels in MedicaidCHIP of FPL
Note on eligibility redetermination indicates that beneficiaries in these states must
recertify every 6 months or more frequently (vs 12 months)
KY
TN
GA
SC
FL
MS AL
NC
200
255
199
196
225
199
201
146
Pregnant Women
KY
TN
GA
FL
MS AL
NC
218
255
214
215
252
213
216
317
SC
Children
MedicaidCHIP Child Participation Rates
StateParticipation Rate
2013
Participation Rate
2016
Alabama 916 963
Florida 850 930
Georgia 855 906
Kentucky 903 956
Mississippi 892 948
North Carolina 919 950
South Carolina 899 955
Tennessee 911 955
Participation Rate = ratio of MedicaidCHIP-eligible enrolled children
to MedicaidCHIP-eligible enrolled children plus MedicaidCHIP-
eligible uninsured children
Continuity of Coverage in Medicaid
StateContinuity Ratio
(All)
Continuity Ratio
(Children)
Alabama 840 852
Florida 743 797
Georgia 763 792
Kentucky 792 830
Mississippi 814 830
North Carolina 802 855
South Carolina 819 821
Tennessee 831 872
The Continuity Ratio measures the portion of a year that an average
beneficiary is enrolled in Medicaid It is the ratio of the average of
Medicaid enrollees in a fiscal year divided by the unduplicated of
annual enrollees
2 Is the service
covered by Medicaid
While all Medicaid programs cover mental health services in general different Medicaid programs make different decisions about which specific services will be covered and under what circumstances
Mandatory benefits inpatient and outpatient hospital care physician visits rural health clinic services etc
Optional benefits prescription drugs targeted case management licensed clinical social work services etc
PR
ES
SU
RE
PO
INT
Pressure Point Medicaid Managed
Care (MMC) Plans Cover Services
on Their Own Terms
Across plans variation in terms of coverage for key SBMH services
Examples psychotherapy services and assessment
1 Initial services may be covered with referral sometimes requiring prior authorization
2 Covered up until a fixed benefit ldquocaprdquo
3 Coverage may be extended above the cap if the provider obtains re-authorization
Plans may give little notice before making changes to coverage terms
Example Preferred Drug List
Pressure Point Multiple Medicaid
Managed Care (MMC) Plans To
Work With
Typically multiple MMC plans serve the same
(child) population
SE region (8 states) 2-17 plans statewide
Some states (eg FL MI TX) contract with MMC plans
separately for distinct geographic service areas
o SE region 20 ndash 57 plans per service area
Multiple sets of MMC plan
coverage terms to manage
Pressure Point Multiple Medicaid
Managed Care (MMC) Plans To
Work With (Part 2)
1 MMC plans may subcontract with specialized BH managed care companies
o 30-50 of MMC plans (esp larger)
2 State-level BH (andor Rx) ldquocarve-outsrdquo
o 11 statesrsquo Medicaid programs with a BH carve-out as of 2017
ldquoLeadrdquo MMC Plans may not administer behavioral health (BH) benefits directly ndash two main reasons
ldquoEXTRArdquo sets of MMC plan
coverage terms to manage
3 Is the provider an eligible
provider +Providers must be credentialed (ie determined to be in good
professional standing) and approved by Medicaid before their claims
will be reimbursable
Major shortages of all behavioral health providers
o Compounded by misallocation of staff
o Therapist shortage has upstream impact on screening
providers report currently accepting any Medicaid patients
Some services may only be covered when provided by certain provider types (eg licensed clinical social worker vs non-clinical)P
RE
SS
UR
E P
OIN
TS
EPSDT is
underleveraged
Pressure Point Medicaid Managed
Care (MMC) Plans Form Provider
Networks
MMC plans (like commercial insurers)hellip
bull Negotiate fee schedules
Do not use standard Medicaid fee schedule
bull Make determinations on network inclusion (or exclusion)
Not all providers who ldquoaccept Medicaid patientsrdquo are in-network for a given MMC plan
Plansrsquo member handbooks (including lists of in-network providers) may be out of date
Pressure Point Multiple Medicaid
Managed Care (MMC) Plans To
Work With (Part 3)
Typically multiple MMC plans serve the same
(child) population
May complicate
bull Rate negotiations (if employing or
contracting with providers)
bull Provider network management
(eg for referrals)
ldquoLeadrdquo MMC Plans may not administer behavioral health (BH) benefits directly
4 Is the care setting
acceptable
Medicaid programs set rules that govern whether a covered service will be reimbursable only if provided in a program-approved setting
Outpatient (non-school-based) clinics generally an acceptable setting
School mental health programs often facilitate transportation tofrom outpatient clinics
Schools may be an accepted care setting for some services in some states but not others
IDEA ndash Schools may submit claims to Medicaid for Medicaid-covered school-based treatment management services listed in the IEP
North Carolina
Medicaid Services
Provided in Schools
Early and Periodic Screening Diagnostic and Treatment (EPSDT) services
Evaluation services (with required written report)cognitive emotional personality adaptive behavior behavior and
perceptual or visual motor
Treatment services may include one or more of the following therapies cognitive-behavioral therapy rational-emotive therapy family
therapy individual interactive psychotherapy using play equipment (et al) sensory integrative therapy
As of January 2019 State Plan Amendment approval
Medicaid Managed Care
Administrative Burden
Anecdotally only the most well-resourced school districts may have the bandwidth to manage this effectively
May be easier to partner with a community provider
District duties
Perform outreach to potentially
Medicaid-eligible students
Assist students with applying for
Medicaid coverage
Assist with re-certifying eligibility
Administrative billing
Know statersquos benefit package (incl
optional benefits)
Track MMC plansrsquo coverage terms
Manage MMC plansrsquo cost containment
tools (eg prior authorization)
Negotiate rates with MMC plans
Monitor MMC plansrsquo provider networks
Avoid confusing rulesprocesses
across multiple MMC plans in area
Track which services are reimbursable
when delivered on school grounds
If Medicaid will pay for SBMH services the following
criteria must be met
Key Takeaways
1) Child is enrolled in Medicaid
2) Service is a covered service
3) Provider is an eligible provider
4) Setting is an accepted setting
Medicaid Managed Care can complicate these matters
in some key ways
Prior authorization other cost containment tools
Provider network management
Separate administration of behavioral health benefits
Identify measure and act on key ldquopressure pointsrdquo in
your states
Key Takeaways ctd
Interviews and survey data collection (state and local)
Barriers and facilitators to leveraging Medicaid to finance
SBMH services and programs
Similar issues for other funding sources particularly
Dept of Education
Relative importance of funding sources
Forthcoming webinars to present findings (stay tuned)
Ongoing Activities at the
SE MHTTC
Thank you
Please contact me with questions
E-mail adamswilkemoryedu
Twitter adamswilk
httpsmhttcnetworkorgcenterssoutheast-mhttchome
References pt 1
Brooks T Roygardner L amp Artiga S 2019 Medicaid and CHIP Eligibility Enrollment and Cost Sharing Policies as of January 2019 Findings from a 50-State Survey Henry J Kaiser Family Foundation
CMS (Centers for Medicare amp Medicaid Services) 2014 Letter from Cindy Mann to state Medicaid directors regarding Medicaid payment for services provided without charge (free care)rdquo December 15 2014 Baltimore MD CMS httpswwwmedicaidgovfederal-policy-guidancedownloadssmd-medicaid-payment-forservices-provided-without-charge-free-carepdf
CMS ldquoManaged Carerdquo httpswwwmedicaidgovmedicaidmanaged-careindexhtml
Chester A and Wright Burak E Fact Sheet Medicaidrsquos Role for Young Children Georgetown University Health Policy Institute Center for Children and Families 13 Dec 2016 httpsccfgeorgetownedu20161213fact-sheet-medicaids-role-for-young-children
Florida Agency for Health Care Administration httpsahcamyfloridacomMedicaidstatewide_mcpdfSMMC_Region_mappdf
Kaiser Family Foundation httpswwwkfforgmedicaidstate-indicatortotal-medicaid-mcoscurrentTimeframe=0ampsortModel=7B22colId2222Location2222sort2222asc227D
Kentucky Cabinet for Family Health and Family Services httpschfskygovagenciesdmsdpqomco-cmbPagesmco-optionsaspx
Ku L Steinmetz E and Bysshe T (2015) Continuity of Medicaid Coverage in an Era of Transition (Working Paper) Milken Institute of Public Health George Washington University
References pt 2
MACPAC (Medicaid and CHIP Payment and Access Commission) Behavioral Health Benefits httpswwwmacpacgovsubtopicbehavioral-health-benefits
MACPAC Issue Brief Medicaid in Schools Washington DC April 2018
MACPAC Section 3 Program enrollment and spendingmdashMedicaid managed care Washington DC December 2016
Mississippi Division of Medicaid httpsmedicaidmsgovprogramsmanaged-care SAMHSA (Substance Abuse and Mental Health Services Administration) Mental Health
Technology Transfer Center Network httpsmhttcnetworkorg
Tuck K amp Smith E ldquoBehavioral Health Coverage in Medicaid Managed Carerdquo Institute for Medicaid Innovation April 2019 httpswwwmedicaidinnovationorg_imagescontent2019-IMI-Behavioral_Health_in_Medicaid-Reportpdf
Urban Institute tabulations of 20132016 American Community Survey (ACS) data from the Integrated Public Use Microdata Series (IPUMS) from Jennifer Haley Genevieve Kenney Robin Wang Victoria Lynch and Matthew Buettgens MedicaidCHIP Participation Reached 937 Percent Among Eligible Children In 2016 The Urban Institute Washington DC August 2018
Wen H Wilk A S Druss B G amp Cummings J R 2019 Medicaid Acceptance by Psychiatrists Implications for Medicaid Expansion JAMA Psychiatry epub 5 Jun 2019
Medicaid is Key in School-based
Mental Health (SBMH) Financing
- Medicaid pays for Tier 2 (screening) and Tier 3
(treatment) SBMH services principally
As of 2016 nationwide nearly 93 of Medicaid-
enrolled children are enrolled in a Medicaid
Managed Care plan (and rising)
Medicaid is the largest payer for behavioral health
services in the US including SBMH services
Why The ldquoFree Care rulerdquo
changed in December 2014
Previously ldquoIf you bill Medicaid you have to bill
patients andor other payers toordquo
Many SBMH programs could not operate
New example starting August 2015 APEX program in
Georgia now in over 400 schools
States may need to file a State Plan Amendment or
pass legislation to leverage
When will Medicaid pay
for a service
SBMH services will be reimbursable through
Medicaid if the following criteria are met
1) Child is enrolled in Medicaid
2) Service is a covered service
3) Provider is an eligible provider
4) Setting is an accepted setting
1 Is the child enrolled in
Medicaid
Many children are not eligible for Medicaid
Many Medicaid-eligible children are not enrolled
Enrollment can fluctuate over time due to fluctuating eligibility or difficulty meeting administrative requirements
Medicaid allows for administrative billing including payment for outreach and enrollment support activities
PR
ES
SU
RE
PO
INT
S
A child must be enrolled in Medicaid in order for Medicaid to pay for the childrsquos SBMH care35 of kids age 6-18 are enrolled in Medicaid
Variation in Jan 2019 Income Eligibility
Levels in MedicaidCHIP of FPL
Note on eligibility redetermination indicates that beneficiaries in these states must
recertify every 6 months or more frequently (vs 12 months)
KY
TN
GA
SC
FL
MS AL
NC
200
255
199
196
225
199
201
146
Pregnant Women
KY
TN
GA
FL
MS AL
NC
218
255
214
215
252
213
216
317
SC
Children
MedicaidCHIP Child Participation Rates
StateParticipation Rate
2013
Participation Rate
2016
Alabama 916 963
Florida 850 930
Georgia 855 906
Kentucky 903 956
Mississippi 892 948
North Carolina 919 950
South Carolina 899 955
Tennessee 911 955
Participation Rate = ratio of MedicaidCHIP-eligible enrolled children
to MedicaidCHIP-eligible enrolled children plus MedicaidCHIP-
eligible uninsured children
Continuity of Coverage in Medicaid
StateContinuity Ratio
(All)
Continuity Ratio
(Children)
Alabama 840 852
Florida 743 797
Georgia 763 792
Kentucky 792 830
Mississippi 814 830
North Carolina 802 855
South Carolina 819 821
Tennessee 831 872
The Continuity Ratio measures the portion of a year that an average
beneficiary is enrolled in Medicaid It is the ratio of the average of
Medicaid enrollees in a fiscal year divided by the unduplicated of
annual enrollees
2 Is the service
covered by Medicaid
While all Medicaid programs cover mental health services in general different Medicaid programs make different decisions about which specific services will be covered and under what circumstances
Mandatory benefits inpatient and outpatient hospital care physician visits rural health clinic services etc
Optional benefits prescription drugs targeted case management licensed clinical social work services etc
PR
ES
SU
RE
PO
INT
Pressure Point Medicaid Managed
Care (MMC) Plans Cover Services
on Their Own Terms
Across plans variation in terms of coverage for key SBMH services
Examples psychotherapy services and assessment
1 Initial services may be covered with referral sometimes requiring prior authorization
2 Covered up until a fixed benefit ldquocaprdquo
3 Coverage may be extended above the cap if the provider obtains re-authorization
Plans may give little notice before making changes to coverage terms
Example Preferred Drug List
Pressure Point Multiple Medicaid
Managed Care (MMC) Plans To
Work With
Typically multiple MMC plans serve the same
(child) population
SE region (8 states) 2-17 plans statewide
Some states (eg FL MI TX) contract with MMC plans
separately for distinct geographic service areas
o SE region 20 ndash 57 plans per service area
Multiple sets of MMC plan
coverage terms to manage
Pressure Point Multiple Medicaid
Managed Care (MMC) Plans To
Work With (Part 2)
1 MMC plans may subcontract with specialized BH managed care companies
o 30-50 of MMC plans (esp larger)
2 State-level BH (andor Rx) ldquocarve-outsrdquo
o 11 statesrsquo Medicaid programs with a BH carve-out as of 2017
ldquoLeadrdquo MMC Plans may not administer behavioral health (BH) benefits directly ndash two main reasons
ldquoEXTRArdquo sets of MMC plan
coverage terms to manage
3 Is the provider an eligible
provider +Providers must be credentialed (ie determined to be in good
professional standing) and approved by Medicaid before their claims
will be reimbursable
Major shortages of all behavioral health providers
o Compounded by misallocation of staff
o Therapist shortage has upstream impact on screening
providers report currently accepting any Medicaid patients
Some services may only be covered when provided by certain provider types (eg licensed clinical social worker vs non-clinical)P
RE
SS
UR
E P
OIN
TS
EPSDT is
underleveraged
Pressure Point Medicaid Managed
Care (MMC) Plans Form Provider
Networks
MMC plans (like commercial insurers)hellip
bull Negotiate fee schedules
Do not use standard Medicaid fee schedule
bull Make determinations on network inclusion (or exclusion)
Not all providers who ldquoaccept Medicaid patientsrdquo are in-network for a given MMC plan
Plansrsquo member handbooks (including lists of in-network providers) may be out of date
Pressure Point Multiple Medicaid
Managed Care (MMC) Plans To
Work With (Part 3)
Typically multiple MMC plans serve the same
(child) population
May complicate
bull Rate negotiations (if employing or
contracting with providers)
bull Provider network management
(eg for referrals)
ldquoLeadrdquo MMC Plans may not administer behavioral health (BH) benefits directly
4 Is the care setting
acceptable
Medicaid programs set rules that govern whether a covered service will be reimbursable only if provided in a program-approved setting
Outpatient (non-school-based) clinics generally an acceptable setting
School mental health programs often facilitate transportation tofrom outpatient clinics
Schools may be an accepted care setting for some services in some states but not others
IDEA ndash Schools may submit claims to Medicaid for Medicaid-covered school-based treatment management services listed in the IEP
North Carolina
Medicaid Services
Provided in Schools
Early and Periodic Screening Diagnostic and Treatment (EPSDT) services
Evaluation services (with required written report)cognitive emotional personality adaptive behavior behavior and
perceptual or visual motor
Treatment services may include one or more of the following therapies cognitive-behavioral therapy rational-emotive therapy family
therapy individual interactive psychotherapy using play equipment (et al) sensory integrative therapy
As of January 2019 State Plan Amendment approval
Medicaid Managed Care
Administrative Burden
Anecdotally only the most well-resourced school districts may have the bandwidth to manage this effectively
May be easier to partner with a community provider
District duties
Perform outreach to potentially
Medicaid-eligible students
Assist students with applying for
Medicaid coverage
Assist with re-certifying eligibility
Administrative billing
Know statersquos benefit package (incl
optional benefits)
Track MMC plansrsquo coverage terms
Manage MMC plansrsquo cost containment
tools (eg prior authorization)
Negotiate rates with MMC plans
Monitor MMC plansrsquo provider networks
Avoid confusing rulesprocesses
across multiple MMC plans in area
Track which services are reimbursable
when delivered on school grounds
If Medicaid will pay for SBMH services the following
criteria must be met
Key Takeaways
1) Child is enrolled in Medicaid
2) Service is a covered service
3) Provider is an eligible provider
4) Setting is an accepted setting
Medicaid Managed Care can complicate these matters
in some key ways
Prior authorization other cost containment tools
Provider network management
Separate administration of behavioral health benefits
Identify measure and act on key ldquopressure pointsrdquo in
your states
Key Takeaways ctd
Interviews and survey data collection (state and local)
Barriers and facilitators to leveraging Medicaid to finance
SBMH services and programs
Similar issues for other funding sources particularly
Dept of Education
Relative importance of funding sources
Forthcoming webinars to present findings (stay tuned)
Ongoing Activities at the
SE MHTTC
Thank you
Please contact me with questions
E-mail adamswilkemoryedu
Twitter adamswilk
httpsmhttcnetworkorgcenterssoutheast-mhttchome
References pt 1
Brooks T Roygardner L amp Artiga S 2019 Medicaid and CHIP Eligibility Enrollment and Cost Sharing Policies as of January 2019 Findings from a 50-State Survey Henry J Kaiser Family Foundation
CMS (Centers for Medicare amp Medicaid Services) 2014 Letter from Cindy Mann to state Medicaid directors regarding Medicaid payment for services provided without charge (free care)rdquo December 15 2014 Baltimore MD CMS httpswwwmedicaidgovfederal-policy-guidancedownloadssmd-medicaid-payment-forservices-provided-without-charge-free-carepdf
CMS ldquoManaged Carerdquo httpswwwmedicaidgovmedicaidmanaged-careindexhtml
Chester A and Wright Burak E Fact Sheet Medicaidrsquos Role for Young Children Georgetown University Health Policy Institute Center for Children and Families 13 Dec 2016 httpsccfgeorgetownedu20161213fact-sheet-medicaids-role-for-young-children
Florida Agency for Health Care Administration httpsahcamyfloridacomMedicaidstatewide_mcpdfSMMC_Region_mappdf
Kaiser Family Foundation httpswwwkfforgmedicaidstate-indicatortotal-medicaid-mcoscurrentTimeframe=0ampsortModel=7B22colId2222Location2222sort2222asc227D
Kentucky Cabinet for Family Health and Family Services httpschfskygovagenciesdmsdpqomco-cmbPagesmco-optionsaspx
Ku L Steinmetz E and Bysshe T (2015) Continuity of Medicaid Coverage in an Era of Transition (Working Paper) Milken Institute of Public Health George Washington University
References pt 2
MACPAC (Medicaid and CHIP Payment and Access Commission) Behavioral Health Benefits httpswwwmacpacgovsubtopicbehavioral-health-benefits
MACPAC Issue Brief Medicaid in Schools Washington DC April 2018
MACPAC Section 3 Program enrollment and spendingmdashMedicaid managed care Washington DC December 2016
Mississippi Division of Medicaid httpsmedicaidmsgovprogramsmanaged-care SAMHSA (Substance Abuse and Mental Health Services Administration) Mental Health
Technology Transfer Center Network httpsmhttcnetworkorg
Tuck K amp Smith E ldquoBehavioral Health Coverage in Medicaid Managed Carerdquo Institute for Medicaid Innovation April 2019 httpswwwmedicaidinnovationorg_imagescontent2019-IMI-Behavioral_Health_in_Medicaid-Reportpdf
Urban Institute tabulations of 20132016 American Community Survey (ACS) data from the Integrated Public Use Microdata Series (IPUMS) from Jennifer Haley Genevieve Kenney Robin Wang Victoria Lynch and Matthew Buettgens MedicaidCHIP Participation Reached 937 Percent Among Eligible Children In 2016 The Urban Institute Washington DC August 2018
Wen H Wilk A S Druss B G amp Cummings J R 2019 Medicaid Acceptance by Psychiatrists Implications for Medicaid Expansion JAMA Psychiatry epub 5 Jun 2019
Why The ldquoFree Care rulerdquo
changed in December 2014
Previously ldquoIf you bill Medicaid you have to bill
patients andor other payers toordquo
Many SBMH programs could not operate
New example starting August 2015 APEX program in
Georgia now in over 400 schools
States may need to file a State Plan Amendment or
pass legislation to leverage
When will Medicaid pay
for a service
SBMH services will be reimbursable through
Medicaid if the following criteria are met
1) Child is enrolled in Medicaid
2) Service is a covered service
3) Provider is an eligible provider
4) Setting is an accepted setting
1 Is the child enrolled in
Medicaid
Many children are not eligible for Medicaid
Many Medicaid-eligible children are not enrolled
Enrollment can fluctuate over time due to fluctuating eligibility or difficulty meeting administrative requirements
Medicaid allows for administrative billing including payment for outreach and enrollment support activities
PR
ES
SU
RE
PO
INT
S
A child must be enrolled in Medicaid in order for Medicaid to pay for the childrsquos SBMH care35 of kids age 6-18 are enrolled in Medicaid
Variation in Jan 2019 Income Eligibility
Levels in MedicaidCHIP of FPL
Note on eligibility redetermination indicates that beneficiaries in these states must
recertify every 6 months or more frequently (vs 12 months)
KY
TN
GA
SC
FL
MS AL
NC
200
255
199
196
225
199
201
146
Pregnant Women
KY
TN
GA
FL
MS AL
NC
218
255
214
215
252
213
216
317
SC
Children
MedicaidCHIP Child Participation Rates
StateParticipation Rate
2013
Participation Rate
2016
Alabama 916 963
Florida 850 930
Georgia 855 906
Kentucky 903 956
Mississippi 892 948
North Carolina 919 950
South Carolina 899 955
Tennessee 911 955
Participation Rate = ratio of MedicaidCHIP-eligible enrolled children
to MedicaidCHIP-eligible enrolled children plus MedicaidCHIP-
eligible uninsured children
Continuity of Coverage in Medicaid
StateContinuity Ratio
(All)
Continuity Ratio
(Children)
Alabama 840 852
Florida 743 797
Georgia 763 792
Kentucky 792 830
Mississippi 814 830
North Carolina 802 855
South Carolina 819 821
Tennessee 831 872
The Continuity Ratio measures the portion of a year that an average
beneficiary is enrolled in Medicaid It is the ratio of the average of
Medicaid enrollees in a fiscal year divided by the unduplicated of
annual enrollees
2 Is the service
covered by Medicaid
While all Medicaid programs cover mental health services in general different Medicaid programs make different decisions about which specific services will be covered and under what circumstances
Mandatory benefits inpatient and outpatient hospital care physician visits rural health clinic services etc
Optional benefits prescription drugs targeted case management licensed clinical social work services etc
PR
ES
SU
RE
PO
INT
Pressure Point Medicaid Managed
Care (MMC) Plans Cover Services
on Their Own Terms
Across plans variation in terms of coverage for key SBMH services
Examples psychotherapy services and assessment
1 Initial services may be covered with referral sometimes requiring prior authorization
2 Covered up until a fixed benefit ldquocaprdquo
3 Coverage may be extended above the cap if the provider obtains re-authorization
Plans may give little notice before making changes to coverage terms
Example Preferred Drug List
Pressure Point Multiple Medicaid
Managed Care (MMC) Plans To
Work With
Typically multiple MMC plans serve the same
(child) population
SE region (8 states) 2-17 plans statewide
Some states (eg FL MI TX) contract with MMC plans
separately for distinct geographic service areas
o SE region 20 ndash 57 plans per service area
Multiple sets of MMC plan
coverage terms to manage
Pressure Point Multiple Medicaid
Managed Care (MMC) Plans To
Work With (Part 2)
1 MMC plans may subcontract with specialized BH managed care companies
o 30-50 of MMC plans (esp larger)
2 State-level BH (andor Rx) ldquocarve-outsrdquo
o 11 statesrsquo Medicaid programs with a BH carve-out as of 2017
ldquoLeadrdquo MMC Plans may not administer behavioral health (BH) benefits directly ndash two main reasons
ldquoEXTRArdquo sets of MMC plan
coverage terms to manage
3 Is the provider an eligible
provider +Providers must be credentialed (ie determined to be in good
professional standing) and approved by Medicaid before their claims
will be reimbursable
Major shortages of all behavioral health providers
o Compounded by misallocation of staff
o Therapist shortage has upstream impact on screening
providers report currently accepting any Medicaid patients
Some services may only be covered when provided by certain provider types (eg licensed clinical social worker vs non-clinical)P
RE
SS
UR
E P
OIN
TS
EPSDT is
underleveraged
Pressure Point Medicaid Managed
Care (MMC) Plans Form Provider
Networks
MMC plans (like commercial insurers)hellip
bull Negotiate fee schedules
Do not use standard Medicaid fee schedule
bull Make determinations on network inclusion (or exclusion)
Not all providers who ldquoaccept Medicaid patientsrdquo are in-network for a given MMC plan
Plansrsquo member handbooks (including lists of in-network providers) may be out of date
Pressure Point Multiple Medicaid
Managed Care (MMC) Plans To
Work With (Part 3)
Typically multiple MMC plans serve the same
(child) population
May complicate
bull Rate negotiations (if employing or
contracting with providers)
bull Provider network management
(eg for referrals)
ldquoLeadrdquo MMC Plans may not administer behavioral health (BH) benefits directly
4 Is the care setting
acceptable
Medicaid programs set rules that govern whether a covered service will be reimbursable only if provided in a program-approved setting
Outpatient (non-school-based) clinics generally an acceptable setting
School mental health programs often facilitate transportation tofrom outpatient clinics
Schools may be an accepted care setting for some services in some states but not others
IDEA ndash Schools may submit claims to Medicaid for Medicaid-covered school-based treatment management services listed in the IEP
North Carolina
Medicaid Services
Provided in Schools
Early and Periodic Screening Diagnostic and Treatment (EPSDT) services
Evaluation services (with required written report)cognitive emotional personality adaptive behavior behavior and
perceptual or visual motor
Treatment services may include one or more of the following therapies cognitive-behavioral therapy rational-emotive therapy family
therapy individual interactive psychotherapy using play equipment (et al) sensory integrative therapy
As of January 2019 State Plan Amendment approval
Medicaid Managed Care
Administrative Burden
Anecdotally only the most well-resourced school districts may have the bandwidth to manage this effectively
May be easier to partner with a community provider
District duties
Perform outreach to potentially
Medicaid-eligible students
Assist students with applying for
Medicaid coverage
Assist with re-certifying eligibility
Administrative billing
Know statersquos benefit package (incl
optional benefits)
Track MMC plansrsquo coverage terms
Manage MMC plansrsquo cost containment
tools (eg prior authorization)
Negotiate rates with MMC plans
Monitor MMC plansrsquo provider networks
Avoid confusing rulesprocesses
across multiple MMC plans in area
Track which services are reimbursable
when delivered on school grounds
If Medicaid will pay for SBMH services the following
criteria must be met
Key Takeaways
1) Child is enrolled in Medicaid
2) Service is a covered service
3) Provider is an eligible provider
4) Setting is an accepted setting
Medicaid Managed Care can complicate these matters
in some key ways
Prior authorization other cost containment tools
Provider network management
Separate administration of behavioral health benefits
Identify measure and act on key ldquopressure pointsrdquo in
your states
Key Takeaways ctd
Interviews and survey data collection (state and local)
Barriers and facilitators to leveraging Medicaid to finance
SBMH services and programs
Similar issues for other funding sources particularly
Dept of Education
Relative importance of funding sources
Forthcoming webinars to present findings (stay tuned)
Ongoing Activities at the
SE MHTTC
Thank you
Please contact me with questions
E-mail adamswilkemoryedu
Twitter adamswilk
httpsmhttcnetworkorgcenterssoutheast-mhttchome
References pt 1
Brooks T Roygardner L amp Artiga S 2019 Medicaid and CHIP Eligibility Enrollment and Cost Sharing Policies as of January 2019 Findings from a 50-State Survey Henry J Kaiser Family Foundation
CMS (Centers for Medicare amp Medicaid Services) 2014 Letter from Cindy Mann to state Medicaid directors regarding Medicaid payment for services provided without charge (free care)rdquo December 15 2014 Baltimore MD CMS httpswwwmedicaidgovfederal-policy-guidancedownloadssmd-medicaid-payment-forservices-provided-without-charge-free-carepdf
CMS ldquoManaged Carerdquo httpswwwmedicaidgovmedicaidmanaged-careindexhtml
Chester A and Wright Burak E Fact Sheet Medicaidrsquos Role for Young Children Georgetown University Health Policy Institute Center for Children and Families 13 Dec 2016 httpsccfgeorgetownedu20161213fact-sheet-medicaids-role-for-young-children
Florida Agency for Health Care Administration httpsahcamyfloridacomMedicaidstatewide_mcpdfSMMC_Region_mappdf
Kaiser Family Foundation httpswwwkfforgmedicaidstate-indicatortotal-medicaid-mcoscurrentTimeframe=0ampsortModel=7B22colId2222Location2222sort2222asc227D
Kentucky Cabinet for Family Health and Family Services httpschfskygovagenciesdmsdpqomco-cmbPagesmco-optionsaspx
Ku L Steinmetz E and Bysshe T (2015) Continuity of Medicaid Coverage in an Era of Transition (Working Paper) Milken Institute of Public Health George Washington University
References pt 2
MACPAC (Medicaid and CHIP Payment and Access Commission) Behavioral Health Benefits httpswwwmacpacgovsubtopicbehavioral-health-benefits
MACPAC Issue Brief Medicaid in Schools Washington DC April 2018
MACPAC Section 3 Program enrollment and spendingmdashMedicaid managed care Washington DC December 2016
Mississippi Division of Medicaid httpsmedicaidmsgovprogramsmanaged-care SAMHSA (Substance Abuse and Mental Health Services Administration) Mental Health
Technology Transfer Center Network httpsmhttcnetworkorg
Tuck K amp Smith E ldquoBehavioral Health Coverage in Medicaid Managed Carerdquo Institute for Medicaid Innovation April 2019 httpswwwmedicaidinnovationorg_imagescontent2019-IMI-Behavioral_Health_in_Medicaid-Reportpdf
Urban Institute tabulations of 20132016 American Community Survey (ACS) data from the Integrated Public Use Microdata Series (IPUMS) from Jennifer Haley Genevieve Kenney Robin Wang Victoria Lynch and Matthew Buettgens MedicaidCHIP Participation Reached 937 Percent Among Eligible Children In 2016 The Urban Institute Washington DC August 2018
Wen H Wilk A S Druss B G amp Cummings J R 2019 Medicaid Acceptance by Psychiatrists Implications for Medicaid Expansion JAMA Psychiatry epub 5 Jun 2019
When will Medicaid pay
for a service
SBMH services will be reimbursable through
Medicaid if the following criteria are met
1) Child is enrolled in Medicaid
2) Service is a covered service
3) Provider is an eligible provider
4) Setting is an accepted setting
1 Is the child enrolled in
Medicaid
Many children are not eligible for Medicaid
Many Medicaid-eligible children are not enrolled
Enrollment can fluctuate over time due to fluctuating eligibility or difficulty meeting administrative requirements
Medicaid allows for administrative billing including payment for outreach and enrollment support activities
PR
ES
SU
RE
PO
INT
S
A child must be enrolled in Medicaid in order for Medicaid to pay for the childrsquos SBMH care35 of kids age 6-18 are enrolled in Medicaid
Variation in Jan 2019 Income Eligibility
Levels in MedicaidCHIP of FPL
Note on eligibility redetermination indicates that beneficiaries in these states must
recertify every 6 months or more frequently (vs 12 months)
KY
TN
GA
SC
FL
MS AL
NC
200
255
199
196
225
199
201
146
Pregnant Women
KY
TN
GA
FL
MS AL
NC
218
255
214
215
252
213
216
317
SC
Children
MedicaidCHIP Child Participation Rates
StateParticipation Rate
2013
Participation Rate
2016
Alabama 916 963
Florida 850 930
Georgia 855 906
Kentucky 903 956
Mississippi 892 948
North Carolina 919 950
South Carolina 899 955
Tennessee 911 955
Participation Rate = ratio of MedicaidCHIP-eligible enrolled children
to MedicaidCHIP-eligible enrolled children plus MedicaidCHIP-
eligible uninsured children
Continuity of Coverage in Medicaid
StateContinuity Ratio
(All)
Continuity Ratio
(Children)
Alabama 840 852
Florida 743 797
Georgia 763 792
Kentucky 792 830
Mississippi 814 830
North Carolina 802 855
South Carolina 819 821
Tennessee 831 872
The Continuity Ratio measures the portion of a year that an average
beneficiary is enrolled in Medicaid It is the ratio of the average of
Medicaid enrollees in a fiscal year divided by the unduplicated of
annual enrollees
2 Is the service
covered by Medicaid
While all Medicaid programs cover mental health services in general different Medicaid programs make different decisions about which specific services will be covered and under what circumstances
Mandatory benefits inpatient and outpatient hospital care physician visits rural health clinic services etc
Optional benefits prescription drugs targeted case management licensed clinical social work services etc
PR
ES
SU
RE
PO
INT
Pressure Point Medicaid Managed
Care (MMC) Plans Cover Services
on Their Own Terms
Across plans variation in terms of coverage for key SBMH services
Examples psychotherapy services and assessment
1 Initial services may be covered with referral sometimes requiring prior authorization
2 Covered up until a fixed benefit ldquocaprdquo
3 Coverage may be extended above the cap if the provider obtains re-authorization
Plans may give little notice before making changes to coverage terms
Example Preferred Drug List
Pressure Point Multiple Medicaid
Managed Care (MMC) Plans To
Work With
Typically multiple MMC plans serve the same
(child) population
SE region (8 states) 2-17 plans statewide
Some states (eg FL MI TX) contract with MMC plans
separately for distinct geographic service areas
o SE region 20 ndash 57 plans per service area
Multiple sets of MMC plan
coverage terms to manage
Pressure Point Multiple Medicaid
Managed Care (MMC) Plans To
Work With (Part 2)
1 MMC plans may subcontract with specialized BH managed care companies
o 30-50 of MMC plans (esp larger)
2 State-level BH (andor Rx) ldquocarve-outsrdquo
o 11 statesrsquo Medicaid programs with a BH carve-out as of 2017
ldquoLeadrdquo MMC Plans may not administer behavioral health (BH) benefits directly ndash two main reasons
ldquoEXTRArdquo sets of MMC plan
coverage terms to manage
3 Is the provider an eligible
provider +Providers must be credentialed (ie determined to be in good
professional standing) and approved by Medicaid before their claims
will be reimbursable
Major shortages of all behavioral health providers
o Compounded by misallocation of staff
o Therapist shortage has upstream impact on screening
providers report currently accepting any Medicaid patients
Some services may only be covered when provided by certain provider types (eg licensed clinical social worker vs non-clinical)P
RE
SS
UR
E P
OIN
TS
EPSDT is
underleveraged
Pressure Point Medicaid Managed
Care (MMC) Plans Form Provider
Networks
MMC plans (like commercial insurers)hellip
bull Negotiate fee schedules
Do not use standard Medicaid fee schedule
bull Make determinations on network inclusion (or exclusion)
Not all providers who ldquoaccept Medicaid patientsrdquo are in-network for a given MMC plan
Plansrsquo member handbooks (including lists of in-network providers) may be out of date
Pressure Point Multiple Medicaid
Managed Care (MMC) Plans To
Work With (Part 3)
Typically multiple MMC plans serve the same
(child) population
May complicate
bull Rate negotiations (if employing or
contracting with providers)
bull Provider network management
(eg for referrals)
ldquoLeadrdquo MMC Plans may not administer behavioral health (BH) benefits directly
4 Is the care setting
acceptable
Medicaid programs set rules that govern whether a covered service will be reimbursable only if provided in a program-approved setting
Outpatient (non-school-based) clinics generally an acceptable setting
School mental health programs often facilitate transportation tofrom outpatient clinics
Schools may be an accepted care setting for some services in some states but not others
IDEA ndash Schools may submit claims to Medicaid for Medicaid-covered school-based treatment management services listed in the IEP
North Carolina
Medicaid Services
Provided in Schools
Early and Periodic Screening Diagnostic and Treatment (EPSDT) services
Evaluation services (with required written report)cognitive emotional personality adaptive behavior behavior and
perceptual or visual motor
Treatment services may include one or more of the following therapies cognitive-behavioral therapy rational-emotive therapy family
therapy individual interactive psychotherapy using play equipment (et al) sensory integrative therapy
As of January 2019 State Plan Amendment approval
Medicaid Managed Care
Administrative Burden
Anecdotally only the most well-resourced school districts may have the bandwidth to manage this effectively
May be easier to partner with a community provider
District duties
Perform outreach to potentially
Medicaid-eligible students
Assist students with applying for
Medicaid coverage
Assist with re-certifying eligibility
Administrative billing
Know statersquos benefit package (incl
optional benefits)
Track MMC plansrsquo coverage terms
Manage MMC plansrsquo cost containment
tools (eg prior authorization)
Negotiate rates with MMC plans
Monitor MMC plansrsquo provider networks
Avoid confusing rulesprocesses
across multiple MMC plans in area
Track which services are reimbursable
when delivered on school grounds
If Medicaid will pay for SBMH services the following
criteria must be met
Key Takeaways
1) Child is enrolled in Medicaid
2) Service is a covered service
3) Provider is an eligible provider
4) Setting is an accepted setting
Medicaid Managed Care can complicate these matters
in some key ways
Prior authorization other cost containment tools
Provider network management
Separate administration of behavioral health benefits
Identify measure and act on key ldquopressure pointsrdquo in
your states
Key Takeaways ctd
Interviews and survey data collection (state and local)
Barriers and facilitators to leveraging Medicaid to finance
SBMH services and programs
Similar issues for other funding sources particularly
Dept of Education
Relative importance of funding sources
Forthcoming webinars to present findings (stay tuned)
Ongoing Activities at the
SE MHTTC
Thank you
Please contact me with questions
E-mail adamswilkemoryedu
Twitter adamswilk
httpsmhttcnetworkorgcenterssoutheast-mhttchome
References pt 1
Brooks T Roygardner L amp Artiga S 2019 Medicaid and CHIP Eligibility Enrollment and Cost Sharing Policies as of January 2019 Findings from a 50-State Survey Henry J Kaiser Family Foundation
CMS (Centers for Medicare amp Medicaid Services) 2014 Letter from Cindy Mann to state Medicaid directors regarding Medicaid payment for services provided without charge (free care)rdquo December 15 2014 Baltimore MD CMS httpswwwmedicaidgovfederal-policy-guidancedownloadssmd-medicaid-payment-forservices-provided-without-charge-free-carepdf
CMS ldquoManaged Carerdquo httpswwwmedicaidgovmedicaidmanaged-careindexhtml
Chester A and Wright Burak E Fact Sheet Medicaidrsquos Role for Young Children Georgetown University Health Policy Institute Center for Children and Families 13 Dec 2016 httpsccfgeorgetownedu20161213fact-sheet-medicaids-role-for-young-children
Florida Agency for Health Care Administration httpsahcamyfloridacomMedicaidstatewide_mcpdfSMMC_Region_mappdf
Kaiser Family Foundation httpswwwkfforgmedicaidstate-indicatortotal-medicaid-mcoscurrentTimeframe=0ampsortModel=7B22colId2222Location2222sort2222asc227D
Kentucky Cabinet for Family Health and Family Services httpschfskygovagenciesdmsdpqomco-cmbPagesmco-optionsaspx
Ku L Steinmetz E and Bysshe T (2015) Continuity of Medicaid Coverage in an Era of Transition (Working Paper) Milken Institute of Public Health George Washington University
References pt 2
MACPAC (Medicaid and CHIP Payment and Access Commission) Behavioral Health Benefits httpswwwmacpacgovsubtopicbehavioral-health-benefits
MACPAC Issue Brief Medicaid in Schools Washington DC April 2018
MACPAC Section 3 Program enrollment and spendingmdashMedicaid managed care Washington DC December 2016
Mississippi Division of Medicaid httpsmedicaidmsgovprogramsmanaged-care SAMHSA (Substance Abuse and Mental Health Services Administration) Mental Health
Technology Transfer Center Network httpsmhttcnetworkorg
Tuck K amp Smith E ldquoBehavioral Health Coverage in Medicaid Managed Carerdquo Institute for Medicaid Innovation April 2019 httpswwwmedicaidinnovationorg_imagescontent2019-IMI-Behavioral_Health_in_Medicaid-Reportpdf
Urban Institute tabulations of 20132016 American Community Survey (ACS) data from the Integrated Public Use Microdata Series (IPUMS) from Jennifer Haley Genevieve Kenney Robin Wang Victoria Lynch and Matthew Buettgens MedicaidCHIP Participation Reached 937 Percent Among Eligible Children In 2016 The Urban Institute Washington DC August 2018
Wen H Wilk A S Druss B G amp Cummings J R 2019 Medicaid Acceptance by Psychiatrists Implications for Medicaid Expansion JAMA Psychiatry epub 5 Jun 2019
1 Is the child enrolled in
Medicaid
Many children are not eligible for Medicaid
Many Medicaid-eligible children are not enrolled
Enrollment can fluctuate over time due to fluctuating eligibility or difficulty meeting administrative requirements
Medicaid allows for administrative billing including payment for outreach and enrollment support activities
PR
ES
SU
RE
PO
INT
S
A child must be enrolled in Medicaid in order for Medicaid to pay for the childrsquos SBMH care35 of kids age 6-18 are enrolled in Medicaid
Variation in Jan 2019 Income Eligibility
Levels in MedicaidCHIP of FPL
Note on eligibility redetermination indicates that beneficiaries in these states must
recertify every 6 months or more frequently (vs 12 months)
KY
TN
GA
SC
FL
MS AL
NC
200
255
199
196
225
199
201
146
Pregnant Women
KY
TN
GA
FL
MS AL
NC
218
255
214
215
252
213
216
317
SC
Children
MedicaidCHIP Child Participation Rates
StateParticipation Rate
2013
Participation Rate
2016
Alabama 916 963
Florida 850 930
Georgia 855 906
Kentucky 903 956
Mississippi 892 948
North Carolina 919 950
South Carolina 899 955
Tennessee 911 955
Participation Rate = ratio of MedicaidCHIP-eligible enrolled children
to MedicaidCHIP-eligible enrolled children plus MedicaidCHIP-
eligible uninsured children
Continuity of Coverage in Medicaid
StateContinuity Ratio
(All)
Continuity Ratio
(Children)
Alabama 840 852
Florida 743 797
Georgia 763 792
Kentucky 792 830
Mississippi 814 830
North Carolina 802 855
South Carolina 819 821
Tennessee 831 872
The Continuity Ratio measures the portion of a year that an average
beneficiary is enrolled in Medicaid It is the ratio of the average of
Medicaid enrollees in a fiscal year divided by the unduplicated of
annual enrollees
2 Is the service
covered by Medicaid
While all Medicaid programs cover mental health services in general different Medicaid programs make different decisions about which specific services will be covered and under what circumstances
Mandatory benefits inpatient and outpatient hospital care physician visits rural health clinic services etc
Optional benefits prescription drugs targeted case management licensed clinical social work services etc
PR
ES
SU
RE
PO
INT
Pressure Point Medicaid Managed
Care (MMC) Plans Cover Services
on Their Own Terms
Across plans variation in terms of coverage for key SBMH services
Examples psychotherapy services and assessment
1 Initial services may be covered with referral sometimes requiring prior authorization
2 Covered up until a fixed benefit ldquocaprdquo
3 Coverage may be extended above the cap if the provider obtains re-authorization
Plans may give little notice before making changes to coverage terms
Example Preferred Drug List
Pressure Point Multiple Medicaid
Managed Care (MMC) Plans To
Work With
Typically multiple MMC plans serve the same
(child) population
SE region (8 states) 2-17 plans statewide
Some states (eg FL MI TX) contract with MMC plans
separately for distinct geographic service areas
o SE region 20 ndash 57 plans per service area
Multiple sets of MMC plan
coverage terms to manage
Pressure Point Multiple Medicaid
Managed Care (MMC) Plans To
Work With (Part 2)
1 MMC plans may subcontract with specialized BH managed care companies
o 30-50 of MMC plans (esp larger)
2 State-level BH (andor Rx) ldquocarve-outsrdquo
o 11 statesrsquo Medicaid programs with a BH carve-out as of 2017
ldquoLeadrdquo MMC Plans may not administer behavioral health (BH) benefits directly ndash two main reasons
ldquoEXTRArdquo sets of MMC plan
coverage terms to manage
3 Is the provider an eligible
provider +Providers must be credentialed (ie determined to be in good
professional standing) and approved by Medicaid before their claims
will be reimbursable
Major shortages of all behavioral health providers
o Compounded by misallocation of staff
o Therapist shortage has upstream impact on screening
providers report currently accepting any Medicaid patients
Some services may only be covered when provided by certain provider types (eg licensed clinical social worker vs non-clinical)P
RE
SS
UR
E P
OIN
TS
EPSDT is
underleveraged
Pressure Point Medicaid Managed
Care (MMC) Plans Form Provider
Networks
MMC plans (like commercial insurers)hellip
bull Negotiate fee schedules
Do not use standard Medicaid fee schedule
bull Make determinations on network inclusion (or exclusion)
Not all providers who ldquoaccept Medicaid patientsrdquo are in-network for a given MMC plan
Plansrsquo member handbooks (including lists of in-network providers) may be out of date
Pressure Point Multiple Medicaid
Managed Care (MMC) Plans To
Work With (Part 3)
Typically multiple MMC plans serve the same
(child) population
May complicate
bull Rate negotiations (if employing or
contracting with providers)
bull Provider network management
(eg for referrals)
ldquoLeadrdquo MMC Plans may not administer behavioral health (BH) benefits directly
4 Is the care setting
acceptable
Medicaid programs set rules that govern whether a covered service will be reimbursable only if provided in a program-approved setting
Outpatient (non-school-based) clinics generally an acceptable setting
School mental health programs often facilitate transportation tofrom outpatient clinics
Schools may be an accepted care setting for some services in some states but not others
IDEA ndash Schools may submit claims to Medicaid for Medicaid-covered school-based treatment management services listed in the IEP
North Carolina
Medicaid Services
Provided in Schools
Early and Periodic Screening Diagnostic and Treatment (EPSDT) services
Evaluation services (with required written report)cognitive emotional personality adaptive behavior behavior and
perceptual or visual motor
Treatment services may include one or more of the following therapies cognitive-behavioral therapy rational-emotive therapy family
therapy individual interactive psychotherapy using play equipment (et al) sensory integrative therapy
As of January 2019 State Plan Amendment approval
Medicaid Managed Care
Administrative Burden
Anecdotally only the most well-resourced school districts may have the bandwidth to manage this effectively
May be easier to partner with a community provider
District duties
Perform outreach to potentially
Medicaid-eligible students
Assist students with applying for
Medicaid coverage
Assist with re-certifying eligibility
Administrative billing
Know statersquos benefit package (incl
optional benefits)
Track MMC plansrsquo coverage terms
Manage MMC plansrsquo cost containment
tools (eg prior authorization)
Negotiate rates with MMC plans
Monitor MMC plansrsquo provider networks
Avoid confusing rulesprocesses
across multiple MMC plans in area
Track which services are reimbursable
when delivered on school grounds
If Medicaid will pay for SBMH services the following
criteria must be met
Key Takeaways
1) Child is enrolled in Medicaid
2) Service is a covered service
3) Provider is an eligible provider
4) Setting is an accepted setting
Medicaid Managed Care can complicate these matters
in some key ways
Prior authorization other cost containment tools
Provider network management
Separate administration of behavioral health benefits
Identify measure and act on key ldquopressure pointsrdquo in
your states
Key Takeaways ctd
Interviews and survey data collection (state and local)
Barriers and facilitators to leveraging Medicaid to finance
SBMH services and programs
Similar issues for other funding sources particularly
Dept of Education
Relative importance of funding sources
Forthcoming webinars to present findings (stay tuned)
Ongoing Activities at the
SE MHTTC
Thank you
Please contact me with questions
E-mail adamswilkemoryedu
Twitter adamswilk
httpsmhttcnetworkorgcenterssoutheast-mhttchome
References pt 1
Brooks T Roygardner L amp Artiga S 2019 Medicaid and CHIP Eligibility Enrollment and Cost Sharing Policies as of January 2019 Findings from a 50-State Survey Henry J Kaiser Family Foundation
CMS (Centers for Medicare amp Medicaid Services) 2014 Letter from Cindy Mann to state Medicaid directors regarding Medicaid payment for services provided without charge (free care)rdquo December 15 2014 Baltimore MD CMS httpswwwmedicaidgovfederal-policy-guidancedownloadssmd-medicaid-payment-forservices-provided-without-charge-free-carepdf
CMS ldquoManaged Carerdquo httpswwwmedicaidgovmedicaidmanaged-careindexhtml
Chester A and Wright Burak E Fact Sheet Medicaidrsquos Role for Young Children Georgetown University Health Policy Institute Center for Children and Families 13 Dec 2016 httpsccfgeorgetownedu20161213fact-sheet-medicaids-role-for-young-children
Florida Agency for Health Care Administration httpsahcamyfloridacomMedicaidstatewide_mcpdfSMMC_Region_mappdf
Kaiser Family Foundation httpswwwkfforgmedicaidstate-indicatortotal-medicaid-mcoscurrentTimeframe=0ampsortModel=7B22colId2222Location2222sort2222asc227D
Kentucky Cabinet for Family Health and Family Services httpschfskygovagenciesdmsdpqomco-cmbPagesmco-optionsaspx
Ku L Steinmetz E and Bysshe T (2015) Continuity of Medicaid Coverage in an Era of Transition (Working Paper) Milken Institute of Public Health George Washington University
References pt 2
MACPAC (Medicaid and CHIP Payment and Access Commission) Behavioral Health Benefits httpswwwmacpacgovsubtopicbehavioral-health-benefits
MACPAC Issue Brief Medicaid in Schools Washington DC April 2018
MACPAC Section 3 Program enrollment and spendingmdashMedicaid managed care Washington DC December 2016
Mississippi Division of Medicaid httpsmedicaidmsgovprogramsmanaged-care SAMHSA (Substance Abuse and Mental Health Services Administration) Mental Health
Technology Transfer Center Network httpsmhttcnetworkorg
Tuck K amp Smith E ldquoBehavioral Health Coverage in Medicaid Managed Carerdquo Institute for Medicaid Innovation April 2019 httpswwwmedicaidinnovationorg_imagescontent2019-IMI-Behavioral_Health_in_Medicaid-Reportpdf
Urban Institute tabulations of 20132016 American Community Survey (ACS) data from the Integrated Public Use Microdata Series (IPUMS) from Jennifer Haley Genevieve Kenney Robin Wang Victoria Lynch and Matthew Buettgens MedicaidCHIP Participation Reached 937 Percent Among Eligible Children In 2016 The Urban Institute Washington DC August 2018
Wen H Wilk A S Druss B G amp Cummings J R 2019 Medicaid Acceptance by Psychiatrists Implications for Medicaid Expansion JAMA Psychiatry epub 5 Jun 2019
Variation in Jan 2019 Income Eligibility
Levels in MedicaidCHIP of FPL
Note on eligibility redetermination indicates that beneficiaries in these states must
recertify every 6 months or more frequently (vs 12 months)
KY
TN
GA
SC
FL
MS AL
NC
200
255
199
196
225
199
201
146
Pregnant Women
KY
TN
GA
FL
MS AL
NC
218
255
214
215
252
213
216
317
SC
Children
MedicaidCHIP Child Participation Rates
StateParticipation Rate
2013
Participation Rate
2016
Alabama 916 963
Florida 850 930
Georgia 855 906
Kentucky 903 956
Mississippi 892 948
North Carolina 919 950
South Carolina 899 955
Tennessee 911 955
Participation Rate = ratio of MedicaidCHIP-eligible enrolled children
to MedicaidCHIP-eligible enrolled children plus MedicaidCHIP-
eligible uninsured children
Continuity of Coverage in Medicaid
StateContinuity Ratio
(All)
Continuity Ratio
(Children)
Alabama 840 852
Florida 743 797
Georgia 763 792
Kentucky 792 830
Mississippi 814 830
North Carolina 802 855
South Carolina 819 821
Tennessee 831 872
The Continuity Ratio measures the portion of a year that an average
beneficiary is enrolled in Medicaid It is the ratio of the average of
Medicaid enrollees in a fiscal year divided by the unduplicated of
annual enrollees
2 Is the service
covered by Medicaid
While all Medicaid programs cover mental health services in general different Medicaid programs make different decisions about which specific services will be covered and under what circumstances
Mandatory benefits inpatient and outpatient hospital care physician visits rural health clinic services etc
Optional benefits prescription drugs targeted case management licensed clinical social work services etc
PR
ES
SU
RE
PO
INT
Pressure Point Medicaid Managed
Care (MMC) Plans Cover Services
on Their Own Terms
Across plans variation in terms of coverage for key SBMH services
Examples psychotherapy services and assessment
1 Initial services may be covered with referral sometimes requiring prior authorization
2 Covered up until a fixed benefit ldquocaprdquo
3 Coverage may be extended above the cap if the provider obtains re-authorization
Plans may give little notice before making changes to coverage terms
Example Preferred Drug List
Pressure Point Multiple Medicaid
Managed Care (MMC) Plans To
Work With
Typically multiple MMC plans serve the same
(child) population
SE region (8 states) 2-17 plans statewide
Some states (eg FL MI TX) contract with MMC plans
separately for distinct geographic service areas
o SE region 20 ndash 57 plans per service area
Multiple sets of MMC plan
coverage terms to manage
Pressure Point Multiple Medicaid
Managed Care (MMC) Plans To
Work With (Part 2)
1 MMC plans may subcontract with specialized BH managed care companies
o 30-50 of MMC plans (esp larger)
2 State-level BH (andor Rx) ldquocarve-outsrdquo
o 11 statesrsquo Medicaid programs with a BH carve-out as of 2017
ldquoLeadrdquo MMC Plans may not administer behavioral health (BH) benefits directly ndash two main reasons
ldquoEXTRArdquo sets of MMC plan
coverage terms to manage
3 Is the provider an eligible
provider +Providers must be credentialed (ie determined to be in good
professional standing) and approved by Medicaid before their claims
will be reimbursable
Major shortages of all behavioral health providers
o Compounded by misallocation of staff
o Therapist shortage has upstream impact on screening
providers report currently accepting any Medicaid patients
Some services may only be covered when provided by certain provider types (eg licensed clinical social worker vs non-clinical)P
RE
SS
UR
E P
OIN
TS
EPSDT is
underleveraged
Pressure Point Medicaid Managed
Care (MMC) Plans Form Provider
Networks
MMC plans (like commercial insurers)hellip
bull Negotiate fee schedules
Do not use standard Medicaid fee schedule
bull Make determinations on network inclusion (or exclusion)
Not all providers who ldquoaccept Medicaid patientsrdquo are in-network for a given MMC plan
Plansrsquo member handbooks (including lists of in-network providers) may be out of date
Pressure Point Multiple Medicaid
Managed Care (MMC) Plans To
Work With (Part 3)
Typically multiple MMC plans serve the same
(child) population
May complicate
bull Rate negotiations (if employing or
contracting with providers)
bull Provider network management
(eg for referrals)
ldquoLeadrdquo MMC Plans may not administer behavioral health (BH) benefits directly
4 Is the care setting
acceptable
Medicaid programs set rules that govern whether a covered service will be reimbursable only if provided in a program-approved setting
Outpatient (non-school-based) clinics generally an acceptable setting
School mental health programs often facilitate transportation tofrom outpatient clinics
Schools may be an accepted care setting for some services in some states but not others
IDEA ndash Schools may submit claims to Medicaid for Medicaid-covered school-based treatment management services listed in the IEP
North Carolina
Medicaid Services
Provided in Schools
Early and Periodic Screening Diagnostic and Treatment (EPSDT) services
Evaluation services (with required written report)cognitive emotional personality adaptive behavior behavior and
perceptual or visual motor
Treatment services may include one or more of the following therapies cognitive-behavioral therapy rational-emotive therapy family
therapy individual interactive psychotherapy using play equipment (et al) sensory integrative therapy
As of January 2019 State Plan Amendment approval
Medicaid Managed Care
Administrative Burden
Anecdotally only the most well-resourced school districts may have the bandwidth to manage this effectively
May be easier to partner with a community provider
District duties
Perform outreach to potentially
Medicaid-eligible students
Assist students with applying for
Medicaid coverage
Assist with re-certifying eligibility
Administrative billing
Know statersquos benefit package (incl
optional benefits)
Track MMC plansrsquo coverage terms
Manage MMC plansrsquo cost containment
tools (eg prior authorization)
Negotiate rates with MMC plans
Monitor MMC plansrsquo provider networks
Avoid confusing rulesprocesses
across multiple MMC plans in area
Track which services are reimbursable
when delivered on school grounds
If Medicaid will pay for SBMH services the following
criteria must be met
Key Takeaways
1) Child is enrolled in Medicaid
2) Service is a covered service
3) Provider is an eligible provider
4) Setting is an accepted setting
Medicaid Managed Care can complicate these matters
in some key ways
Prior authorization other cost containment tools
Provider network management
Separate administration of behavioral health benefits
Identify measure and act on key ldquopressure pointsrdquo in
your states
Key Takeaways ctd
Interviews and survey data collection (state and local)
Barriers and facilitators to leveraging Medicaid to finance
SBMH services and programs
Similar issues for other funding sources particularly
Dept of Education
Relative importance of funding sources
Forthcoming webinars to present findings (stay tuned)
Ongoing Activities at the
SE MHTTC
Thank you
Please contact me with questions
E-mail adamswilkemoryedu
Twitter adamswilk
httpsmhttcnetworkorgcenterssoutheast-mhttchome
References pt 1
Brooks T Roygardner L amp Artiga S 2019 Medicaid and CHIP Eligibility Enrollment and Cost Sharing Policies as of January 2019 Findings from a 50-State Survey Henry J Kaiser Family Foundation
CMS (Centers for Medicare amp Medicaid Services) 2014 Letter from Cindy Mann to state Medicaid directors regarding Medicaid payment for services provided without charge (free care)rdquo December 15 2014 Baltimore MD CMS httpswwwmedicaidgovfederal-policy-guidancedownloadssmd-medicaid-payment-forservices-provided-without-charge-free-carepdf
CMS ldquoManaged Carerdquo httpswwwmedicaidgovmedicaidmanaged-careindexhtml
Chester A and Wright Burak E Fact Sheet Medicaidrsquos Role for Young Children Georgetown University Health Policy Institute Center for Children and Families 13 Dec 2016 httpsccfgeorgetownedu20161213fact-sheet-medicaids-role-for-young-children
Florida Agency for Health Care Administration httpsahcamyfloridacomMedicaidstatewide_mcpdfSMMC_Region_mappdf
Kaiser Family Foundation httpswwwkfforgmedicaidstate-indicatortotal-medicaid-mcoscurrentTimeframe=0ampsortModel=7B22colId2222Location2222sort2222asc227D
Kentucky Cabinet for Family Health and Family Services httpschfskygovagenciesdmsdpqomco-cmbPagesmco-optionsaspx
Ku L Steinmetz E and Bysshe T (2015) Continuity of Medicaid Coverage in an Era of Transition (Working Paper) Milken Institute of Public Health George Washington University
References pt 2
MACPAC (Medicaid and CHIP Payment and Access Commission) Behavioral Health Benefits httpswwwmacpacgovsubtopicbehavioral-health-benefits
MACPAC Issue Brief Medicaid in Schools Washington DC April 2018
MACPAC Section 3 Program enrollment and spendingmdashMedicaid managed care Washington DC December 2016
Mississippi Division of Medicaid httpsmedicaidmsgovprogramsmanaged-care SAMHSA (Substance Abuse and Mental Health Services Administration) Mental Health
Technology Transfer Center Network httpsmhttcnetworkorg
Tuck K amp Smith E ldquoBehavioral Health Coverage in Medicaid Managed Carerdquo Institute for Medicaid Innovation April 2019 httpswwwmedicaidinnovationorg_imagescontent2019-IMI-Behavioral_Health_in_Medicaid-Reportpdf
Urban Institute tabulations of 20132016 American Community Survey (ACS) data from the Integrated Public Use Microdata Series (IPUMS) from Jennifer Haley Genevieve Kenney Robin Wang Victoria Lynch and Matthew Buettgens MedicaidCHIP Participation Reached 937 Percent Among Eligible Children In 2016 The Urban Institute Washington DC August 2018
Wen H Wilk A S Druss B G amp Cummings J R 2019 Medicaid Acceptance by Psychiatrists Implications for Medicaid Expansion JAMA Psychiatry epub 5 Jun 2019
MedicaidCHIP Child Participation Rates
StateParticipation Rate
2013
Participation Rate
2016
Alabama 916 963
Florida 850 930
Georgia 855 906
Kentucky 903 956
Mississippi 892 948
North Carolina 919 950
South Carolina 899 955
Tennessee 911 955
Participation Rate = ratio of MedicaidCHIP-eligible enrolled children
to MedicaidCHIP-eligible enrolled children plus MedicaidCHIP-
eligible uninsured children
Continuity of Coverage in Medicaid
StateContinuity Ratio
(All)
Continuity Ratio
(Children)
Alabama 840 852
Florida 743 797
Georgia 763 792
Kentucky 792 830
Mississippi 814 830
North Carolina 802 855
South Carolina 819 821
Tennessee 831 872
The Continuity Ratio measures the portion of a year that an average
beneficiary is enrolled in Medicaid It is the ratio of the average of
Medicaid enrollees in a fiscal year divided by the unduplicated of
annual enrollees
2 Is the service
covered by Medicaid
While all Medicaid programs cover mental health services in general different Medicaid programs make different decisions about which specific services will be covered and under what circumstances
Mandatory benefits inpatient and outpatient hospital care physician visits rural health clinic services etc
Optional benefits prescription drugs targeted case management licensed clinical social work services etc
PR
ES
SU
RE
PO
INT
Pressure Point Medicaid Managed
Care (MMC) Plans Cover Services
on Their Own Terms
Across plans variation in terms of coverage for key SBMH services
Examples psychotherapy services and assessment
1 Initial services may be covered with referral sometimes requiring prior authorization
2 Covered up until a fixed benefit ldquocaprdquo
3 Coverage may be extended above the cap if the provider obtains re-authorization
Plans may give little notice before making changes to coverage terms
Example Preferred Drug List
Pressure Point Multiple Medicaid
Managed Care (MMC) Plans To
Work With
Typically multiple MMC plans serve the same
(child) population
SE region (8 states) 2-17 plans statewide
Some states (eg FL MI TX) contract with MMC plans
separately for distinct geographic service areas
o SE region 20 ndash 57 plans per service area
Multiple sets of MMC plan
coverage terms to manage
Pressure Point Multiple Medicaid
Managed Care (MMC) Plans To
Work With (Part 2)
1 MMC plans may subcontract with specialized BH managed care companies
o 30-50 of MMC plans (esp larger)
2 State-level BH (andor Rx) ldquocarve-outsrdquo
o 11 statesrsquo Medicaid programs with a BH carve-out as of 2017
ldquoLeadrdquo MMC Plans may not administer behavioral health (BH) benefits directly ndash two main reasons
ldquoEXTRArdquo sets of MMC plan
coverage terms to manage
3 Is the provider an eligible
provider +Providers must be credentialed (ie determined to be in good
professional standing) and approved by Medicaid before their claims
will be reimbursable
Major shortages of all behavioral health providers
o Compounded by misallocation of staff
o Therapist shortage has upstream impact on screening
providers report currently accepting any Medicaid patients
Some services may only be covered when provided by certain provider types (eg licensed clinical social worker vs non-clinical)P
RE
SS
UR
E P
OIN
TS
EPSDT is
underleveraged
Pressure Point Medicaid Managed
Care (MMC) Plans Form Provider
Networks
MMC plans (like commercial insurers)hellip
bull Negotiate fee schedules
Do not use standard Medicaid fee schedule
bull Make determinations on network inclusion (or exclusion)
Not all providers who ldquoaccept Medicaid patientsrdquo are in-network for a given MMC plan
Plansrsquo member handbooks (including lists of in-network providers) may be out of date
Pressure Point Multiple Medicaid
Managed Care (MMC) Plans To
Work With (Part 3)
Typically multiple MMC plans serve the same
(child) population
May complicate
bull Rate negotiations (if employing or
contracting with providers)
bull Provider network management
(eg for referrals)
ldquoLeadrdquo MMC Plans may not administer behavioral health (BH) benefits directly
4 Is the care setting
acceptable
Medicaid programs set rules that govern whether a covered service will be reimbursable only if provided in a program-approved setting
Outpatient (non-school-based) clinics generally an acceptable setting
School mental health programs often facilitate transportation tofrom outpatient clinics
Schools may be an accepted care setting for some services in some states but not others
IDEA ndash Schools may submit claims to Medicaid for Medicaid-covered school-based treatment management services listed in the IEP
North Carolina
Medicaid Services
Provided in Schools
Early and Periodic Screening Diagnostic and Treatment (EPSDT) services
Evaluation services (with required written report)cognitive emotional personality adaptive behavior behavior and
perceptual or visual motor
Treatment services may include one or more of the following therapies cognitive-behavioral therapy rational-emotive therapy family
therapy individual interactive psychotherapy using play equipment (et al) sensory integrative therapy
As of January 2019 State Plan Amendment approval
Medicaid Managed Care
Administrative Burden
Anecdotally only the most well-resourced school districts may have the bandwidth to manage this effectively
May be easier to partner with a community provider
District duties
Perform outreach to potentially
Medicaid-eligible students
Assist students with applying for
Medicaid coverage
Assist with re-certifying eligibility
Administrative billing
Know statersquos benefit package (incl
optional benefits)
Track MMC plansrsquo coverage terms
Manage MMC plansrsquo cost containment
tools (eg prior authorization)
Negotiate rates with MMC plans
Monitor MMC plansrsquo provider networks
Avoid confusing rulesprocesses
across multiple MMC plans in area
Track which services are reimbursable
when delivered on school grounds
If Medicaid will pay for SBMH services the following
criteria must be met
Key Takeaways
1) Child is enrolled in Medicaid
2) Service is a covered service
3) Provider is an eligible provider
4) Setting is an accepted setting
Medicaid Managed Care can complicate these matters
in some key ways
Prior authorization other cost containment tools
Provider network management
Separate administration of behavioral health benefits
Identify measure and act on key ldquopressure pointsrdquo in
your states
Key Takeaways ctd
Interviews and survey data collection (state and local)
Barriers and facilitators to leveraging Medicaid to finance
SBMH services and programs
Similar issues for other funding sources particularly
Dept of Education
Relative importance of funding sources
Forthcoming webinars to present findings (stay tuned)
Ongoing Activities at the
SE MHTTC
Thank you
Please contact me with questions
E-mail adamswilkemoryedu
Twitter adamswilk
httpsmhttcnetworkorgcenterssoutheast-mhttchome
References pt 1
Brooks T Roygardner L amp Artiga S 2019 Medicaid and CHIP Eligibility Enrollment and Cost Sharing Policies as of January 2019 Findings from a 50-State Survey Henry J Kaiser Family Foundation
CMS (Centers for Medicare amp Medicaid Services) 2014 Letter from Cindy Mann to state Medicaid directors regarding Medicaid payment for services provided without charge (free care)rdquo December 15 2014 Baltimore MD CMS httpswwwmedicaidgovfederal-policy-guidancedownloadssmd-medicaid-payment-forservices-provided-without-charge-free-carepdf
CMS ldquoManaged Carerdquo httpswwwmedicaidgovmedicaidmanaged-careindexhtml
Chester A and Wright Burak E Fact Sheet Medicaidrsquos Role for Young Children Georgetown University Health Policy Institute Center for Children and Families 13 Dec 2016 httpsccfgeorgetownedu20161213fact-sheet-medicaids-role-for-young-children
Florida Agency for Health Care Administration httpsahcamyfloridacomMedicaidstatewide_mcpdfSMMC_Region_mappdf
Kaiser Family Foundation httpswwwkfforgmedicaidstate-indicatortotal-medicaid-mcoscurrentTimeframe=0ampsortModel=7B22colId2222Location2222sort2222asc227D
Kentucky Cabinet for Family Health and Family Services httpschfskygovagenciesdmsdpqomco-cmbPagesmco-optionsaspx
Ku L Steinmetz E and Bysshe T (2015) Continuity of Medicaid Coverage in an Era of Transition (Working Paper) Milken Institute of Public Health George Washington University
References pt 2
MACPAC (Medicaid and CHIP Payment and Access Commission) Behavioral Health Benefits httpswwwmacpacgovsubtopicbehavioral-health-benefits
MACPAC Issue Brief Medicaid in Schools Washington DC April 2018
MACPAC Section 3 Program enrollment and spendingmdashMedicaid managed care Washington DC December 2016
Mississippi Division of Medicaid httpsmedicaidmsgovprogramsmanaged-care SAMHSA (Substance Abuse and Mental Health Services Administration) Mental Health
Technology Transfer Center Network httpsmhttcnetworkorg
Tuck K amp Smith E ldquoBehavioral Health Coverage in Medicaid Managed Carerdquo Institute for Medicaid Innovation April 2019 httpswwwmedicaidinnovationorg_imagescontent2019-IMI-Behavioral_Health_in_Medicaid-Reportpdf
Urban Institute tabulations of 20132016 American Community Survey (ACS) data from the Integrated Public Use Microdata Series (IPUMS) from Jennifer Haley Genevieve Kenney Robin Wang Victoria Lynch and Matthew Buettgens MedicaidCHIP Participation Reached 937 Percent Among Eligible Children In 2016 The Urban Institute Washington DC August 2018
Wen H Wilk A S Druss B G amp Cummings J R 2019 Medicaid Acceptance by Psychiatrists Implications for Medicaid Expansion JAMA Psychiatry epub 5 Jun 2019
Continuity of Coverage in Medicaid
StateContinuity Ratio
(All)
Continuity Ratio
(Children)
Alabama 840 852
Florida 743 797
Georgia 763 792
Kentucky 792 830
Mississippi 814 830
North Carolina 802 855
South Carolina 819 821
Tennessee 831 872
The Continuity Ratio measures the portion of a year that an average
beneficiary is enrolled in Medicaid It is the ratio of the average of
Medicaid enrollees in a fiscal year divided by the unduplicated of
annual enrollees
2 Is the service
covered by Medicaid
While all Medicaid programs cover mental health services in general different Medicaid programs make different decisions about which specific services will be covered and under what circumstances
Mandatory benefits inpatient and outpatient hospital care physician visits rural health clinic services etc
Optional benefits prescription drugs targeted case management licensed clinical social work services etc
PR
ES
SU
RE
PO
INT
Pressure Point Medicaid Managed
Care (MMC) Plans Cover Services
on Their Own Terms
Across plans variation in terms of coverage for key SBMH services
Examples psychotherapy services and assessment
1 Initial services may be covered with referral sometimes requiring prior authorization
2 Covered up until a fixed benefit ldquocaprdquo
3 Coverage may be extended above the cap if the provider obtains re-authorization
Plans may give little notice before making changes to coverage terms
Example Preferred Drug List
Pressure Point Multiple Medicaid
Managed Care (MMC) Plans To
Work With
Typically multiple MMC plans serve the same
(child) population
SE region (8 states) 2-17 plans statewide
Some states (eg FL MI TX) contract with MMC plans
separately for distinct geographic service areas
o SE region 20 ndash 57 plans per service area
Multiple sets of MMC plan
coverage terms to manage
Pressure Point Multiple Medicaid
Managed Care (MMC) Plans To
Work With (Part 2)
1 MMC plans may subcontract with specialized BH managed care companies
o 30-50 of MMC plans (esp larger)
2 State-level BH (andor Rx) ldquocarve-outsrdquo
o 11 statesrsquo Medicaid programs with a BH carve-out as of 2017
ldquoLeadrdquo MMC Plans may not administer behavioral health (BH) benefits directly ndash two main reasons
ldquoEXTRArdquo sets of MMC plan
coverage terms to manage
3 Is the provider an eligible
provider +Providers must be credentialed (ie determined to be in good
professional standing) and approved by Medicaid before their claims
will be reimbursable
Major shortages of all behavioral health providers
o Compounded by misallocation of staff
o Therapist shortage has upstream impact on screening
providers report currently accepting any Medicaid patients
Some services may only be covered when provided by certain provider types (eg licensed clinical social worker vs non-clinical)P
RE
SS
UR
E P
OIN
TS
EPSDT is
underleveraged
Pressure Point Medicaid Managed
Care (MMC) Plans Form Provider
Networks
MMC plans (like commercial insurers)hellip
bull Negotiate fee schedules
Do not use standard Medicaid fee schedule
bull Make determinations on network inclusion (or exclusion)
Not all providers who ldquoaccept Medicaid patientsrdquo are in-network for a given MMC plan
Plansrsquo member handbooks (including lists of in-network providers) may be out of date
Pressure Point Multiple Medicaid
Managed Care (MMC) Plans To
Work With (Part 3)
Typically multiple MMC plans serve the same
(child) population
May complicate
bull Rate negotiations (if employing or
contracting with providers)
bull Provider network management
(eg for referrals)
ldquoLeadrdquo MMC Plans may not administer behavioral health (BH) benefits directly
4 Is the care setting
acceptable
Medicaid programs set rules that govern whether a covered service will be reimbursable only if provided in a program-approved setting
Outpatient (non-school-based) clinics generally an acceptable setting
School mental health programs often facilitate transportation tofrom outpatient clinics
Schools may be an accepted care setting for some services in some states but not others
IDEA ndash Schools may submit claims to Medicaid for Medicaid-covered school-based treatment management services listed in the IEP
North Carolina
Medicaid Services
Provided in Schools
Early and Periodic Screening Diagnostic and Treatment (EPSDT) services
Evaluation services (with required written report)cognitive emotional personality adaptive behavior behavior and
perceptual or visual motor
Treatment services may include one or more of the following therapies cognitive-behavioral therapy rational-emotive therapy family
therapy individual interactive psychotherapy using play equipment (et al) sensory integrative therapy
As of January 2019 State Plan Amendment approval
Medicaid Managed Care
Administrative Burden
Anecdotally only the most well-resourced school districts may have the bandwidth to manage this effectively
May be easier to partner with a community provider
District duties
Perform outreach to potentially
Medicaid-eligible students
Assist students with applying for
Medicaid coverage
Assist with re-certifying eligibility
Administrative billing
Know statersquos benefit package (incl
optional benefits)
Track MMC plansrsquo coverage terms
Manage MMC plansrsquo cost containment
tools (eg prior authorization)
Negotiate rates with MMC plans
Monitor MMC plansrsquo provider networks
Avoid confusing rulesprocesses
across multiple MMC plans in area
Track which services are reimbursable
when delivered on school grounds
If Medicaid will pay for SBMH services the following
criteria must be met
Key Takeaways
1) Child is enrolled in Medicaid
2) Service is a covered service
3) Provider is an eligible provider
4) Setting is an accepted setting
Medicaid Managed Care can complicate these matters
in some key ways
Prior authorization other cost containment tools
Provider network management
Separate administration of behavioral health benefits
Identify measure and act on key ldquopressure pointsrdquo in
your states
Key Takeaways ctd
Interviews and survey data collection (state and local)
Barriers and facilitators to leveraging Medicaid to finance
SBMH services and programs
Similar issues for other funding sources particularly
Dept of Education
Relative importance of funding sources
Forthcoming webinars to present findings (stay tuned)
Ongoing Activities at the
SE MHTTC
Thank you
Please contact me with questions
E-mail adamswilkemoryedu
Twitter adamswilk
httpsmhttcnetworkorgcenterssoutheast-mhttchome
References pt 1
Brooks T Roygardner L amp Artiga S 2019 Medicaid and CHIP Eligibility Enrollment and Cost Sharing Policies as of January 2019 Findings from a 50-State Survey Henry J Kaiser Family Foundation
CMS (Centers for Medicare amp Medicaid Services) 2014 Letter from Cindy Mann to state Medicaid directors regarding Medicaid payment for services provided without charge (free care)rdquo December 15 2014 Baltimore MD CMS httpswwwmedicaidgovfederal-policy-guidancedownloadssmd-medicaid-payment-forservices-provided-without-charge-free-carepdf
CMS ldquoManaged Carerdquo httpswwwmedicaidgovmedicaidmanaged-careindexhtml
Chester A and Wright Burak E Fact Sheet Medicaidrsquos Role for Young Children Georgetown University Health Policy Institute Center for Children and Families 13 Dec 2016 httpsccfgeorgetownedu20161213fact-sheet-medicaids-role-for-young-children
Florida Agency for Health Care Administration httpsahcamyfloridacomMedicaidstatewide_mcpdfSMMC_Region_mappdf
Kaiser Family Foundation httpswwwkfforgmedicaidstate-indicatortotal-medicaid-mcoscurrentTimeframe=0ampsortModel=7B22colId2222Location2222sort2222asc227D
Kentucky Cabinet for Family Health and Family Services httpschfskygovagenciesdmsdpqomco-cmbPagesmco-optionsaspx
Ku L Steinmetz E and Bysshe T (2015) Continuity of Medicaid Coverage in an Era of Transition (Working Paper) Milken Institute of Public Health George Washington University
References pt 2
MACPAC (Medicaid and CHIP Payment and Access Commission) Behavioral Health Benefits httpswwwmacpacgovsubtopicbehavioral-health-benefits
MACPAC Issue Brief Medicaid in Schools Washington DC April 2018
MACPAC Section 3 Program enrollment and spendingmdashMedicaid managed care Washington DC December 2016
Mississippi Division of Medicaid httpsmedicaidmsgovprogramsmanaged-care SAMHSA (Substance Abuse and Mental Health Services Administration) Mental Health
Technology Transfer Center Network httpsmhttcnetworkorg
Tuck K amp Smith E ldquoBehavioral Health Coverage in Medicaid Managed Carerdquo Institute for Medicaid Innovation April 2019 httpswwwmedicaidinnovationorg_imagescontent2019-IMI-Behavioral_Health_in_Medicaid-Reportpdf
Urban Institute tabulations of 20132016 American Community Survey (ACS) data from the Integrated Public Use Microdata Series (IPUMS) from Jennifer Haley Genevieve Kenney Robin Wang Victoria Lynch and Matthew Buettgens MedicaidCHIP Participation Reached 937 Percent Among Eligible Children In 2016 The Urban Institute Washington DC August 2018
Wen H Wilk A S Druss B G amp Cummings J R 2019 Medicaid Acceptance by Psychiatrists Implications for Medicaid Expansion JAMA Psychiatry epub 5 Jun 2019
2 Is the service
covered by Medicaid
While all Medicaid programs cover mental health services in general different Medicaid programs make different decisions about which specific services will be covered and under what circumstances
Mandatory benefits inpatient and outpatient hospital care physician visits rural health clinic services etc
Optional benefits prescription drugs targeted case management licensed clinical social work services etc
PR
ES
SU
RE
PO
INT
Pressure Point Medicaid Managed
Care (MMC) Plans Cover Services
on Their Own Terms
Across plans variation in terms of coverage for key SBMH services
Examples psychotherapy services and assessment
1 Initial services may be covered with referral sometimes requiring prior authorization
2 Covered up until a fixed benefit ldquocaprdquo
3 Coverage may be extended above the cap if the provider obtains re-authorization
Plans may give little notice before making changes to coverage terms
Example Preferred Drug List
Pressure Point Multiple Medicaid
Managed Care (MMC) Plans To
Work With
Typically multiple MMC plans serve the same
(child) population
SE region (8 states) 2-17 plans statewide
Some states (eg FL MI TX) contract with MMC plans
separately for distinct geographic service areas
o SE region 20 ndash 57 plans per service area
Multiple sets of MMC plan
coverage terms to manage
Pressure Point Multiple Medicaid
Managed Care (MMC) Plans To
Work With (Part 2)
1 MMC plans may subcontract with specialized BH managed care companies
o 30-50 of MMC plans (esp larger)
2 State-level BH (andor Rx) ldquocarve-outsrdquo
o 11 statesrsquo Medicaid programs with a BH carve-out as of 2017
ldquoLeadrdquo MMC Plans may not administer behavioral health (BH) benefits directly ndash two main reasons
ldquoEXTRArdquo sets of MMC plan
coverage terms to manage
3 Is the provider an eligible
provider +Providers must be credentialed (ie determined to be in good
professional standing) and approved by Medicaid before their claims
will be reimbursable
Major shortages of all behavioral health providers
o Compounded by misallocation of staff
o Therapist shortage has upstream impact on screening
providers report currently accepting any Medicaid patients
Some services may only be covered when provided by certain provider types (eg licensed clinical social worker vs non-clinical)P
RE
SS
UR
E P
OIN
TS
EPSDT is
underleveraged
Pressure Point Medicaid Managed
Care (MMC) Plans Form Provider
Networks
MMC plans (like commercial insurers)hellip
bull Negotiate fee schedules
Do not use standard Medicaid fee schedule
bull Make determinations on network inclusion (or exclusion)
Not all providers who ldquoaccept Medicaid patientsrdquo are in-network for a given MMC plan
Plansrsquo member handbooks (including lists of in-network providers) may be out of date
Pressure Point Multiple Medicaid
Managed Care (MMC) Plans To
Work With (Part 3)
Typically multiple MMC plans serve the same
(child) population
May complicate
bull Rate negotiations (if employing or
contracting with providers)
bull Provider network management
(eg for referrals)
ldquoLeadrdquo MMC Plans may not administer behavioral health (BH) benefits directly
4 Is the care setting
acceptable
Medicaid programs set rules that govern whether a covered service will be reimbursable only if provided in a program-approved setting
Outpatient (non-school-based) clinics generally an acceptable setting
School mental health programs often facilitate transportation tofrom outpatient clinics
Schools may be an accepted care setting for some services in some states but not others
IDEA ndash Schools may submit claims to Medicaid for Medicaid-covered school-based treatment management services listed in the IEP
North Carolina
Medicaid Services
Provided in Schools
Early and Periodic Screening Diagnostic and Treatment (EPSDT) services
Evaluation services (with required written report)cognitive emotional personality adaptive behavior behavior and
perceptual or visual motor
Treatment services may include one or more of the following therapies cognitive-behavioral therapy rational-emotive therapy family
therapy individual interactive psychotherapy using play equipment (et al) sensory integrative therapy
As of January 2019 State Plan Amendment approval
Medicaid Managed Care
Administrative Burden
Anecdotally only the most well-resourced school districts may have the bandwidth to manage this effectively
May be easier to partner with a community provider
District duties
Perform outreach to potentially
Medicaid-eligible students
Assist students with applying for
Medicaid coverage
Assist with re-certifying eligibility
Administrative billing
Know statersquos benefit package (incl
optional benefits)
Track MMC plansrsquo coverage terms
Manage MMC plansrsquo cost containment
tools (eg prior authorization)
Negotiate rates with MMC plans
Monitor MMC plansrsquo provider networks
Avoid confusing rulesprocesses
across multiple MMC plans in area
Track which services are reimbursable
when delivered on school grounds
If Medicaid will pay for SBMH services the following
criteria must be met
Key Takeaways
1) Child is enrolled in Medicaid
2) Service is a covered service
3) Provider is an eligible provider
4) Setting is an accepted setting
Medicaid Managed Care can complicate these matters
in some key ways
Prior authorization other cost containment tools
Provider network management
Separate administration of behavioral health benefits
Identify measure and act on key ldquopressure pointsrdquo in
your states
Key Takeaways ctd
Interviews and survey data collection (state and local)
Barriers and facilitators to leveraging Medicaid to finance
SBMH services and programs
Similar issues for other funding sources particularly
Dept of Education
Relative importance of funding sources
Forthcoming webinars to present findings (stay tuned)
Ongoing Activities at the
SE MHTTC
Thank you
Please contact me with questions
E-mail adamswilkemoryedu
Twitter adamswilk
httpsmhttcnetworkorgcenterssoutheast-mhttchome
References pt 1
Brooks T Roygardner L amp Artiga S 2019 Medicaid and CHIP Eligibility Enrollment and Cost Sharing Policies as of January 2019 Findings from a 50-State Survey Henry J Kaiser Family Foundation
CMS (Centers for Medicare amp Medicaid Services) 2014 Letter from Cindy Mann to state Medicaid directors regarding Medicaid payment for services provided without charge (free care)rdquo December 15 2014 Baltimore MD CMS httpswwwmedicaidgovfederal-policy-guidancedownloadssmd-medicaid-payment-forservices-provided-without-charge-free-carepdf
CMS ldquoManaged Carerdquo httpswwwmedicaidgovmedicaidmanaged-careindexhtml
Chester A and Wright Burak E Fact Sheet Medicaidrsquos Role for Young Children Georgetown University Health Policy Institute Center for Children and Families 13 Dec 2016 httpsccfgeorgetownedu20161213fact-sheet-medicaids-role-for-young-children
Florida Agency for Health Care Administration httpsahcamyfloridacomMedicaidstatewide_mcpdfSMMC_Region_mappdf
Kaiser Family Foundation httpswwwkfforgmedicaidstate-indicatortotal-medicaid-mcoscurrentTimeframe=0ampsortModel=7B22colId2222Location2222sort2222asc227D
Kentucky Cabinet for Family Health and Family Services httpschfskygovagenciesdmsdpqomco-cmbPagesmco-optionsaspx
Ku L Steinmetz E and Bysshe T (2015) Continuity of Medicaid Coverage in an Era of Transition (Working Paper) Milken Institute of Public Health George Washington University
References pt 2
MACPAC (Medicaid and CHIP Payment and Access Commission) Behavioral Health Benefits httpswwwmacpacgovsubtopicbehavioral-health-benefits
MACPAC Issue Brief Medicaid in Schools Washington DC April 2018
MACPAC Section 3 Program enrollment and spendingmdashMedicaid managed care Washington DC December 2016
Mississippi Division of Medicaid httpsmedicaidmsgovprogramsmanaged-care SAMHSA (Substance Abuse and Mental Health Services Administration) Mental Health
Technology Transfer Center Network httpsmhttcnetworkorg
Tuck K amp Smith E ldquoBehavioral Health Coverage in Medicaid Managed Carerdquo Institute for Medicaid Innovation April 2019 httpswwwmedicaidinnovationorg_imagescontent2019-IMI-Behavioral_Health_in_Medicaid-Reportpdf
Urban Institute tabulations of 20132016 American Community Survey (ACS) data from the Integrated Public Use Microdata Series (IPUMS) from Jennifer Haley Genevieve Kenney Robin Wang Victoria Lynch and Matthew Buettgens MedicaidCHIP Participation Reached 937 Percent Among Eligible Children In 2016 The Urban Institute Washington DC August 2018
Wen H Wilk A S Druss B G amp Cummings J R 2019 Medicaid Acceptance by Psychiatrists Implications for Medicaid Expansion JAMA Psychiatry epub 5 Jun 2019
Pressure Point Medicaid Managed
Care (MMC) Plans Cover Services
on Their Own Terms
Across plans variation in terms of coverage for key SBMH services
Examples psychotherapy services and assessment
1 Initial services may be covered with referral sometimes requiring prior authorization
2 Covered up until a fixed benefit ldquocaprdquo
3 Coverage may be extended above the cap if the provider obtains re-authorization
Plans may give little notice before making changes to coverage terms
Example Preferred Drug List
Pressure Point Multiple Medicaid
Managed Care (MMC) Plans To
Work With
Typically multiple MMC plans serve the same
(child) population
SE region (8 states) 2-17 plans statewide
Some states (eg FL MI TX) contract with MMC plans
separately for distinct geographic service areas
o SE region 20 ndash 57 plans per service area
Multiple sets of MMC plan
coverage terms to manage
Pressure Point Multiple Medicaid
Managed Care (MMC) Plans To
Work With (Part 2)
1 MMC plans may subcontract with specialized BH managed care companies
o 30-50 of MMC plans (esp larger)
2 State-level BH (andor Rx) ldquocarve-outsrdquo
o 11 statesrsquo Medicaid programs with a BH carve-out as of 2017
ldquoLeadrdquo MMC Plans may not administer behavioral health (BH) benefits directly ndash two main reasons
ldquoEXTRArdquo sets of MMC plan
coverage terms to manage
3 Is the provider an eligible
provider +Providers must be credentialed (ie determined to be in good
professional standing) and approved by Medicaid before their claims
will be reimbursable
Major shortages of all behavioral health providers
o Compounded by misallocation of staff
o Therapist shortage has upstream impact on screening
providers report currently accepting any Medicaid patients
Some services may only be covered when provided by certain provider types (eg licensed clinical social worker vs non-clinical)P
RE
SS
UR
E P
OIN
TS
EPSDT is
underleveraged
Pressure Point Medicaid Managed
Care (MMC) Plans Form Provider
Networks
MMC plans (like commercial insurers)hellip
bull Negotiate fee schedules
Do not use standard Medicaid fee schedule
bull Make determinations on network inclusion (or exclusion)
Not all providers who ldquoaccept Medicaid patientsrdquo are in-network for a given MMC plan
Plansrsquo member handbooks (including lists of in-network providers) may be out of date
Pressure Point Multiple Medicaid
Managed Care (MMC) Plans To
Work With (Part 3)
Typically multiple MMC plans serve the same
(child) population
May complicate
bull Rate negotiations (if employing or
contracting with providers)
bull Provider network management
(eg for referrals)
ldquoLeadrdquo MMC Plans may not administer behavioral health (BH) benefits directly
4 Is the care setting
acceptable
Medicaid programs set rules that govern whether a covered service will be reimbursable only if provided in a program-approved setting
Outpatient (non-school-based) clinics generally an acceptable setting
School mental health programs often facilitate transportation tofrom outpatient clinics
Schools may be an accepted care setting for some services in some states but not others
IDEA ndash Schools may submit claims to Medicaid for Medicaid-covered school-based treatment management services listed in the IEP
North Carolina
Medicaid Services
Provided in Schools
Early and Periodic Screening Diagnostic and Treatment (EPSDT) services
Evaluation services (with required written report)cognitive emotional personality adaptive behavior behavior and
perceptual or visual motor
Treatment services may include one or more of the following therapies cognitive-behavioral therapy rational-emotive therapy family
therapy individual interactive psychotherapy using play equipment (et al) sensory integrative therapy
As of January 2019 State Plan Amendment approval
Medicaid Managed Care
Administrative Burden
Anecdotally only the most well-resourced school districts may have the bandwidth to manage this effectively
May be easier to partner with a community provider
District duties
Perform outreach to potentially
Medicaid-eligible students
Assist students with applying for
Medicaid coverage
Assist with re-certifying eligibility
Administrative billing
Know statersquos benefit package (incl
optional benefits)
Track MMC plansrsquo coverage terms
Manage MMC plansrsquo cost containment
tools (eg prior authorization)
Negotiate rates with MMC plans
Monitor MMC plansrsquo provider networks
Avoid confusing rulesprocesses
across multiple MMC plans in area
Track which services are reimbursable
when delivered on school grounds
If Medicaid will pay for SBMH services the following
criteria must be met
Key Takeaways
1) Child is enrolled in Medicaid
2) Service is a covered service
3) Provider is an eligible provider
4) Setting is an accepted setting
Medicaid Managed Care can complicate these matters
in some key ways
Prior authorization other cost containment tools
Provider network management
Separate administration of behavioral health benefits
Identify measure and act on key ldquopressure pointsrdquo in
your states
Key Takeaways ctd
Interviews and survey data collection (state and local)
Barriers and facilitators to leveraging Medicaid to finance
SBMH services and programs
Similar issues for other funding sources particularly
Dept of Education
Relative importance of funding sources
Forthcoming webinars to present findings (stay tuned)
Ongoing Activities at the
SE MHTTC
Thank you
Please contact me with questions
E-mail adamswilkemoryedu
Twitter adamswilk
httpsmhttcnetworkorgcenterssoutheast-mhttchome
References pt 1
Brooks T Roygardner L amp Artiga S 2019 Medicaid and CHIP Eligibility Enrollment and Cost Sharing Policies as of January 2019 Findings from a 50-State Survey Henry J Kaiser Family Foundation
CMS (Centers for Medicare amp Medicaid Services) 2014 Letter from Cindy Mann to state Medicaid directors regarding Medicaid payment for services provided without charge (free care)rdquo December 15 2014 Baltimore MD CMS httpswwwmedicaidgovfederal-policy-guidancedownloadssmd-medicaid-payment-forservices-provided-without-charge-free-carepdf
CMS ldquoManaged Carerdquo httpswwwmedicaidgovmedicaidmanaged-careindexhtml
Chester A and Wright Burak E Fact Sheet Medicaidrsquos Role for Young Children Georgetown University Health Policy Institute Center for Children and Families 13 Dec 2016 httpsccfgeorgetownedu20161213fact-sheet-medicaids-role-for-young-children
Florida Agency for Health Care Administration httpsahcamyfloridacomMedicaidstatewide_mcpdfSMMC_Region_mappdf
Kaiser Family Foundation httpswwwkfforgmedicaidstate-indicatortotal-medicaid-mcoscurrentTimeframe=0ampsortModel=7B22colId2222Location2222sort2222asc227D
Kentucky Cabinet for Family Health and Family Services httpschfskygovagenciesdmsdpqomco-cmbPagesmco-optionsaspx
Ku L Steinmetz E and Bysshe T (2015) Continuity of Medicaid Coverage in an Era of Transition (Working Paper) Milken Institute of Public Health George Washington University
References pt 2
MACPAC (Medicaid and CHIP Payment and Access Commission) Behavioral Health Benefits httpswwwmacpacgovsubtopicbehavioral-health-benefits
MACPAC Issue Brief Medicaid in Schools Washington DC April 2018
MACPAC Section 3 Program enrollment and spendingmdashMedicaid managed care Washington DC December 2016
Mississippi Division of Medicaid httpsmedicaidmsgovprogramsmanaged-care SAMHSA (Substance Abuse and Mental Health Services Administration) Mental Health
Technology Transfer Center Network httpsmhttcnetworkorg
Tuck K amp Smith E ldquoBehavioral Health Coverage in Medicaid Managed Carerdquo Institute for Medicaid Innovation April 2019 httpswwwmedicaidinnovationorg_imagescontent2019-IMI-Behavioral_Health_in_Medicaid-Reportpdf
Urban Institute tabulations of 20132016 American Community Survey (ACS) data from the Integrated Public Use Microdata Series (IPUMS) from Jennifer Haley Genevieve Kenney Robin Wang Victoria Lynch and Matthew Buettgens MedicaidCHIP Participation Reached 937 Percent Among Eligible Children In 2016 The Urban Institute Washington DC August 2018
Wen H Wilk A S Druss B G amp Cummings J R 2019 Medicaid Acceptance by Psychiatrists Implications for Medicaid Expansion JAMA Psychiatry epub 5 Jun 2019
Pressure Point Multiple Medicaid
Managed Care (MMC) Plans To
Work With
Typically multiple MMC plans serve the same
(child) population
SE region (8 states) 2-17 plans statewide
Some states (eg FL MI TX) contract with MMC plans
separately for distinct geographic service areas
o SE region 20 ndash 57 plans per service area
Multiple sets of MMC plan
coverage terms to manage
Pressure Point Multiple Medicaid
Managed Care (MMC) Plans To
Work With (Part 2)
1 MMC plans may subcontract with specialized BH managed care companies
o 30-50 of MMC plans (esp larger)
2 State-level BH (andor Rx) ldquocarve-outsrdquo
o 11 statesrsquo Medicaid programs with a BH carve-out as of 2017
ldquoLeadrdquo MMC Plans may not administer behavioral health (BH) benefits directly ndash two main reasons
ldquoEXTRArdquo sets of MMC plan
coverage terms to manage
3 Is the provider an eligible
provider +Providers must be credentialed (ie determined to be in good
professional standing) and approved by Medicaid before their claims
will be reimbursable
Major shortages of all behavioral health providers
o Compounded by misallocation of staff
o Therapist shortage has upstream impact on screening
providers report currently accepting any Medicaid patients
Some services may only be covered when provided by certain provider types (eg licensed clinical social worker vs non-clinical)P
RE
SS
UR
E P
OIN
TS
EPSDT is
underleveraged
Pressure Point Medicaid Managed
Care (MMC) Plans Form Provider
Networks
MMC plans (like commercial insurers)hellip
bull Negotiate fee schedules
Do not use standard Medicaid fee schedule
bull Make determinations on network inclusion (or exclusion)
Not all providers who ldquoaccept Medicaid patientsrdquo are in-network for a given MMC plan
Plansrsquo member handbooks (including lists of in-network providers) may be out of date
Pressure Point Multiple Medicaid
Managed Care (MMC) Plans To
Work With (Part 3)
Typically multiple MMC plans serve the same
(child) population
May complicate
bull Rate negotiations (if employing or
contracting with providers)
bull Provider network management
(eg for referrals)
ldquoLeadrdquo MMC Plans may not administer behavioral health (BH) benefits directly
4 Is the care setting
acceptable
Medicaid programs set rules that govern whether a covered service will be reimbursable only if provided in a program-approved setting
Outpatient (non-school-based) clinics generally an acceptable setting
School mental health programs often facilitate transportation tofrom outpatient clinics
Schools may be an accepted care setting for some services in some states but not others
IDEA ndash Schools may submit claims to Medicaid for Medicaid-covered school-based treatment management services listed in the IEP
North Carolina
Medicaid Services
Provided in Schools
Early and Periodic Screening Diagnostic and Treatment (EPSDT) services
Evaluation services (with required written report)cognitive emotional personality adaptive behavior behavior and
perceptual or visual motor
Treatment services may include one or more of the following therapies cognitive-behavioral therapy rational-emotive therapy family
therapy individual interactive psychotherapy using play equipment (et al) sensory integrative therapy
As of January 2019 State Plan Amendment approval
Medicaid Managed Care
Administrative Burden
Anecdotally only the most well-resourced school districts may have the bandwidth to manage this effectively
May be easier to partner with a community provider
District duties
Perform outreach to potentially
Medicaid-eligible students
Assist students with applying for
Medicaid coverage
Assist with re-certifying eligibility
Administrative billing
Know statersquos benefit package (incl
optional benefits)
Track MMC plansrsquo coverage terms
Manage MMC plansrsquo cost containment
tools (eg prior authorization)
Negotiate rates with MMC plans
Monitor MMC plansrsquo provider networks
Avoid confusing rulesprocesses
across multiple MMC plans in area
Track which services are reimbursable
when delivered on school grounds
If Medicaid will pay for SBMH services the following
criteria must be met
Key Takeaways
1) Child is enrolled in Medicaid
2) Service is a covered service
3) Provider is an eligible provider
4) Setting is an accepted setting
Medicaid Managed Care can complicate these matters
in some key ways
Prior authorization other cost containment tools
Provider network management
Separate administration of behavioral health benefits
Identify measure and act on key ldquopressure pointsrdquo in
your states
Key Takeaways ctd
Interviews and survey data collection (state and local)
Barriers and facilitators to leveraging Medicaid to finance
SBMH services and programs
Similar issues for other funding sources particularly
Dept of Education
Relative importance of funding sources
Forthcoming webinars to present findings (stay tuned)
Ongoing Activities at the
SE MHTTC
Thank you
Please contact me with questions
E-mail adamswilkemoryedu
Twitter adamswilk
httpsmhttcnetworkorgcenterssoutheast-mhttchome
References pt 1
Brooks T Roygardner L amp Artiga S 2019 Medicaid and CHIP Eligibility Enrollment and Cost Sharing Policies as of January 2019 Findings from a 50-State Survey Henry J Kaiser Family Foundation
CMS (Centers for Medicare amp Medicaid Services) 2014 Letter from Cindy Mann to state Medicaid directors regarding Medicaid payment for services provided without charge (free care)rdquo December 15 2014 Baltimore MD CMS httpswwwmedicaidgovfederal-policy-guidancedownloadssmd-medicaid-payment-forservices-provided-without-charge-free-carepdf
CMS ldquoManaged Carerdquo httpswwwmedicaidgovmedicaidmanaged-careindexhtml
Chester A and Wright Burak E Fact Sheet Medicaidrsquos Role for Young Children Georgetown University Health Policy Institute Center for Children and Families 13 Dec 2016 httpsccfgeorgetownedu20161213fact-sheet-medicaids-role-for-young-children
Florida Agency for Health Care Administration httpsahcamyfloridacomMedicaidstatewide_mcpdfSMMC_Region_mappdf
Kaiser Family Foundation httpswwwkfforgmedicaidstate-indicatortotal-medicaid-mcoscurrentTimeframe=0ampsortModel=7B22colId2222Location2222sort2222asc227D
Kentucky Cabinet for Family Health and Family Services httpschfskygovagenciesdmsdpqomco-cmbPagesmco-optionsaspx
Ku L Steinmetz E and Bysshe T (2015) Continuity of Medicaid Coverage in an Era of Transition (Working Paper) Milken Institute of Public Health George Washington University
References pt 2
MACPAC (Medicaid and CHIP Payment and Access Commission) Behavioral Health Benefits httpswwwmacpacgovsubtopicbehavioral-health-benefits
MACPAC Issue Brief Medicaid in Schools Washington DC April 2018
MACPAC Section 3 Program enrollment and spendingmdashMedicaid managed care Washington DC December 2016
Mississippi Division of Medicaid httpsmedicaidmsgovprogramsmanaged-care SAMHSA (Substance Abuse and Mental Health Services Administration) Mental Health
Technology Transfer Center Network httpsmhttcnetworkorg
Tuck K amp Smith E ldquoBehavioral Health Coverage in Medicaid Managed Carerdquo Institute for Medicaid Innovation April 2019 httpswwwmedicaidinnovationorg_imagescontent2019-IMI-Behavioral_Health_in_Medicaid-Reportpdf
Urban Institute tabulations of 20132016 American Community Survey (ACS) data from the Integrated Public Use Microdata Series (IPUMS) from Jennifer Haley Genevieve Kenney Robin Wang Victoria Lynch and Matthew Buettgens MedicaidCHIP Participation Reached 937 Percent Among Eligible Children In 2016 The Urban Institute Washington DC August 2018
Wen H Wilk A S Druss B G amp Cummings J R 2019 Medicaid Acceptance by Psychiatrists Implications for Medicaid Expansion JAMA Psychiatry epub 5 Jun 2019
Pressure Point Multiple Medicaid
Managed Care (MMC) Plans To
Work With (Part 2)
1 MMC plans may subcontract with specialized BH managed care companies
o 30-50 of MMC plans (esp larger)
2 State-level BH (andor Rx) ldquocarve-outsrdquo
o 11 statesrsquo Medicaid programs with a BH carve-out as of 2017
ldquoLeadrdquo MMC Plans may not administer behavioral health (BH) benefits directly ndash two main reasons
ldquoEXTRArdquo sets of MMC plan
coverage terms to manage
3 Is the provider an eligible
provider +Providers must be credentialed (ie determined to be in good
professional standing) and approved by Medicaid before their claims
will be reimbursable
Major shortages of all behavioral health providers
o Compounded by misallocation of staff
o Therapist shortage has upstream impact on screening
providers report currently accepting any Medicaid patients
Some services may only be covered when provided by certain provider types (eg licensed clinical social worker vs non-clinical)P
RE
SS
UR
E P
OIN
TS
EPSDT is
underleveraged
Pressure Point Medicaid Managed
Care (MMC) Plans Form Provider
Networks
MMC plans (like commercial insurers)hellip
bull Negotiate fee schedules
Do not use standard Medicaid fee schedule
bull Make determinations on network inclusion (or exclusion)
Not all providers who ldquoaccept Medicaid patientsrdquo are in-network for a given MMC plan
Plansrsquo member handbooks (including lists of in-network providers) may be out of date
Pressure Point Multiple Medicaid
Managed Care (MMC) Plans To
Work With (Part 3)
Typically multiple MMC plans serve the same
(child) population
May complicate
bull Rate negotiations (if employing or
contracting with providers)
bull Provider network management
(eg for referrals)
ldquoLeadrdquo MMC Plans may not administer behavioral health (BH) benefits directly
4 Is the care setting
acceptable
Medicaid programs set rules that govern whether a covered service will be reimbursable only if provided in a program-approved setting
Outpatient (non-school-based) clinics generally an acceptable setting
School mental health programs often facilitate transportation tofrom outpatient clinics
Schools may be an accepted care setting for some services in some states but not others
IDEA ndash Schools may submit claims to Medicaid for Medicaid-covered school-based treatment management services listed in the IEP
North Carolina
Medicaid Services
Provided in Schools
Early and Periodic Screening Diagnostic and Treatment (EPSDT) services
Evaluation services (with required written report)cognitive emotional personality adaptive behavior behavior and
perceptual or visual motor
Treatment services may include one or more of the following therapies cognitive-behavioral therapy rational-emotive therapy family
therapy individual interactive psychotherapy using play equipment (et al) sensory integrative therapy
As of January 2019 State Plan Amendment approval
Medicaid Managed Care
Administrative Burden
Anecdotally only the most well-resourced school districts may have the bandwidth to manage this effectively
May be easier to partner with a community provider
District duties
Perform outreach to potentially
Medicaid-eligible students
Assist students with applying for
Medicaid coverage
Assist with re-certifying eligibility
Administrative billing
Know statersquos benefit package (incl
optional benefits)
Track MMC plansrsquo coverage terms
Manage MMC plansrsquo cost containment
tools (eg prior authorization)
Negotiate rates with MMC plans
Monitor MMC plansrsquo provider networks
Avoid confusing rulesprocesses
across multiple MMC plans in area
Track which services are reimbursable
when delivered on school grounds
If Medicaid will pay for SBMH services the following
criteria must be met
Key Takeaways
1) Child is enrolled in Medicaid
2) Service is a covered service
3) Provider is an eligible provider
4) Setting is an accepted setting
Medicaid Managed Care can complicate these matters
in some key ways
Prior authorization other cost containment tools
Provider network management
Separate administration of behavioral health benefits
Identify measure and act on key ldquopressure pointsrdquo in
your states
Key Takeaways ctd
Interviews and survey data collection (state and local)
Barriers and facilitators to leveraging Medicaid to finance
SBMH services and programs
Similar issues for other funding sources particularly
Dept of Education
Relative importance of funding sources
Forthcoming webinars to present findings (stay tuned)
Ongoing Activities at the
SE MHTTC
Thank you
Please contact me with questions
E-mail adamswilkemoryedu
Twitter adamswilk
httpsmhttcnetworkorgcenterssoutheast-mhttchome
References pt 1
Brooks T Roygardner L amp Artiga S 2019 Medicaid and CHIP Eligibility Enrollment and Cost Sharing Policies as of January 2019 Findings from a 50-State Survey Henry J Kaiser Family Foundation
CMS (Centers for Medicare amp Medicaid Services) 2014 Letter from Cindy Mann to state Medicaid directors regarding Medicaid payment for services provided without charge (free care)rdquo December 15 2014 Baltimore MD CMS httpswwwmedicaidgovfederal-policy-guidancedownloadssmd-medicaid-payment-forservices-provided-without-charge-free-carepdf
CMS ldquoManaged Carerdquo httpswwwmedicaidgovmedicaidmanaged-careindexhtml
Chester A and Wright Burak E Fact Sheet Medicaidrsquos Role for Young Children Georgetown University Health Policy Institute Center for Children and Families 13 Dec 2016 httpsccfgeorgetownedu20161213fact-sheet-medicaids-role-for-young-children
Florida Agency for Health Care Administration httpsahcamyfloridacomMedicaidstatewide_mcpdfSMMC_Region_mappdf
Kaiser Family Foundation httpswwwkfforgmedicaidstate-indicatortotal-medicaid-mcoscurrentTimeframe=0ampsortModel=7B22colId2222Location2222sort2222asc227D
Kentucky Cabinet for Family Health and Family Services httpschfskygovagenciesdmsdpqomco-cmbPagesmco-optionsaspx
Ku L Steinmetz E and Bysshe T (2015) Continuity of Medicaid Coverage in an Era of Transition (Working Paper) Milken Institute of Public Health George Washington University
References pt 2
MACPAC (Medicaid and CHIP Payment and Access Commission) Behavioral Health Benefits httpswwwmacpacgovsubtopicbehavioral-health-benefits
MACPAC Issue Brief Medicaid in Schools Washington DC April 2018
MACPAC Section 3 Program enrollment and spendingmdashMedicaid managed care Washington DC December 2016
Mississippi Division of Medicaid httpsmedicaidmsgovprogramsmanaged-care SAMHSA (Substance Abuse and Mental Health Services Administration) Mental Health
Technology Transfer Center Network httpsmhttcnetworkorg
Tuck K amp Smith E ldquoBehavioral Health Coverage in Medicaid Managed Carerdquo Institute for Medicaid Innovation April 2019 httpswwwmedicaidinnovationorg_imagescontent2019-IMI-Behavioral_Health_in_Medicaid-Reportpdf
Urban Institute tabulations of 20132016 American Community Survey (ACS) data from the Integrated Public Use Microdata Series (IPUMS) from Jennifer Haley Genevieve Kenney Robin Wang Victoria Lynch and Matthew Buettgens MedicaidCHIP Participation Reached 937 Percent Among Eligible Children In 2016 The Urban Institute Washington DC August 2018
Wen H Wilk A S Druss B G amp Cummings J R 2019 Medicaid Acceptance by Psychiatrists Implications for Medicaid Expansion JAMA Psychiatry epub 5 Jun 2019
3 Is the provider an eligible
provider +Providers must be credentialed (ie determined to be in good
professional standing) and approved by Medicaid before their claims
will be reimbursable
Major shortages of all behavioral health providers
o Compounded by misallocation of staff
o Therapist shortage has upstream impact on screening
providers report currently accepting any Medicaid patients
Some services may only be covered when provided by certain provider types (eg licensed clinical social worker vs non-clinical)P
RE
SS
UR
E P
OIN
TS
EPSDT is
underleveraged
Pressure Point Medicaid Managed
Care (MMC) Plans Form Provider
Networks
MMC plans (like commercial insurers)hellip
bull Negotiate fee schedules
Do not use standard Medicaid fee schedule
bull Make determinations on network inclusion (or exclusion)
Not all providers who ldquoaccept Medicaid patientsrdquo are in-network for a given MMC plan
Plansrsquo member handbooks (including lists of in-network providers) may be out of date
Pressure Point Multiple Medicaid
Managed Care (MMC) Plans To
Work With (Part 3)
Typically multiple MMC plans serve the same
(child) population
May complicate
bull Rate negotiations (if employing or
contracting with providers)
bull Provider network management
(eg for referrals)
ldquoLeadrdquo MMC Plans may not administer behavioral health (BH) benefits directly
4 Is the care setting
acceptable
Medicaid programs set rules that govern whether a covered service will be reimbursable only if provided in a program-approved setting
Outpatient (non-school-based) clinics generally an acceptable setting
School mental health programs often facilitate transportation tofrom outpatient clinics
Schools may be an accepted care setting for some services in some states but not others
IDEA ndash Schools may submit claims to Medicaid for Medicaid-covered school-based treatment management services listed in the IEP
North Carolina
Medicaid Services
Provided in Schools
Early and Periodic Screening Diagnostic and Treatment (EPSDT) services
Evaluation services (with required written report)cognitive emotional personality adaptive behavior behavior and
perceptual or visual motor
Treatment services may include one or more of the following therapies cognitive-behavioral therapy rational-emotive therapy family
therapy individual interactive psychotherapy using play equipment (et al) sensory integrative therapy
As of January 2019 State Plan Amendment approval
Medicaid Managed Care
Administrative Burden
Anecdotally only the most well-resourced school districts may have the bandwidth to manage this effectively
May be easier to partner with a community provider
District duties
Perform outreach to potentially
Medicaid-eligible students
Assist students with applying for
Medicaid coverage
Assist with re-certifying eligibility
Administrative billing
Know statersquos benefit package (incl
optional benefits)
Track MMC plansrsquo coverage terms
Manage MMC plansrsquo cost containment
tools (eg prior authorization)
Negotiate rates with MMC plans
Monitor MMC plansrsquo provider networks
Avoid confusing rulesprocesses
across multiple MMC plans in area
Track which services are reimbursable
when delivered on school grounds
If Medicaid will pay for SBMH services the following
criteria must be met
Key Takeaways
1) Child is enrolled in Medicaid
2) Service is a covered service
3) Provider is an eligible provider
4) Setting is an accepted setting
Medicaid Managed Care can complicate these matters
in some key ways
Prior authorization other cost containment tools
Provider network management
Separate administration of behavioral health benefits
Identify measure and act on key ldquopressure pointsrdquo in
your states
Key Takeaways ctd
Interviews and survey data collection (state and local)
Barriers and facilitators to leveraging Medicaid to finance
SBMH services and programs
Similar issues for other funding sources particularly
Dept of Education
Relative importance of funding sources
Forthcoming webinars to present findings (stay tuned)
Ongoing Activities at the
SE MHTTC
Thank you
Please contact me with questions
E-mail adamswilkemoryedu
Twitter adamswilk
httpsmhttcnetworkorgcenterssoutheast-mhttchome
References pt 1
Brooks T Roygardner L amp Artiga S 2019 Medicaid and CHIP Eligibility Enrollment and Cost Sharing Policies as of January 2019 Findings from a 50-State Survey Henry J Kaiser Family Foundation
CMS (Centers for Medicare amp Medicaid Services) 2014 Letter from Cindy Mann to state Medicaid directors regarding Medicaid payment for services provided without charge (free care)rdquo December 15 2014 Baltimore MD CMS httpswwwmedicaidgovfederal-policy-guidancedownloadssmd-medicaid-payment-forservices-provided-without-charge-free-carepdf
CMS ldquoManaged Carerdquo httpswwwmedicaidgovmedicaidmanaged-careindexhtml
Chester A and Wright Burak E Fact Sheet Medicaidrsquos Role for Young Children Georgetown University Health Policy Institute Center for Children and Families 13 Dec 2016 httpsccfgeorgetownedu20161213fact-sheet-medicaids-role-for-young-children
Florida Agency for Health Care Administration httpsahcamyfloridacomMedicaidstatewide_mcpdfSMMC_Region_mappdf
Kaiser Family Foundation httpswwwkfforgmedicaidstate-indicatortotal-medicaid-mcoscurrentTimeframe=0ampsortModel=7B22colId2222Location2222sort2222asc227D
Kentucky Cabinet for Family Health and Family Services httpschfskygovagenciesdmsdpqomco-cmbPagesmco-optionsaspx
Ku L Steinmetz E and Bysshe T (2015) Continuity of Medicaid Coverage in an Era of Transition (Working Paper) Milken Institute of Public Health George Washington University
References pt 2
MACPAC (Medicaid and CHIP Payment and Access Commission) Behavioral Health Benefits httpswwwmacpacgovsubtopicbehavioral-health-benefits
MACPAC Issue Brief Medicaid in Schools Washington DC April 2018
MACPAC Section 3 Program enrollment and spendingmdashMedicaid managed care Washington DC December 2016
Mississippi Division of Medicaid httpsmedicaidmsgovprogramsmanaged-care SAMHSA (Substance Abuse and Mental Health Services Administration) Mental Health
Technology Transfer Center Network httpsmhttcnetworkorg
Tuck K amp Smith E ldquoBehavioral Health Coverage in Medicaid Managed Carerdquo Institute for Medicaid Innovation April 2019 httpswwwmedicaidinnovationorg_imagescontent2019-IMI-Behavioral_Health_in_Medicaid-Reportpdf
Urban Institute tabulations of 20132016 American Community Survey (ACS) data from the Integrated Public Use Microdata Series (IPUMS) from Jennifer Haley Genevieve Kenney Robin Wang Victoria Lynch and Matthew Buettgens MedicaidCHIP Participation Reached 937 Percent Among Eligible Children In 2016 The Urban Institute Washington DC August 2018
Wen H Wilk A S Druss B G amp Cummings J R 2019 Medicaid Acceptance by Psychiatrists Implications for Medicaid Expansion JAMA Psychiatry epub 5 Jun 2019
Pressure Point Medicaid Managed
Care (MMC) Plans Form Provider
Networks
MMC plans (like commercial insurers)hellip
bull Negotiate fee schedules
Do not use standard Medicaid fee schedule
bull Make determinations on network inclusion (or exclusion)
Not all providers who ldquoaccept Medicaid patientsrdquo are in-network for a given MMC plan
Plansrsquo member handbooks (including lists of in-network providers) may be out of date
Pressure Point Multiple Medicaid
Managed Care (MMC) Plans To
Work With (Part 3)
Typically multiple MMC plans serve the same
(child) population
May complicate
bull Rate negotiations (if employing or
contracting with providers)
bull Provider network management
(eg for referrals)
ldquoLeadrdquo MMC Plans may not administer behavioral health (BH) benefits directly
4 Is the care setting
acceptable
Medicaid programs set rules that govern whether a covered service will be reimbursable only if provided in a program-approved setting
Outpatient (non-school-based) clinics generally an acceptable setting
School mental health programs often facilitate transportation tofrom outpatient clinics
Schools may be an accepted care setting for some services in some states but not others
IDEA ndash Schools may submit claims to Medicaid for Medicaid-covered school-based treatment management services listed in the IEP
North Carolina
Medicaid Services
Provided in Schools
Early and Periodic Screening Diagnostic and Treatment (EPSDT) services
Evaluation services (with required written report)cognitive emotional personality adaptive behavior behavior and
perceptual or visual motor
Treatment services may include one or more of the following therapies cognitive-behavioral therapy rational-emotive therapy family
therapy individual interactive psychotherapy using play equipment (et al) sensory integrative therapy
As of January 2019 State Plan Amendment approval
Medicaid Managed Care
Administrative Burden
Anecdotally only the most well-resourced school districts may have the bandwidth to manage this effectively
May be easier to partner with a community provider
District duties
Perform outreach to potentially
Medicaid-eligible students
Assist students with applying for
Medicaid coverage
Assist with re-certifying eligibility
Administrative billing
Know statersquos benefit package (incl
optional benefits)
Track MMC plansrsquo coverage terms
Manage MMC plansrsquo cost containment
tools (eg prior authorization)
Negotiate rates with MMC plans
Monitor MMC plansrsquo provider networks
Avoid confusing rulesprocesses
across multiple MMC plans in area
Track which services are reimbursable
when delivered on school grounds
If Medicaid will pay for SBMH services the following
criteria must be met
Key Takeaways
1) Child is enrolled in Medicaid
2) Service is a covered service
3) Provider is an eligible provider
4) Setting is an accepted setting
Medicaid Managed Care can complicate these matters
in some key ways
Prior authorization other cost containment tools
Provider network management
Separate administration of behavioral health benefits
Identify measure and act on key ldquopressure pointsrdquo in
your states
Key Takeaways ctd
Interviews and survey data collection (state and local)
Barriers and facilitators to leveraging Medicaid to finance
SBMH services and programs
Similar issues for other funding sources particularly
Dept of Education
Relative importance of funding sources
Forthcoming webinars to present findings (stay tuned)
Ongoing Activities at the
SE MHTTC
Thank you
Please contact me with questions
E-mail adamswilkemoryedu
Twitter adamswilk
httpsmhttcnetworkorgcenterssoutheast-mhttchome
References pt 1
Brooks T Roygardner L amp Artiga S 2019 Medicaid and CHIP Eligibility Enrollment and Cost Sharing Policies as of January 2019 Findings from a 50-State Survey Henry J Kaiser Family Foundation
CMS (Centers for Medicare amp Medicaid Services) 2014 Letter from Cindy Mann to state Medicaid directors regarding Medicaid payment for services provided without charge (free care)rdquo December 15 2014 Baltimore MD CMS httpswwwmedicaidgovfederal-policy-guidancedownloadssmd-medicaid-payment-forservices-provided-without-charge-free-carepdf
CMS ldquoManaged Carerdquo httpswwwmedicaidgovmedicaidmanaged-careindexhtml
Chester A and Wright Burak E Fact Sheet Medicaidrsquos Role for Young Children Georgetown University Health Policy Institute Center for Children and Families 13 Dec 2016 httpsccfgeorgetownedu20161213fact-sheet-medicaids-role-for-young-children
Florida Agency for Health Care Administration httpsahcamyfloridacomMedicaidstatewide_mcpdfSMMC_Region_mappdf
Kaiser Family Foundation httpswwwkfforgmedicaidstate-indicatortotal-medicaid-mcoscurrentTimeframe=0ampsortModel=7B22colId2222Location2222sort2222asc227D
Kentucky Cabinet for Family Health and Family Services httpschfskygovagenciesdmsdpqomco-cmbPagesmco-optionsaspx
Ku L Steinmetz E and Bysshe T (2015) Continuity of Medicaid Coverage in an Era of Transition (Working Paper) Milken Institute of Public Health George Washington University
References pt 2
MACPAC (Medicaid and CHIP Payment and Access Commission) Behavioral Health Benefits httpswwwmacpacgovsubtopicbehavioral-health-benefits
MACPAC Issue Brief Medicaid in Schools Washington DC April 2018
MACPAC Section 3 Program enrollment and spendingmdashMedicaid managed care Washington DC December 2016
Mississippi Division of Medicaid httpsmedicaidmsgovprogramsmanaged-care SAMHSA (Substance Abuse and Mental Health Services Administration) Mental Health
Technology Transfer Center Network httpsmhttcnetworkorg
Tuck K amp Smith E ldquoBehavioral Health Coverage in Medicaid Managed Carerdquo Institute for Medicaid Innovation April 2019 httpswwwmedicaidinnovationorg_imagescontent2019-IMI-Behavioral_Health_in_Medicaid-Reportpdf
Urban Institute tabulations of 20132016 American Community Survey (ACS) data from the Integrated Public Use Microdata Series (IPUMS) from Jennifer Haley Genevieve Kenney Robin Wang Victoria Lynch and Matthew Buettgens MedicaidCHIP Participation Reached 937 Percent Among Eligible Children In 2016 The Urban Institute Washington DC August 2018
Wen H Wilk A S Druss B G amp Cummings J R 2019 Medicaid Acceptance by Psychiatrists Implications for Medicaid Expansion JAMA Psychiatry epub 5 Jun 2019
Pressure Point Multiple Medicaid
Managed Care (MMC) Plans To
Work With (Part 3)
Typically multiple MMC plans serve the same
(child) population
May complicate
bull Rate negotiations (if employing or
contracting with providers)
bull Provider network management
(eg for referrals)
ldquoLeadrdquo MMC Plans may not administer behavioral health (BH) benefits directly
4 Is the care setting
acceptable
Medicaid programs set rules that govern whether a covered service will be reimbursable only if provided in a program-approved setting
Outpatient (non-school-based) clinics generally an acceptable setting
School mental health programs often facilitate transportation tofrom outpatient clinics
Schools may be an accepted care setting for some services in some states but not others
IDEA ndash Schools may submit claims to Medicaid for Medicaid-covered school-based treatment management services listed in the IEP
North Carolina
Medicaid Services
Provided in Schools
Early and Periodic Screening Diagnostic and Treatment (EPSDT) services
Evaluation services (with required written report)cognitive emotional personality adaptive behavior behavior and
perceptual or visual motor
Treatment services may include one or more of the following therapies cognitive-behavioral therapy rational-emotive therapy family
therapy individual interactive psychotherapy using play equipment (et al) sensory integrative therapy
As of January 2019 State Plan Amendment approval
Medicaid Managed Care
Administrative Burden
Anecdotally only the most well-resourced school districts may have the bandwidth to manage this effectively
May be easier to partner with a community provider
District duties
Perform outreach to potentially
Medicaid-eligible students
Assist students with applying for
Medicaid coverage
Assist with re-certifying eligibility
Administrative billing
Know statersquos benefit package (incl
optional benefits)
Track MMC plansrsquo coverage terms
Manage MMC plansrsquo cost containment
tools (eg prior authorization)
Negotiate rates with MMC plans
Monitor MMC plansrsquo provider networks
Avoid confusing rulesprocesses
across multiple MMC plans in area
Track which services are reimbursable
when delivered on school grounds
If Medicaid will pay for SBMH services the following
criteria must be met
Key Takeaways
1) Child is enrolled in Medicaid
2) Service is a covered service
3) Provider is an eligible provider
4) Setting is an accepted setting
Medicaid Managed Care can complicate these matters
in some key ways
Prior authorization other cost containment tools
Provider network management
Separate administration of behavioral health benefits
Identify measure and act on key ldquopressure pointsrdquo in
your states
Key Takeaways ctd
Interviews and survey data collection (state and local)
Barriers and facilitators to leveraging Medicaid to finance
SBMH services and programs
Similar issues for other funding sources particularly
Dept of Education
Relative importance of funding sources
Forthcoming webinars to present findings (stay tuned)
Ongoing Activities at the
SE MHTTC
Thank you
Please contact me with questions
E-mail adamswilkemoryedu
Twitter adamswilk
httpsmhttcnetworkorgcenterssoutheast-mhttchome
References pt 1
Brooks T Roygardner L amp Artiga S 2019 Medicaid and CHIP Eligibility Enrollment and Cost Sharing Policies as of January 2019 Findings from a 50-State Survey Henry J Kaiser Family Foundation
CMS (Centers for Medicare amp Medicaid Services) 2014 Letter from Cindy Mann to state Medicaid directors regarding Medicaid payment for services provided without charge (free care)rdquo December 15 2014 Baltimore MD CMS httpswwwmedicaidgovfederal-policy-guidancedownloadssmd-medicaid-payment-forservices-provided-without-charge-free-carepdf
CMS ldquoManaged Carerdquo httpswwwmedicaidgovmedicaidmanaged-careindexhtml
Chester A and Wright Burak E Fact Sheet Medicaidrsquos Role for Young Children Georgetown University Health Policy Institute Center for Children and Families 13 Dec 2016 httpsccfgeorgetownedu20161213fact-sheet-medicaids-role-for-young-children
Florida Agency for Health Care Administration httpsahcamyfloridacomMedicaidstatewide_mcpdfSMMC_Region_mappdf
Kaiser Family Foundation httpswwwkfforgmedicaidstate-indicatortotal-medicaid-mcoscurrentTimeframe=0ampsortModel=7B22colId2222Location2222sort2222asc227D
Kentucky Cabinet for Family Health and Family Services httpschfskygovagenciesdmsdpqomco-cmbPagesmco-optionsaspx
Ku L Steinmetz E and Bysshe T (2015) Continuity of Medicaid Coverage in an Era of Transition (Working Paper) Milken Institute of Public Health George Washington University
References pt 2
MACPAC (Medicaid and CHIP Payment and Access Commission) Behavioral Health Benefits httpswwwmacpacgovsubtopicbehavioral-health-benefits
MACPAC Issue Brief Medicaid in Schools Washington DC April 2018
MACPAC Section 3 Program enrollment and spendingmdashMedicaid managed care Washington DC December 2016
Mississippi Division of Medicaid httpsmedicaidmsgovprogramsmanaged-care SAMHSA (Substance Abuse and Mental Health Services Administration) Mental Health
Technology Transfer Center Network httpsmhttcnetworkorg
Tuck K amp Smith E ldquoBehavioral Health Coverage in Medicaid Managed Carerdquo Institute for Medicaid Innovation April 2019 httpswwwmedicaidinnovationorg_imagescontent2019-IMI-Behavioral_Health_in_Medicaid-Reportpdf
Urban Institute tabulations of 20132016 American Community Survey (ACS) data from the Integrated Public Use Microdata Series (IPUMS) from Jennifer Haley Genevieve Kenney Robin Wang Victoria Lynch and Matthew Buettgens MedicaidCHIP Participation Reached 937 Percent Among Eligible Children In 2016 The Urban Institute Washington DC August 2018
Wen H Wilk A S Druss B G amp Cummings J R 2019 Medicaid Acceptance by Psychiatrists Implications for Medicaid Expansion JAMA Psychiatry epub 5 Jun 2019
4 Is the care setting
acceptable
Medicaid programs set rules that govern whether a covered service will be reimbursable only if provided in a program-approved setting
Outpatient (non-school-based) clinics generally an acceptable setting
School mental health programs often facilitate transportation tofrom outpatient clinics
Schools may be an accepted care setting for some services in some states but not others
IDEA ndash Schools may submit claims to Medicaid for Medicaid-covered school-based treatment management services listed in the IEP
North Carolina
Medicaid Services
Provided in Schools
Early and Periodic Screening Diagnostic and Treatment (EPSDT) services
Evaluation services (with required written report)cognitive emotional personality adaptive behavior behavior and
perceptual or visual motor
Treatment services may include one or more of the following therapies cognitive-behavioral therapy rational-emotive therapy family
therapy individual interactive psychotherapy using play equipment (et al) sensory integrative therapy
As of January 2019 State Plan Amendment approval
Medicaid Managed Care
Administrative Burden
Anecdotally only the most well-resourced school districts may have the bandwidth to manage this effectively
May be easier to partner with a community provider
District duties
Perform outreach to potentially
Medicaid-eligible students
Assist students with applying for
Medicaid coverage
Assist with re-certifying eligibility
Administrative billing
Know statersquos benefit package (incl
optional benefits)
Track MMC plansrsquo coverage terms
Manage MMC plansrsquo cost containment
tools (eg prior authorization)
Negotiate rates with MMC plans
Monitor MMC plansrsquo provider networks
Avoid confusing rulesprocesses
across multiple MMC plans in area
Track which services are reimbursable
when delivered on school grounds
If Medicaid will pay for SBMH services the following
criteria must be met
Key Takeaways
1) Child is enrolled in Medicaid
2) Service is a covered service
3) Provider is an eligible provider
4) Setting is an accepted setting
Medicaid Managed Care can complicate these matters
in some key ways
Prior authorization other cost containment tools
Provider network management
Separate administration of behavioral health benefits
Identify measure and act on key ldquopressure pointsrdquo in
your states
Key Takeaways ctd
Interviews and survey data collection (state and local)
Barriers and facilitators to leveraging Medicaid to finance
SBMH services and programs
Similar issues for other funding sources particularly
Dept of Education
Relative importance of funding sources
Forthcoming webinars to present findings (stay tuned)
Ongoing Activities at the
SE MHTTC
Thank you
Please contact me with questions
E-mail adamswilkemoryedu
Twitter adamswilk
httpsmhttcnetworkorgcenterssoutheast-mhttchome
References pt 1
Brooks T Roygardner L amp Artiga S 2019 Medicaid and CHIP Eligibility Enrollment and Cost Sharing Policies as of January 2019 Findings from a 50-State Survey Henry J Kaiser Family Foundation
CMS (Centers for Medicare amp Medicaid Services) 2014 Letter from Cindy Mann to state Medicaid directors regarding Medicaid payment for services provided without charge (free care)rdquo December 15 2014 Baltimore MD CMS httpswwwmedicaidgovfederal-policy-guidancedownloadssmd-medicaid-payment-forservices-provided-without-charge-free-carepdf
CMS ldquoManaged Carerdquo httpswwwmedicaidgovmedicaidmanaged-careindexhtml
Chester A and Wright Burak E Fact Sheet Medicaidrsquos Role for Young Children Georgetown University Health Policy Institute Center for Children and Families 13 Dec 2016 httpsccfgeorgetownedu20161213fact-sheet-medicaids-role-for-young-children
Florida Agency for Health Care Administration httpsahcamyfloridacomMedicaidstatewide_mcpdfSMMC_Region_mappdf
Kaiser Family Foundation httpswwwkfforgmedicaidstate-indicatortotal-medicaid-mcoscurrentTimeframe=0ampsortModel=7B22colId2222Location2222sort2222asc227D
Kentucky Cabinet for Family Health and Family Services httpschfskygovagenciesdmsdpqomco-cmbPagesmco-optionsaspx
Ku L Steinmetz E and Bysshe T (2015) Continuity of Medicaid Coverage in an Era of Transition (Working Paper) Milken Institute of Public Health George Washington University
References pt 2
MACPAC (Medicaid and CHIP Payment and Access Commission) Behavioral Health Benefits httpswwwmacpacgovsubtopicbehavioral-health-benefits
MACPAC Issue Brief Medicaid in Schools Washington DC April 2018
MACPAC Section 3 Program enrollment and spendingmdashMedicaid managed care Washington DC December 2016
Mississippi Division of Medicaid httpsmedicaidmsgovprogramsmanaged-care SAMHSA (Substance Abuse and Mental Health Services Administration) Mental Health
Technology Transfer Center Network httpsmhttcnetworkorg
Tuck K amp Smith E ldquoBehavioral Health Coverage in Medicaid Managed Carerdquo Institute for Medicaid Innovation April 2019 httpswwwmedicaidinnovationorg_imagescontent2019-IMI-Behavioral_Health_in_Medicaid-Reportpdf
Urban Institute tabulations of 20132016 American Community Survey (ACS) data from the Integrated Public Use Microdata Series (IPUMS) from Jennifer Haley Genevieve Kenney Robin Wang Victoria Lynch and Matthew Buettgens MedicaidCHIP Participation Reached 937 Percent Among Eligible Children In 2016 The Urban Institute Washington DC August 2018
Wen H Wilk A S Druss B G amp Cummings J R 2019 Medicaid Acceptance by Psychiatrists Implications for Medicaid Expansion JAMA Psychiatry epub 5 Jun 2019
North Carolina
Medicaid Services
Provided in Schools
Early and Periodic Screening Diagnostic and Treatment (EPSDT) services
Evaluation services (with required written report)cognitive emotional personality adaptive behavior behavior and
perceptual or visual motor
Treatment services may include one or more of the following therapies cognitive-behavioral therapy rational-emotive therapy family
therapy individual interactive psychotherapy using play equipment (et al) sensory integrative therapy
As of January 2019 State Plan Amendment approval
Medicaid Managed Care
Administrative Burden
Anecdotally only the most well-resourced school districts may have the bandwidth to manage this effectively
May be easier to partner with a community provider
District duties
Perform outreach to potentially
Medicaid-eligible students
Assist students with applying for
Medicaid coverage
Assist with re-certifying eligibility
Administrative billing
Know statersquos benefit package (incl
optional benefits)
Track MMC plansrsquo coverage terms
Manage MMC plansrsquo cost containment
tools (eg prior authorization)
Negotiate rates with MMC plans
Monitor MMC plansrsquo provider networks
Avoid confusing rulesprocesses
across multiple MMC plans in area
Track which services are reimbursable
when delivered on school grounds
If Medicaid will pay for SBMH services the following
criteria must be met
Key Takeaways
1) Child is enrolled in Medicaid
2) Service is a covered service
3) Provider is an eligible provider
4) Setting is an accepted setting
Medicaid Managed Care can complicate these matters
in some key ways
Prior authorization other cost containment tools
Provider network management
Separate administration of behavioral health benefits
Identify measure and act on key ldquopressure pointsrdquo in
your states
Key Takeaways ctd
Interviews and survey data collection (state and local)
Barriers and facilitators to leveraging Medicaid to finance
SBMH services and programs
Similar issues for other funding sources particularly
Dept of Education
Relative importance of funding sources
Forthcoming webinars to present findings (stay tuned)
Ongoing Activities at the
SE MHTTC
Thank you
Please contact me with questions
E-mail adamswilkemoryedu
Twitter adamswilk
httpsmhttcnetworkorgcenterssoutheast-mhttchome
References pt 1
Brooks T Roygardner L amp Artiga S 2019 Medicaid and CHIP Eligibility Enrollment and Cost Sharing Policies as of January 2019 Findings from a 50-State Survey Henry J Kaiser Family Foundation
CMS (Centers for Medicare amp Medicaid Services) 2014 Letter from Cindy Mann to state Medicaid directors regarding Medicaid payment for services provided without charge (free care)rdquo December 15 2014 Baltimore MD CMS httpswwwmedicaidgovfederal-policy-guidancedownloadssmd-medicaid-payment-forservices-provided-without-charge-free-carepdf
CMS ldquoManaged Carerdquo httpswwwmedicaidgovmedicaidmanaged-careindexhtml
Chester A and Wright Burak E Fact Sheet Medicaidrsquos Role for Young Children Georgetown University Health Policy Institute Center for Children and Families 13 Dec 2016 httpsccfgeorgetownedu20161213fact-sheet-medicaids-role-for-young-children
Florida Agency for Health Care Administration httpsahcamyfloridacomMedicaidstatewide_mcpdfSMMC_Region_mappdf
Kaiser Family Foundation httpswwwkfforgmedicaidstate-indicatortotal-medicaid-mcoscurrentTimeframe=0ampsortModel=7B22colId2222Location2222sort2222asc227D
Kentucky Cabinet for Family Health and Family Services httpschfskygovagenciesdmsdpqomco-cmbPagesmco-optionsaspx
Ku L Steinmetz E and Bysshe T (2015) Continuity of Medicaid Coverage in an Era of Transition (Working Paper) Milken Institute of Public Health George Washington University
References pt 2
MACPAC (Medicaid and CHIP Payment and Access Commission) Behavioral Health Benefits httpswwwmacpacgovsubtopicbehavioral-health-benefits
MACPAC Issue Brief Medicaid in Schools Washington DC April 2018
MACPAC Section 3 Program enrollment and spendingmdashMedicaid managed care Washington DC December 2016
Mississippi Division of Medicaid httpsmedicaidmsgovprogramsmanaged-care SAMHSA (Substance Abuse and Mental Health Services Administration) Mental Health
Technology Transfer Center Network httpsmhttcnetworkorg
Tuck K amp Smith E ldquoBehavioral Health Coverage in Medicaid Managed Carerdquo Institute for Medicaid Innovation April 2019 httpswwwmedicaidinnovationorg_imagescontent2019-IMI-Behavioral_Health_in_Medicaid-Reportpdf
Urban Institute tabulations of 20132016 American Community Survey (ACS) data from the Integrated Public Use Microdata Series (IPUMS) from Jennifer Haley Genevieve Kenney Robin Wang Victoria Lynch and Matthew Buettgens MedicaidCHIP Participation Reached 937 Percent Among Eligible Children In 2016 The Urban Institute Washington DC August 2018
Wen H Wilk A S Druss B G amp Cummings J R 2019 Medicaid Acceptance by Psychiatrists Implications for Medicaid Expansion JAMA Psychiatry epub 5 Jun 2019
Medicaid Managed Care
Administrative Burden
Anecdotally only the most well-resourced school districts may have the bandwidth to manage this effectively
May be easier to partner with a community provider
District duties
Perform outreach to potentially
Medicaid-eligible students
Assist students with applying for
Medicaid coverage
Assist with re-certifying eligibility
Administrative billing
Know statersquos benefit package (incl
optional benefits)
Track MMC plansrsquo coverage terms
Manage MMC plansrsquo cost containment
tools (eg prior authorization)
Negotiate rates with MMC plans
Monitor MMC plansrsquo provider networks
Avoid confusing rulesprocesses
across multiple MMC plans in area
Track which services are reimbursable
when delivered on school grounds
If Medicaid will pay for SBMH services the following
criteria must be met
Key Takeaways
1) Child is enrolled in Medicaid
2) Service is a covered service
3) Provider is an eligible provider
4) Setting is an accepted setting
Medicaid Managed Care can complicate these matters
in some key ways
Prior authorization other cost containment tools
Provider network management
Separate administration of behavioral health benefits
Identify measure and act on key ldquopressure pointsrdquo in
your states
Key Takeaways ctd
Interviews and survey data collection (state and local)
Barriers and facilitators to leveraging Medicaid to finance
SBMH services and programs
Similar issues for other funding sources particularly
Dept of Education
Relative importance of funding sources
Forthcoming webinars to present findings (stay tuned)
Ongoing Activities at the
SE MHTTC
Thank you
Please contact me with questions
E-mail adamswilkemoryedu
Twitter adamswilk
httpsmhttcnetworkorgcenterssoutheast-mhttchome
References pt 1
Brooks T Roygardner L amp Artiga S 2019 Medicaid and CHIP Eligibility Enrollment and Cost Sharing Policies as of January 2019 Findings from a 50-State Survey Henry J Kaiser Family Foundation
CMS (Centers for Medicare amp Medicaid Services) 2014 Letter from Cindy Mann to state Medicaid directors regarding Medicaid payment for services provided without charge (free care)rdquo December 15 2014 Baltimore MD CMS httpswwwmedicaidgovfederal-policy-guidancedownloadssmd-medicaid-payment-forservices-provided-without-charge-free-carepdf
CMS ldquoManaged Carerdquo httpswwwmedicaidgovmedicaidmanaged-careindexhtml
Chester A and Wright Burak E Fact Sheet Medicaidrsquos Role for Young Children Georgetown University Health Policy Institute Center for Children and Families 13 Dec 2016 httpsccfgeorgetownedu20161213fact-sheet-medicaids-role-for-young-children
Florida Agency for Health Care Administration httpsahcamyfloridacomMedicaidstatewide_mcpdfSMMC_Region_mappdf
Kaiser Family Foundation httpswwwkfforgmedicaidstate-indicatortotal-medicaid-mcoscurrentTimeframe=0ampsortModel=7B22colId2222Location2222sort2222asc227D
Kentucky Cabinet for Family Health and Family Services httpschfskygovagenciesdmsdpqomco-cmbPagesmco-optionsaspx
Ku L Steinmetz E and Bysshe T (2015) Continuity of Medicaid Coverage in an Era of Transition (Working Paper) Milken Institute of Public Health George Washington University
References pt 2
MACPAC (Medicaid and CHIP Payment and Access Commission) Behavioral Health Benefits httpswwwmacpacgovsubtopicbehavioral-health-benefits
MACPAC Issue Brief Medicaid in Schools Washington DC April 2018
MACPAC Section 3 Program enrollment and spendingmdashMedicaid managed care Washington DC December 2016
Mississippi Division of Medicaid httpsmedicaidmsgovprogramsmanaged-care SAMHSA (Substance Abuse and Mental Health Services Administration) Mental Health
Technology Transfer Center Network httpsmhttcnetworkorg
Tuck K amp Smith E ldquoBehavioral Health Coverage in Medicaid Managed Carerdquo Institute for Medicaid Innovation April 2019 httpswwwmedicaidinnovationorg_imagescontent2019-IMI-Behavioral_Health_in_Medicaid-Reportpdf
Urban Institute tabulations of 20132016 American Community Survey (ACS) data from the Integrated Public Use Microdata Series (IPUMS) from Jennifer Haley Genevieve Kenney Robin Wang Victoria Lynch and Matthew Buettgens MedicaidCHIP Participation Reached 937 Percent Among Eligible Children In 2016 The Urban Institute Washington DC August 2018
Wen H Wilk A S Druss B G amp Cummings J R 2019 Medicaid Acceptance by Psychiatrists Implications for Medicaid Expansion JAMA Psychiatry epub 5 Jun 2019
If Medicaid will pay for SBMH services the following
criteria must be met
Key Takeaways
1) Child is enrolled in Medicaid
2) Service is a covered service
3) Provider is an eligible provider
4) Setting is an accepted setting
Medicaid Managed Care can complicate these matters
in some key ways
Prior authorization other cost containment tools
Provider network management
Separate administration of behavioral health benefits
Identify measure and act on key ldquopressure pointsrdquo in
your states
Key Takeaways ctd
Interviews and survey data collection (state and local)
Barriers and facilitators to leveraging Medicaid to finance
SBMH services and programs
Similar issues for other funding sources particularly
Dept of Education
Relative importance of funding sources
Forthcoming webinars to present findings (stay tuned)
Ongoing Activities at the
SE MHTTC
Thank you
Please contact me with questions
E-mail adamswilkemoryedu
Twitter adamswilk
httpsmhttcnetworkorgcenterssoutheast-mhttchome
References pt 1
Brooks T Roygardner L amp Artiga S 2019 Medicaid and CHIP Eligibility Enrollment and Cost Sharing Policies as of January 2019 Findings from a 50-State Survey Henry J Kaiser Family Foundation
CMS (Centers for Medicare amp Medicaid Services) 2014 Letter from Cindy Mann to state Medicaid directors regarding Medicaid payment for services provided without charge (free care)rdquo December 15 2014 Baltimore MD CMS httpswwwmedicaidgovfederal-policy-guidancedownloadssmd-medicaid-payment-forservices-provided-without-charge-free-carepdf
CMS ldquoManaged Carerdquo httpswwwmedicaidgovmedicaidmanaged-careindexhtml
Chester A and Wright Burak E Fact Sheet Medicaidrsquos Role for Young Children Georgetown University Health Policy Institute Center for Children and Families 13 Dec 2016 httpsccfgeorgetownedu20161213fact-sheet-medicaids-role-for-young-children
Florida Agency for Health Care Administration httpsahcamyfloridacomMedicaidstatewide_mcpdfSMMC_Region_mappdf
Kaiser Family Foundation httpswwwkfforgmedicaidstate-indicatortotal-medicaid-mcoscurrentTimeframe=0ampsortModel=7B22colId2222Location2222sort2222asc227D
Kentucky Cabinet for Family Health and Family Services httpschfskygovagenciesdmsdpqomco-cmbPagesmco-optionsaspx
Ku L Steinmetz E and Bysshe T (2015) Continuity of Medicaid Coverage in an Era of Transition (Working Paper) Milken Institute of Public Health George Washington University
References pt 2
MACPAC (Medicaid and CHIP Payment and Access Commission) Behavioral Health Benefits httpswwwmacpacgovsubtopicbehavioral-health-benefits
MACPAC Issue Brief Medicaid in Schools Washington DC April 2018
MACPAC Section 3 Program enrollment and spendingmdashMedicaid managed care Washington DC December 2016
Mississippi Division of Medicaid httpsmedicaidmsgovprogramsmanaged-care SAMHSA (Substance Abuse and Mental Health Services Administration) Mental Health
Technology Transfer Center Network httpsmhttcnetworkorg
Tuck K amp Smith E ldquoBehavioral Health Coverage in Medicaid Managed Carerdquo Institute for Medicaid Innovation April 2019 httpswwwmedicaidinnovationorg_imagescontent2019-IMI-Behavioral_Health_in_Medicaid-Reportpdf
Urban Institute tabulations of 20132016 American Community Survey (ACS) data from the Integrated Public Use Microdata Series (IPUMS) from Jennifer Haley Genevieve Kenney Robin Wang Victoria Lynch and Matthew Buettgens MedicaidCHIP Participation Reached 937 Percent Among Eligible Children In 2016 The Urban Institute Washington DC August 2018
Wen H Wilk A S Druss B G amp Cummings J R 2019 Medicaid Acceptance by Psychiatrists Implications for Medicaid Expansion JAMA Psychiatry epub 5 Jun 2019
Medicaid Managed Care can complicate these matters
in some key ways
Prior authorization other cost containment tools
Provider network management
Separate administration of behavioral health benefits
Identify measure and act on key ldquopressure pointsrdquo in
your states
Key Takeaways ctd
Interviews and survey data collection (state and local)
Barriers and facilitators to leveraging Medicaid to finance
SBMH services and programs
Similar issues for other funding sources particularly
Dept of Education
Relative importance of funding sources
Forthcoming webinars to present findings (stay tuned)
Ongoing Activities at the
SE MHTTC
Thank you
Please contact me with questions
E-mail adamswilkemoryedu
Twitter adamswilk
httpsmhttcnetworkorgcenterssoutheast-mhttchome
References pt 1
Brooks T Roygardner L amp Artiga S 2019 Medicaid and CHIP Eligibility Enrollment and Cost Sharing Policies as of January 2019 Findings from a 50-State Survey Henry J Kaiser Family Foundation
CMS (Centers for Medicare amp Medicaid Services) 2014 Letter from Cindy Mann to state Medicaid directors regarding Medicaid payment for services provided without charge (free care)rdquo December 15 2014 Baltimore MD CMS httpswwwmedicaidgovfederal-policy-guidancedownloadssmd-medicaid-payment-forservices-provided-without-charge-free-carepdf
CMS ldquoManaged Carerdquo httpswwwmedicaidgovmedicaidmanaged-careindexhtml
Chester A and Wright Burak E Fact Sheet Medicaidrsquos Role for Young Children Georgetown University Health Policy Institute Center for Children and Families 13 Dec 2016 httpsccfgeorgetownedu20161213fact-sheet-medicaids-role-for-young-children
Florida Agency for Health Care Administration httpsahcamyfloridacomMedicaidstatewide_mcpdfSMMC_Region_mappdf
Kaiser Family Foundation httpswwwkfforgmedicaidstate-indicatortotal-medicaid-mcoscurrentTimeframe=0ampsortModel=7B22colId2222Location2222sort2222asc227D
Kentucky Cabinet for Family Health and Family Services httpschfskygovagenciesdmsdpqomco-cmbPagesmco-optionsaspx
Ku L Steinmetz E and Bysshe T (2015) Continuity of Medicaid Coverage in an Era of Transition (Working Paper) Milken Institute of Public Health George Washington University
References pt 2
MACPAC (Medicaid and CHIP Payment and Access Commission) Behavioral Health Benefits httpswwwmacpacgovsubtopicbehavioral-health-benefits
MACPAC Issue Brief Medicaid in Schools Washington DC April 2018
MACPAC Section 3 Program enrollment and spendingmdashMedicaid managed care Washington DC December 2016
Mississippi Division of Medicaid httpsmedicaidmsgovprogramsmanaged-care SAMHSA (Substance Abuse and Mental Health Services Administration) Mental Health
Technology Transfer Center Network httpsmhttcnetworkorg
Tuck K amp Smith E ldquoBehavioral Health Coverage in Medicaid Managed Carerdquo Institute for Medicaid Innovation April 2019 httpswwwmedicaidinnovationorg_imagescontent2019-IMI-Behavioral_Health_in_Medicaid-Reportpdf
Urban Institute tabulations of 20132016 American Community Survey (ACS) data from the Integrated Public Use Microdata Series (IPUMS) from Jennifer Haley Genevieve Kenney Robin Wang Victoria Lynch and Matthew Buettgens MedicaidCHIP Participation Reached 937 Percent Among Eligible Children In 2016 The Urban Institute Washington DC August 2018
Wen H Wilk A S Druss B G amp Cummings J R 2019 Medicaid Acceptance by Psychiatrists Implications for Medicaid Expansion JAMA Psychiatry epub 5 Jun 2019
Interviews and survey data collection (state and local)
Barriers and facilitators to leveraging Medicaid to finance
SBMH services and programs
Similar issues for other funding sources particularly
Dept of Education
Relative importance of funding sources
Forthcoming webinars to present findings (stay tuned)
Ongoing Activities at the
SE MHTTC
Thank you
Please contact me with questions
E-mail adamswilkemoryedu
Twitter adamswilk
httpsmhttcnetworkorgcenterssoutheast-mhttchome
References pt 1
Brooks T Roygardner L amp Artiga S 2019 Medicaid and CHIP Eligibility Enrollment and Cost Sharing Policies as of January 2019 Findings from a 50-State Survey Henry J Kaiser Family Foundation
CMS (Centers for Medicare amp Medicaid Services) 2014 Letter from Cindy Mann to state Medicaid directors regarding Medicaid payment for services provided without charge (free care)rdquo December 15 2014 Baltimore MD CMS httpswwwmedicaidgovfederal-policy-guidancedownloadssmd-medicaid-payment-forservices-provided-without-charge-free-carepdf
CMS ldquoManaged Carerdquo httpswwwmedicaidgovmedicaidmanaged-careindexhtml
Chester A and Wright Burak E Fact Sheet Medicaidrsquos Role for Young Children Georgetown University Health Policy Institute Center for Children and Families 13 Dec 2016 httpsccfgeorgetownedu20161213fact-sheet-medicaids-role-for-young-children
Florida Agency for Health Care Administration httpsahcamyfloridacomMedicaidstatewide_mcpdfSMMC_Region_mappdf
Kaiser Family Foundation httpswwwkfforgmedicaidstate-indicatortotal-medicaid-mcoscurrentTimeframe=0ampsortModel=7B22colId2222Location2222sort2222asc227D
Kentucky Cabinet for Family Health and Family Services httpschfskygovagenciesdmsdpqomco-cmbPagesmco-optionsaspx
Ku L Steinmetz E and Bysshe T (2015) Continuity of Medicaid Coverage in an Era of Transition (Working Paper) Milken Institute of Public Health George Washington University
References pt 2
MACPAC (Medicaid and CHIP Payment and Access Commission) Behavioral Health Benefits httpswwwmacpacgovsubtopicbehavioral-health-benefits
MACPAC Issue Brief Medicaid in Schools Washington DC April 2018
MACPAC Section 3 Program enrollment and spendingmdashMedicaid managed care Washington DC December 2016
Mississippi Division of Medicaid httpsmedicaidmsgovprogramsmanaged-care SAMHSA (Substance Abuse and Mental Health Services Administration) Mental Health
Technology Transfer Center Network httpsmhttcnetworkorg
Tuck K amp Smith E ldquoBehavioral Health Coverage in Medicaid Managed Carerdquo Institute for Medicaid Innovation April 2019 httpswwwmedicaidinnovationorg_imagescontent2019-IMI-Behavioral_Health_in_Medicaid-Reportpdf
Urban Institute tabulations of 20132016 American Community Survey (ACS) data from the Integrated Public Use Microdata Series (IPUMS) from Jennifer Haley Genevieve Kenney Robin Wang Victoria Lynch and Matthew Buettgens MedicaidCHIP Participation Reached 937 Percent Among Eligible Children In 2016 The Urban Institute Washington DC August 2018
Wen H Wilk A S Druss B G amp Cummings J R 2019 Medicaid Acceptance by Psychiatrists Implications for Medicaid Expansion JAMA Psychiatry epub 5 Jun 2019
Thank you
Please contact me with questions
E-mail adamswilkemoryedu
Twitter adamswilk
httpsmhttcnetworkorgcenterssoutheast-mhttchome
References pt 1
Brooks T Roygardner L amp Artiga S 2019 Medicaid and CHIP Eligibility Enrollment and Cost Sharing Policies as of January 2019 Findings from a 50-State Survey Henry J Kaiser Family Foundation
CMS (Centers for Medicare amp Medicaid Services) 2014 Letter from Cindy Mann to state Medicaid directors regarding Medicaid payment for services provided without charge (free care)rdquo December 15 2014 Baltimore MD CMS httpswwwmedicaidgovfederal-policy-guidancedownloadssmd-medicaid-payment-forservices-provided-without-charge-free-carepdf
CMS ldquoManaged Carerdquo httpswwwmedicaidgovmedicaidmanaged-careindexhtml
Chester A and Wright Burak E Fact Sheet Medicaidrsquos Role for Young Children Georgetown University Health Policy Institute Center for Children and Families 13 Dec 2016 httpsccfgeorgetownedu20161213fact-sheet-medicaids-role-for-young-children
Florida Agency for Health Care Administration httpsahcamyfloridacomMedicaidstatewide_mcpdfSMMC_Region_mappdf
Kaiser Family Foundation httpswwwkfforgmedicaidstate-indicatortotal-medicaid-mcoscurrentTimeframe=0ampsortModel=7B22colId2222Location2222sort2222asc227D
Kentucky Cabinet for Family Health and Family Services httpschfskygovagenciesdmsdpqomco-cmbPagesmco-optionsaspx
Ku L Steinmetz E and Bysshe T (2015) Continuity of Medicaid Coverage in an Era of Transition (Working Paper) Milken Institute of Public Health George Washington University
References pt 2
MACPAC (Medicaid and CHIP Payment and Access Commission) Behavioral Health Benefits httpswwwmacpacgovsubtopicbehavioral-health-benefits
MACPAC Issue Brief Medicaid in Schools Washington DC April 2018
MACPAC Section 3 Program enrollment and spendingmdashMedicaid managed care Washington DC December 2016
Mississippi Division of Medicaid httpsmedicaidmsgovprogramsmanaged-care SAMHSA (Substance Abuse and Mental Health Services Administration) Mental Health
Technology Transfer Center Network httpsmhttcnetworkorg
Tuck K amp Smith E ldquoBehavioral Health Coverage in Medicaid Managed Carerdquo Institute for Medicaid Innovation April 2019 httpswwwmedicaidinnovationorg_imagescontent2019-IMI-Behavioral_Health_in_Medicaid-Reportpdf
Urban Institute tabulations of 20132016 American Community Survey (ACS) data from the Integrated Public Use Microdata Series (IPUMS) from Jennifer Haley Genevieve Kenney Robin Wang Victoria Lynch and Matthew Buettgens MedicaidCHIP Participation Reached 937 Percent Among Eligible Children In 2016 The Urban Institute Washington DC August 2018
Wen H Wilk A S Druss B G amp Cummings J R 2019 Medicaid Acceptance by Psychiatrists Implications for Medicaid Expansion JAMA Psychiatry epub 5 Jun 2019
References pt 1
Brooks T Roygardner L amp Artiga S 2019 Medicaid and CHIP Eligibility Enrollment and Cost Sharing Policies as of January 2019 Findings from a 50-State Survey Henry J Kaiser Family Foundation
CMS (Centers for Medicare amp Medicaid Services) 2014 Letter from Cindy Mann to state Medicaid directors regarding Medicaid payment for services provided without charge (free care)rdquo December 15 2014 Baltimore MD CMS httpswwwmedicaidgovfederal-policy-guidancedownloadssmd-medicaid-payment-forservices-provided-without-charge-free-carepdf
CMS ldquoManaged Carerdquo httpswwwmedicaidgovmedicaidmanaged-careindexhtml
Chester A and Wright Burak E Fact Sheet Medicaidrsquos Role for Young Children Georgetown University Health Policy Institute Center for Children and Families 13 Dec 2016 httpsccfgeorgetownedu20161213fact-sheet-medicaids-role-for-young-children
Florida Agency for Health Care Administration httpsahcamyfloridacomMedicaidstatewide_mcpdfSMMC_Region_mappdf
Kaiser Family Foundation httpswwwkfforgmedicaidstate-indicatortotal-medicaid-mcoscurrentTimeframe=0ampsortModel=7B22colId2222Location2222sort2222asc227D
Kentucky Cabinet for Family Health and Family Services httpschfskygovagenciesdmsdpqomco-cmbPagesmco-optionsaspx
Ku L Steinmetz E and Bysshe T (2015) Continuity of Medicaid Coverage in an Era of Transition (Working Paper) Milken Institute of Public Health George Washington University
References pt 2
MACPAC (Medicaid and CHIP Payment and Access Commission) Behavioral Health Benefits httpswwwmacpacgovsubtopicbehavioral-health-benefits
MACPAC Issue Brief Medicaid in Schools Washington DC April 2018
MACPAC Section 3 Program enrollment and spendingmdashMedicaid managed care Washington DC December 2016
Mississippi Division of Medicaid httpsmedicaidmsgovprogramsmanaged-care SAMHSA (Substance Abuse and Mental Health Services Administration) Mental Health
Technology Transfer Center Network httpsmhttcnetworkorg
Tuck K amp Smith E ldquoBehavioral Health Coverage in Medicaid Managed Carerdquo Institute for Medicaid Innovation April 2019 httpswwwmedicaidinnovationorg_imagescontent2019-IMI-Behavioral_Health_in_Medicaid-Reportpdf
Urban Institute tabulations of 20132016 American Community Survey (ACS) data from the Integrated Public Use Microdata Series (IPUMS) from Jennifer Haley Genevieve Kenney Robin Wang Victoria Lynch and Matthew Buettgens MedicaidCHIP Participation Reached 937 Percent Among Eligible Children In 2016 The Urban Institute Washington DC August 2018
Wen H Wilk A S Druss B G amp Cummings J R 2019 Medicaid Acceptance by Psychiatrists Implications for Medicaid Expansion JAMA Psychiatry epub 5 Jun 2019
References pt 2
MACPAC (Medicaid and CHIP Payment and Access Commission) Behavioral Health Benefits httpswwwmacpacgovsubtopicbehavioral-health-benefits
MACPAC Issue Brief Medicaid in Schools Washington DC April 2018
MACPAC Section 3 Program enrollment and spendingmdashMedicaid managed care Washington DC December 2016
Mississippi Division of Medicaid httpsmedicaidmsgovprogramsmanaged-care SAMHSA (Substance Abuse and Mental Health Services Administration) Mental Health
Technology Transfer Center Network httpsmhttcnetworkorg
Tuck K amp Smith E ldquoBehavioral Health Coverage in Medicaid Managed Carerdquo Institute for Medicaid Innovation April 2019 httpswwwmedicaidinnovationorg_imagescontent2019-IMI-Behavioral_Health_in_Medicaid-Reportpdf
Urban Institute tabulations of 20132016 American Community Survey (ACS) data from the Integrated Public Use Microdata Series (IPUMS) from Jennifer Haley Genevieve Kenney Robin Wang Victoria Lynch and Matthew Buettgens MedicaidCHIP Participation Reached 937 Percent Among Eligible Children In 2016 The Urban Institute Washington DC August 2018
Wen H Wilk A S Druss B G amp Cummings J R 2019 Medicaid Acceptance by Psychiatrists Implications for Medicaid Expansion JAMA Psychiatry epub 5 Jun 2019
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