MEDICAID

EPSDT and BHRS

The Greatest Treatment

Funding Secret
Ever Concealed
Steven Kossor, Licensed Psychologist
Executive Director, The Institute for Behavior Change
The short version….
 A word of
thanks….

US Congressman Jim Gerlach

has been a strong supporter of
the Institute for Behavior
Change and of my efforts to
bring quality mental health
treatment services to people,
especially those who have
developmental disabilities,
for many years. I deeply
appreciate his consistent and
enthusiastic endorsement of
my work and look forward to
future opportunities to share
new ideas with others.

Steve Kossor
July 9, 1868 (the first Johnson Administration)

14th Amendment to the Constitution

All US citizens [of any age] shall have

equal protection under the law.

rich or poor
rich or poor
rich or poor
rich or poor
rich or poor
1965 (the second Johnson Administration)

“A great society protects its weakest members.”

Medicaid is created as a joint federal and state

program to finance health care treatment for
diagnosed, episodic illness in low-income
individuals.

It has no specific standards related to children.

1965

Medicaid:
To provide Medically Necessary
treatment to those who need it.

Requires no Federal Reauthorization.

It’s▲forever.
functionally
1965 Medicaid “Medical Necessity”

Is it Reasonable?
Is it Necessary?
Is it Appropriate, according to
evidence-based practices?

Then it’s Medically

Necessary.
1967 Height of the Vietnam war

50% of draftees
ARE UNFIT FOR MILITARY SERVICE!
(because of untreated childhood illnesses)

Who will fight our wars?

 1967 E arly and P eriodic S creening, D iagnosis and T
reatment

For children under 21 years of age:

Question: Is it intended to correct or

ameliorate defects & physical & mental
illnesses and conditions discovered by
the screening process?

Yes? Then it’s “Medically Necessary.”

Each state is permitted to create its own version of the “medically necessary” treatment
definition, but all states are required to comply with the federal EPSDT standard in order to
continue accessing federal Medicaid funds, so the definitions can’t stray too far…..
1988 and 1989

The Medicare Catastrophic Coverage Act

of 1988, P.L.100-360
Less-restrictive Medicaid eligibility standards

The Omnibus Budget Reconciliation Act

of 1989
Mandatory EPSDT services in all 50 states
No “Asset Test” for Medicaid Eligibility
Medicaid Spending in 2004 (in millions)
Medicaid Cost Containment Efforts

Note: Most changes do not apply to “EPSDT”

Positive Changes in Medicaid

Note: Most changes do apply to “EPSDT”

Key concepts in treatment funding
 EPSDT services must be provided
to children enrolled in Medicaid
whether or not the services are
provided for in any State Plan.

 Medicaid, not the school, must

pay for covered services to a child
if funding is in dispute.
Pending Plans for changes in Medicaid
What is the official PA DPW
stance on Behavioral Health
Rehabilitation Services
(BHRS)?

This is an excerpt from the

document submitted to the
CMS by Pennsylvania’s DPW
regarding the changes that
the CMS was proposing to the
“Rehabilitation Option.”
Rehabilitation vs. “habilitation”

Treatment Effect

“Neurotypical”

With Treatment

Without Treatment
 EPSDT Benefits
 Treatment AND Prevention services
 Physical, Speech & Related Therapies
 Hearing Services
 Eye Examinations & Eyeglasses
 Durable Medical Equipment
 Home, Residential & Inpatient Care
 Dental Care
 Other Services (including mental health care)

The remainder of this presentation will focus on the

Behavioral Health Rehabilitation Services that can be
delivered to disabled children through the EPSDT
mandate of Medicaid. See 42 USC §1396d (r) (5).
 2005 The Deficit Reduction Act (DRA)
Children will… “still be entitled to receive EPSDT
benefits in addition to the benefits provided by the
benchmark coverage...”

The Centers for Medicare and Medicaid Services (CMS)

“will not approve any state Medicaid plan that does not
include the provision of EPSDT benefits.”

CMS Administrator Mark B. McClellan, “Statement on EPSDT Coverage for Children Under 19,” April 2006.
Available at www.tilrc.org/Real%20Choice%20Website/epsdt0406htm.
 42 CFR Chapter VII Subchapter XIX §1396d
[Sec. 1905(a)] “The Social Security Act”

Definitions
For purposes of this subchapter—

(a) Medical assistance

The term “medical assistance” means payment of part or all

of the cost of the following care and services …

(if provided in or after the third month before the

month in which the recipient makes application for
assistance) …

for individuals who are—

(i) under the age of 21, or, at the option of the State,
under the age of 20, 19, or 18 as the State may choose,
…
42 CFR Chapter VII Subchapter XIX §1396d
[Sec. 1905(r)(5)] “The Social Security Act”

(r) Early and periodic screening, diagnostic, and treatment services

(5) Such other necessary health care, diagnostic services, treatment,

and other measures described in subsection (a) of this section to
correct or ameliorate defects and physical and mental illnesses and
conditions discovered by the screening services, whether or not such
services are covered under the State plan.

Nothing in this subchapter shall be construed as limiting

providers of early and periodic screening, diagnostic, and
treatment services to providers who are qualified to provide all of
the items and services described in the previous sentence or as
preventing a provider that is qualified under the plan to furnish
one or more (but not all) of such items or services from being
qualified to provide such items and services as part of early and
periodic screening, diagnostic, and treatment services.
42 CFR Chapter IV Part 440.130
[Sec. 1905(a)(13)] “The Social Security Act”
(a) ‘‘Diagnostic services,’’ except as otherwise provided under this subpart,
includes any medical procedures or supplies recommended by a physician or
other licensed practitioner of the healing arts, within the scope of his practice
under State law, to enable him to identify the existence, nature, or extent of
illness, injury, or other health deviation in a recipient.

(c) ‘‘Preventive services’’ means services provided by a physician or other

licensed practitioner of the healing arts within the scope of his practice under
State law to
(1) Prevent disease, disability, and other health conditions or their progression;
(2) Prolong life; and
(3) Promote physical and mental health and efficiency.

(d) ‘‘Rehabilitative services,’’ except as otherwise provided under this subpart,

includes any medical or remedial services recommended by a physician or
other licensed practitioner of the healing arts, within the scope of his practice
under State law, for maximum reduction of physical or mental disability and
restoration of a recipient to his best possible functional level.
Medicaid Eligibility:
CATEGORICALLY needy

 Qualified Medicare beneficiaries

 Pregnant women
 Low-income families with children
 Supplemental Security Income (SSI)
recipients
 Anyone under age 21 with income less
than a specified percent of the Federal
Poverty Level
Medicaid Eligibility:
Medically Needy
 Those who, except for income and
resources (assets), would be eligible
as “categorically needy.”
 There are no “asset tests” anymore.
 How much “income” does a child have?

 Does parental income always “count?”

hint: no
Pennsylvania’s “Medically Necessary”
definition under Medicaid Regulations
STATEMENT OF POLICY DEPARTMENT OF PUBLIC WELFARE
OFFICE OF MEDICAL ASSISTANCE PROGRAMS
[55 Pa. Code Chapter 1101] General Provisions

§1101.21a. Clarification Regarding the Definition of “Medically Necessary” –

statement of policy.

A service, item, procedure or level of care that is necessary for the proper treatment
or management of an illness, injury or disability is one that:

(1) Will, or is reasonably expected to, prevent the onset of an illness,

condition, injury or disability.

(2) Will, or is reasonably expected to, reduce or ameliorate the physical, mental
or developmental effects of an illness, condition, injury or disability.

(3) Will assist the recipient to achieve or maintain maximum functional capacity
in performing daily activities, taking into account both the functional
capacity of the recipient and those functional capacities that are
appropriate of recipients of the same age.
 Who decides if treatment is
“medically necessary”

If a licensed practitioner of the

healing arts prescribes a treatment
“to correct or ameliorate a physical
or mental defect or condition” and it
works, it is medically necessary and
Medicaid can fund it, regardless of
whether it is an “accepted medical
practice” in someone else’s opinion.
The Social Security
“Blue Book”
lists disabilities
that qualify a child
as a person with a
disability under
Medicaid
42 CFR Chapter IV Part 440.230
(b) Each service must be sufficient in amount, duration,
and scope to reasonably achieve its purpose.

(c) The Medicaid agency may not arbitrarily deny or

reduce the amount, duration, or scope of a required
service […] to an otherwise eligible recipient solely
because of the diagnosis, type of illness, or condition.

(d) The agency may place appropriate limits on a

service based on such criteria as medical necessity or
on utilization control procedures. Here enters
the MCO
 The children by numbers
15,575 children receiving Medical Assistance in the County.
(SAMHSA estimates 10% of children require MH treatment)
1,557 children on MA in the County who should be getting
MH treatment (not D&A), based on SAMHSA’s estimate.
658 children on MA in the County who are getting some
Mental Health services from any source whatsoever.

899 children on MA not getting any MH help whatsoever.

But less than 20 cases are on the MCO Waiting List…

Guess which number the MCO & County government

focuses on….
Relationship between “levels of need” and
PA DPW “medical necessity” criteria
Wraparound Philosophy

 Services must be “time limited” (a year or less).

 Services must be “titrated” (reduced over time).
 Services must be replaced by “naturally occurring”
[i.e., low-cost or no-cost] supports as quickly as
possible.
 Treatment skills must be “transferred” to parents
and other caretakers.
 Caretakers must be present at all times while
treatment services are being rendered.
 Services can not be delivered in a doctor’s office.

NONE of this is part of the EPSDT system!

…they make bullets – we make armor
Now, as a professional who has prescribed BHRS treatment, we
expect you to predict exactly what troublesome behavior the
child will be displaying between 10 and 11 am on Mondays,
Tuesdays, Wednesdays…. and use this form to do it.
 Titration that makes sense
T

T
T

Ô
20 20 20 20
 Here are some other things that most
people don’t know anything about….

This is the “last word”

about what children
with Autism spectrum
disorders require in
order to have a
reasonable
probability of
reducing their
symptoms of autism.
© 2001 National Academy Press
Here are some other things that most
people don’t know anything about….

The National Academy

of Sciences completed
this research with
funding from the US
Dept. of Education
and that’s the only
reason it’s called
“Educating” and not
“Treating” children
with Autism.
 Here are some other things that most
people don’t know anything about….

AT LEAST 25 hours of
“intensive, individualized
treatment” every week.

2008:

“There are no other studies

planned. This was intended
to be a definitive report
about what children on the
Autism spectrum need.”
- James P. McGee, Study Director
For every expert, there is an equal and
opposite expert….

BHRS was
never meant
to treat
children with
PART II:
How to treat mental illness in children

We’ve explored the Medicaid statute.

We’ve explored the EPSDT mandate.

We’ve identified what is possible.

Now, we’ll look at what is working.

They Work! 300 Treatment records 2002-2006 Children ages 2-17

Overall Treatment Effectiveness

WORSE
11%

STABILIZED
18%

BETTER
71%
They Work! 300 Treatment records 2002-2006 Children ages 2-17

Lack of Safety Awareness Physical Aggression

STABILIZED
WORSE
6%
11%
WORSE
14%

STABILIZED
14%

BETTER BETTER
85% 72%

Noncompliance with Adult Prompts

WORSE
7%

STABILIZED
11%

BETTER
82%
They Work! 300 Treatment records 2002-2006 Children ages 2-17

Communication Deficits Socialization Deficits

WOR SE WORSE
14%
11%

ST A B I LI ZE D STABILIZED
26% 22%
BETTER BETTER
63% 64%
 One of the 301 treatment records of a
child with an Autism Spectrum Disorder

TSS effect on behavior

12

10

physical aggression
6 socialization
noncompliance

BEFORE TSS AFTER TSS

0
1 2 3 4 5 6 7 8 9 10 11 12 13

Weeks
 Another successful treatment record of a
child with an Autism Spectrum Disorder

TSS effect on behavior

12

10

Safety Awareness
6 P hysical Aggression
Noncompliance

BEFORE TSS AFTER TSS

0
1 2 3 4 5 6 7 8 9 10 11 12 13

Weeks
 They Worked!

treatmentplansthatworked.com

has more than 150 “treatment plans that

worked” available on-line for download
– with the data that documents it.

A subscription with unlimited access (including

loads of information on EPSDT and especially
“BHR” mental health treatment services) is $65
The #1 source for information worldwide
Google “Treatment plans for children”
PA Prescriptions for EPSDT services

Behavior Specialist Consultant (BSC)

 licensed or unlicensed psychologist
 Masters or Doctoral degree “in a clinical field”
 One year of experience working with children
 Philadelphia requires 2 years post-graduate experience

Mobile Therapist (MT)

 licensed or unlicensed psychologist
 Masters or Doctoral degree “in a clinical field”
 One year of experience working with children
BSC and MT providers are supervised closely each week by licensed
psychologists at the Institute for Behavior Change in Pennsylvania.

See http://www.ibc-pa.org/job_descriptions.htm for more information.

TSS? What’s that?

Therapeutic Staff Support (TSS) is provided

in Pennsylvania by a person with a Bachelors
degree (usually in psychology) who works 1:1
with the child for several hours each day, at
home, in school, and in the community.

Prescriptions for 20 or more TSS hours weekly are often

appropriate, necessary and authorized by the MCO if the
child’s behavioral data supports the need for TSS service.
w w w . ib c - p a .or g
 Recommendations
Ribbit…

Parents and others interested in quality mental health care for children
should look into EPSDT Behavioral Health Rehabilitation (BHR)
services. EPSDT is in your state, EPDST BHR Services work, and
they may be totally free regardless of family income.

There isn’t a private health insurance plan anywhere in America that

offers treatment options like EPSDT BHR services.

The Institute for Behavior Change is available to help any State

government, psychologist or other “licensed practitioner of the healing
arts” implement a more successful, cost-efficient, professional and
outcome-based implementation of EPSDT BHR services.

More information is available at www.ibc-pa.org