NASHP

American Rescue Plan Act Allows States to Expand Mobile Crisis Intervention Services for Children and Youth Through Medicaid

August 2, 2021/by Olivia Randi

The behavioral health needs of children and youth have grown during the COVID-19 pandemic due to various factors including disruptions in care, social isolation, trauma exposure, and financial instability. These needs have highlighted and exacerbated the shortage of available pediatric behavioral health services in many states. Children experiencing behavioral health crises are increasingly being served by emergency departments, and are often responded to by law enforcement, but these encounters may result in a range of adverse outcomes.

Mobile crisis intervention services (MCIS) can support appropriate responses to youth behavioral health crises while reducing the need for emergency department use and law enforcement involvement. States can leverage a new state option through the American Rescue Plan Act (ARPA) to access an enhanced federal matching rate and expand the availability of MCIS through state Medicaid programs. There are specific considerations for states that choose to implement this option in designing MCIS for children and youth.

Section 9813 of the ARPA creates a new state Medicaid option for qualifying community mobile crisis intervention services. States that implement this option can receive an 85 percent federal match for MCIS provided to Medicaid beneficiaries for three years starting on April 1, 2022. In order for MCIS to qualify for the enhanced federal match rate, MCIS must be provided to Medicaid beneficiaries experiencing a behavioral health crisis by a team that is available twenty-four seven, 365 days per year. These teams must meet training requirements, including trauma-informed care, and maintain partnerships with community-based providers. States have flexibility in defining staffing requirements for the team, as long as at least one behavioral health professional in the team is qualified to conduct a behavioral health assessment. ARPA also provides funding for planning grants to support states in developing a state plan amendment or waiver authority (e.g., 1915(b), 1915(c), 1115) to implement this option. Final applications for this grant opportunity are due August 13, 2021.

While Medicaid is an important funding source for MCIS in some states, there is wide variation in how MCIS are covered by state Medicaid programs and how states reimburse crisis providers. For example, some states define MCIS within their policy manuals as a covered service, while others do not define it, but allow MCIS providers to bill for Crisis Intervention Services. MCIS may include numerous service and operational costs, such as for travel time for MCIS teams to reach the individual’s location and state Medicaid programs typically do not cover all components of a MCIS system. As a result, these services are often funded through a combination of state and local general funds, Medicaid programs, and other sources. Medicaid typically covers MCIS for both children and adults, but many crisis systems serve adults and children through separate parallel programs, which can contribute to the complexity of MCIS financing and service delivery.

Behavioral Health Needs of Children and Youth 

The mental health needs of children and youth have been rising for over a decade. These trends have been accelerated by the pandemic, as children and youth have experienced higher rates of mental health crises, suicidal ideation and suicide attempts. This trend also appears to apply to increased rates of substance use among adolescents. Many states face limitations in addressing behavioral health needs, including behavioral health workforce shortages that limit access to care.

Children and youth who are Black, Latinx, American Indian/Alaska Native, and Asian are at higher risk of mental health needs than non-Latinx white adolescents, yet face greater barriers in accessing mental health services. Suicide-related behavior and suicidal ideation is most common among children and youth who are American Indian/Alaska Native, and the suicidal death rate is growing the fastest among Black youth in comparison to any racial or ethnic group. Mental health disparities may widen due to the pandemic, given the disproportionate impact of COVID-19 on families of color.

Emergency Department Use and Law Enforcement Response 

In the absence of adequate and accessible behavioral health and crisis support services, emergency departments and law enforcement agencies are often the first line of response to children and youth experiencing a behavioral health emergency. Children experiencing a behavioral health crisis have increasingly relied on emergency departments, which are often ill-equipped to provide psychiatric treatment and support services for pediatric populations. This has been exacerbated during the pandemic, as a greater proportion of pediatric emergency department visits have been behavioral-health related.  Use of emergency services also can result in law enforcement involvement with an estimated six to ten percent of police encounters in the U.S. involving a person (of any age) with a mental health need. Law enforcement involvement in youth behavioral health crisis response may result in emergency department use, arrest, and juvenile justice involvement for children who would be better supported through behavioral health services, and can also lead to higher overall costs for states.

In comparison to White children, Black and Latinx youth experiencing a behavioral health crisis are more likely to face a law enforcement response rather than connection to services. Law enforcement responses can be punitive and lead to increased stigma and trauma for families. For children who are Black, these encounters may be particularly distressing given the history of over-policing and police use of force in Black communities and the resulting racial trauma.

Youth Mobile Crisis Intervention Services 

MCIS are provided by teams of professionals that are available to respond to a person experiencing a behavioral health crisis at their current location (e.g., home, school, work). The MCIS provided by these teams include screening and assessment, stabilization and de-escalation services, and connections to community-based services and supports. MCIS teams can serve as an important response option for children, youth and adults  experiencing a behavioral health crisis, and may reduce law enforcement involvement and prevent emergency department use, which may have the potential to both reduce costs for states and improve behavioral health outcomes for affected individuals. According to national guidelines from the Substance Abuse and Mental Health Services Administration (SAMHSA), MCIS are one component of a comprehensive crisis system, which also includes crisis call centers and crisis receiving centers. A comprehensive crisis system, along with a strong network of community-based health and social services, are critical to best supporting the health and health-related social needs of adults, children, and families.

Given that 38 percent of children were covered by Medicaid and CHIP as of 2019 – and this rate has been increasing during the pandemic – this new option is an important opportunity for states to support more comprehensive MCIS while reducing emergency department use and law enforcement involvement in responses to persons experiencing a behavioral health crisis. While it is still too early to know which states will pursue this option, states can consider the following strategies to utilize the new MCIS funding through ARPA and meet the unique needs of children and youth:

  • Supporting partnerships and formalized policies between mobile crisis systems and other child-serving systems (e.g., public health, education, mental health, social services, and child welfare).Connecticut’s School-Based Diversion Initiative is an interagency partnership between the state’s Court Support Services Division of the Judicial Branch, Department of Children and Families, State Department of Education, and the Connecticut Department of Mental Health and Addiction Services. This initiative supports schools in connecting students to community-based services in an effort to prevent in-school arrests, expulsions, and suspensions. A key component of this initiative is providing guidance and training for schools in collaborating with mobile crisis services.
  • Recommending or requiring family or youth peer support specialists as members of mobile crisis teams.Oklahoma’s Mobile Response Stabilization System is a statewide mobile crisis system for children, youth, and young adults operated through the Oklahoma Department of Mental Health and Substance Abuse Services (ODMHSAS). The teams that deliver MCIS services are contracted through ODMHSAS or the state Medicaid agency, and may include a licensed behavioral health professional and a care coordinator, family support provider, and/or peer support specialist.
  • Providing child- and family-centered training for mobile crisis systems. In Massachusetts, the Medicaid program, MassHealth, contracts with a behavioral health organization that manages MCIS for children and youth across the state, in collaboration with the state Department of Mental Health. The state has developed practice guidelines for these services specific to children and youth. This includes special considerations for transition-age youth, those involved with the Department of Children and Families, and those involved with the juvenile justice system. The guidelines also include information to support culturally and linguistically competent MCIS for families.
  • Implementing a standardized crisis screening and assessment tool for children and youth.Nevada’s Division of Child and Family Services operates Mobile Crisis Response Teams throughout the state to respond to children and youth experiencing a behavioral health crisis. These teams use the Crisis Assessment Tool, which is designed to assess a child’s strengths and needs during a crisis, as well as a Crisis Needs Assessment to assess the family’s strengths and needs, both with the goal of identifying appropriate interventions most likely to yield positive behavioral health outcomes.

MCIS are an important component of a crisis intervention system that can improve responses and outcomes for Medicaid beneficiaries, including children and youth, experiencing a behavioral health crisis. As behavioral health needs among children and youth have risen during the COVID-19 pandemic, the new state option established through ARPA offers an important opportunity for states to expand access to MCIS. Since the enhanced federal funding under ARPA for this state option expires after three years, states may be less likely to adopt this option. However, states that elect to pursue this provision may use it as an opportunity to pilot a new funding mechanism to support MCIS, expand state funding for existing programs, and identify strategies for sustaining these programs long term.

As states develop and enhance policies to support MCIS, they can consider how to align these services with the implementation of 988, a national crisis and suicide prevention hotline that will take effect in July 2022. Additional federal legislation has been introduced that may further support states in providing MCIS, including S.764, CAHOOTS Act and H.R. 1368, Mental Health Justice Act of 2021. The National Academy for State Health Policy will continue to track how states are supporting crisis intervention service systems for children and youth.

Acknowledgements: This issue brief was supported by the Health Resources and Services Administration (HRSA) of the US Department of Health and Human Services (HHS) under grant number U2MOA39467 the National Organizations of State and Local Officials co-operative agreement. This information or content and conclusions are those of the authors and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the US government.

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