(As of April 2013)
At a glance:
- The Children’s Mental Health Division of the state mental health authority supports community-based service for children, including through local children’s mental health collaborative
- Separate billing is allowed for standardized developmental and mental health screening instruments in primary care settings, and the state has compiled a list of screening instruments
- The state implemented a Medicaid benefit, children’s therapeutic services and supports, for children with a range of therapeutic and rehabilitative behavioral health needs
- The state has supported the expansion of evidence based early childhood mental health services for children birth to five throughout the state.
Minnesota, through a robust partnership between Medicaid and the state children’s mental health authority, has worked to increase developmental and mental health screenings for Medicaid-enrolled children and to develop a package of mental health treatment services and supports for children. (The Medicaid children’s benefit is also known as the Early and Periodic, Screening Diagnostic, and Treatment benefit or EPSDT.) Children in Medicaid enroll in the Minnesota Prepaid Medical Assistance Program, a comprehensive Medicaid managed care program that includes mental health and substance abuse services. The mental health screening and treatment services covered by Medicaid are specified by the Department of Human Services (DHS)—which houses the Medicaid program—and included in managed care contracts.
Coordination and Collaboration
The state Medicaid agency and the state mental health authority, both located within the DHS, work together in close collaboration. The state mental health authority is responsible for Medicaid behavioral health policy within the department; accordingly, the authority’s Children’s Mental Health Division (CMHD) assumes responsibility for children’s behavioral health policy in Medicaid. The CMHD is responsible for supporting an array of community-based mental health services for children.
The CMHD works with other county and state-level partners to implement developmental and mental health screenings for children across agencies and child-serving systems in Minnesota. State law requires that children in the juvenile justice and child welfare systems receive mental health screenings; in addition to working with those partners, CMHD has worked with Head Start agencies, early childhood and education programs, and the Medicaid children’s benefit (also known as the Early and Periodic, Screening Diagnostic, and Treatment benefit or EPSDT) to promote screening.
Since 1993 the state has had a Children’s Mental Health Integrated Fund that supports a number of children’s mental health collaborative and family services collaborative. These collaborative connect key partners—including counties, school districts, local mental health entities, juvenile corrections, public health, parents, and other community-based organizations—to provide wraparound services for children with serious emotional disturbance (SED). The collaborative pool funding, including Medicaid dollars, to design a set of integrated and coordinated services for children. The collaborative help to create links across governmental agencies and other organizations to provide individualized care to meet each child’s needs.
Screening, Assessment and Referrals
Beginning in 2004, under the Assuring Better Child Development (ABCD) II program, Minnesota committed to expanding early childhood mental health screenings and establishing a separate billing mechanism for the screens. The state followed up on this with an ABCD III project, Communities Coordinating for Health Development, beginning in 2009 that sought to create more effective linkages between primary care practices and other child and family service providers in the community for young children identified as at-risk for developmental delays through standardized screening.
Minnesota’s provider manual for Child and Teen Checkups (Minnesota’s name for the Medicaid children’s benefit) states that providers can receive additional reimbursement for developmental and mental health screenings during well-child visits if they use a standardized screening instrument; providers must document this by providing the name of the instrument used, the score, and the anticipatory guidance provided based on the screening results. If the screenings are done without the use of a standardized instrument, then the reimbursement for the screening is included in the payment of the evaluation and management code used for the visit and cannot be billed separately.
Providers are instructed to use the CPT code 96110 to bill for developmental screenings conducted with a standardized instrument; the same code, when used with a modifier (UC), is used to indicate a mental health screening conducted with a standardized instrument. The state allows providers to bill both a developmental and a mental health screening on the same date of service on the same claim, though the manual is clear that no single recommended standardized instrument can cover both developmental and mental health screening.
The Department of Human Services and Department of Health jointly produced a fact sheet on socio-emotional/mental health for primary care providers offering well-child visits to Medicaid-enrolled children. In addition to recommendations for mental health history items to include and tips for how to conduct mental health and chemical use screenings, the fact sheet lists three recommended social-emotional/mental health screening instruments: the Ages & States Questionnaire: Social—Emotional (ASQ:SE), the Brief Infant Toddler Social Emotional Assessment (BITSEA), and the Pediatric Symptom Checklist (PSC). The departments have also produced an “All Instruments at a Glance” chart that compares features of these three instruments, as well as a range of standardized developmental screening instruments.
The Department of Human Services has also moved to place greater emphasis on screening for co-occurring substance abuse and mental health disorders. In June 2011, substance use disorders screenings became a required component of Medicaid-reimbursable mental health diagnostic assessments. The department has approved two standardized screening tools for the detection of co-occurring disorders: the CAGE-Adapted to Include Drugs (CAGE-AID) and the Global Appraisal of Individual Needs – Short Screener (GAIN-SS). The department noted in its provider bulletin that the CAGE-AID is validated for use with adolescents aged 12-17, while the GAIN-SS is validated for adolescents aged 10 or older.
Following a screening, a face-to-face diagnostic assessment must be completed by a mental health professional to determine if a Medicaid beneficiary is eligible for mental health services. In 2011 the State of Minnesota revised its Mental Health Outpatient Rules to include extended diagnostic assessments for children under the age of five using the DC:0-3R- a diagnostic process for young children grounded in developmental and attachment theory. Since 2004, over 1000 mental health professionals have been trained in using the DC:0-3R. In addition, the Department of Human Services requires mental health providers to utilize at intake the Child & Adolescent Service Intensity Instrument (CASII) or the Early Childhood Service Intensity Instrument (ECSII) and the Strength & Difficulties Questionnaire (SDQ) on all children under 6 years of age receiving mental health services.
A number of mental health treatment services are available to children under Medicaid, ranging from inpatient and outpatient mental health treatment and medication management to more specialized services for children. Managed care organizations (MCOs) in Minnesota are responsible for securing access to behavioral health treatment services for Medicaid-enrolled children who need them, including chemical dependency services such as Screening Brief Intervention and/or Referral to Treatment in primary care clinics.
Medicaid covers psychiatric consultations to primary care providers (including pediatricians) via phone, email, and other means of communication. Children under the age of 18 meeting the criteria for serious emotional disturbance (SED) are eligible for children’s mental health residential treatment. Residential treatment is designed to help the child to improve family living and social interaction skills to facilitate a return to the community. Children’s Mental Health Targeted Case Management (or a substitute model offered by the MCO) provides children with SED access to a case manager who works with the family to develop an individual family community support plan.
For children experiencing a mental health crisis, Minnesota Medicaid supports Children’s Mental Health Crisis Response Services. The statute authorizing them specifies that these supports include mental health crisis assessments, mental health mobile crisis intervention services, and mental health crisis stabilization services. Before they can receive crisis services, children must be screened for a potential crisis, followed by a crisis assessment that evaluates the child’s immediate needs. Mental health mobile crisis intervention services are short-term intensive mental health services that are provided on site and face-to-face during a mental health crisis emergency. They are intended to help children cope with immediate stressors, identify and utilize available resources and strengths, and begin to return to a baseline level of functioning. Crisis stabilization services include further assessment, help with referrals, updates to the crisis stabilization treatment plan, supportive counseling, skills training, and collaboration with other service providers in the community.
Minnesota has also designed a set of rehabilitative mental health services for children. Medicaid covers children’s therapeutic services and supports, defined by the state as a flexible package of mental health services for children who require varying therapeutic and rehabilitative levels of intervention. These supports are available under the Medicaid benefit and include: individual, family, and group psychotherapy; individual, family, or group skills training provided by a mental health professional or mental health practitioner; crisis assistance; mental health behavioral aide services; and direction of a mental health behavioral aide. These services can be combined to form therapeutic programs, including children’s day treatment programs and therapeutic preschool programs.
In December 2012, the CMHD notified providers that Youth Assertive Community Treatment (ACT) would become a covered service under Medicaid once it is added to the State Medicaid Plan and approved by the Centers for Medicare and Medicaid Services. Youth ACT is an intensive rehabilitative service provided by an interdisciplinary team to a youth with a serious mental illness.
In providing access to mental health treatment services, MCOs agree to certain stipulations for care delivery. MCO contract language requires MCO care management systems to include procedures for coordinating with care coordination and services provided by the children’s mental health collaborative and the family services collaboratives. MCOs must also reimburse the travel time of mental health providers who provide community-based mental health services at a place other than their usual place of work. They must also allow telemedicine to be utilized for covered mental health services.
The authors wish to thank the many state officials and stakeholders who contributed to and reviewed the information in this document.
This document was prepared by NASHP for the Centers for Medicare & Medicaid Services (CMS) under a contract to NORC at the University of Chicago. It does not reflect the views of CMS.