Behavioral Health in the Medicaid Benefit for Children and Adolescents: Iowa

(As of April 2013) 

At a Glance

  • A unique partnership between the Department of Public Health and the Department of Human Services (Medicaid) uses care coordinators at local Title V agencies to help children access Medicaid services
  • A provider website crosswalks developmental and mental health screening codes to specific tools
  • Three major sources of mental health treatment are available for children: the Iowa Plan for Behavioral Health, Behavioral Health Intervention Services for children in communities or residential settings, and a Children’s Mental Health Waiver for children with a serious emotional disturbance

Introduction

Iowa, through close collaboration between its Department of Human Services, Department of Public Health, and regional Title V agencies, has developed a robust system for providing services, including screenings (e.g. developmental and behavioral health screenings), under the Medicaid children’s benefit and linking children to follow-up services. In Iowa, Medicaid behavioral health services are available through the Iowa Plan for Behavioral Health. The Iowa Plan is a managed care program that delivers mental health and substance abuse services to almost all Medicaid beneficiaries in Iowa through a behavioral health organization (BHO), Magellan Health Services. Both 1931-eligible and SSI children are required to enroll.  Only a few groups, such as dual eligibles and presumptive eligibles are excluded.

A behavioral health design effort in the state will seek to extend a Systems of Care approach to children with behavioral issues using specialty health homes.   The state has convened a workgroup that made preliminary recommendations in late 2011. Final reports from several workgroups, including a Children’s Disability Services Workgroup, were released in December 2012.  The report from the children’s workgroup reiterated a call to use health homes to coordinate services for Medicaid-enrolled children with serious emotional disturbances, while also foreseeing that “the system will eventually evolve to include children with mental health, behavioral, intellectual, developmental and physical challenges.”

Coordination and Collaboration 

While Iowa Medicaid is located in the Department of Human Services, Iowa’s Department of Public Health, under an agreement with Iowa Medicaid, has established contracts throughout the state with regional Title V agencies both to assist families in accessing Medicaid services and to assist primary care providers in linking families to services. All of these agencies also participate in the state Medicaid program. The regional Title V agencies have four responsibilities for the Medicaid children’s benefit: informing, care coordination, screening, and diagnosis and treatment. The agencies bill the Department of Public Health for informing and care coordination on a fee-for-service basis and bill the Medicaid agency for Medicaid-covered services (such as various screens) through the claims processing system, as would any other qualified provider.

 

The Department of Public Health supports the regional Title V agencies with an internet-based system that helps them identify families in need of informing, assist with linkages to community services and coordination across systems, and bill public health for care coordination services. The public health agency has also created a manual to help coordinators perform these tasks, which includes information on how to form and support community linkages and establish referral pathways.

 

The Iowa Department of Public Health’s 1st Five Healthy Mental Development Initiative was designed to bridge public and private health care systems—building partnerships between physician practices and public service providers—to improve early detection of social-emotional delays and promote prevention of mental health problems among young children. The model promotes the use of standardized screening tools, educates and supports medical practices in implementing developmental screening tools, and uses trained care coordinators who work with families to assure follow-up and access to services. The initiative also offers the Healthy Families line, a 1-800 number that connects families to a local EPSDT Provider Training Consultant to facilitate access to additional screening, evaluation, or intervention services.

 

Community Circle of Care, a collaboration among the Iowa Department of Human Services, Iowa Child Health Specialty Clinics, and the Center for Disabilities and Development, offers care coordination, diagnosis, and assessment services to children and youth with emotional and behavioral challenges in Northeast Iowa in collaboration with local service providers.  The organization uses care coordinators and wraparound plans to ensure that the child and his/her family are involved in treatment decisions and to facilitate delivery of community-based care.

 

Screening, Assessment and Referrals 

Supported by its participation in the Assuring Better Child Development program, Iowa has bolstered its commitment to developmental and mental health screenings and services. Iowa Medicaid pays for developmental screening, including screening for delays in social emotional development and autism. This coverage grew out of the recommendations of the Healthy Mental Development Panel, a group of public and private stakeholders that identifies standards, tools, and referral processes for early identification of developmental problems in children. This panel recommended that Iowa establish three levels of behavioral and developmental services for children, focusing on (1) preventive services, including behavioral and developmental screening, assessment, family risk factors, counseling, and care coordination for all Medicaid eligible children; (2) developmental services, such as problem-based counseling and coordination of care for all Medicaid eligible children identified at risk for developmental or emotional problems; and (3) intensive developmental or mental health services for those children identified in need of therapy. This approach and the information needed to provide and bill for these services has been broadly disseminated to providers in Iowa.

 

The state also supports Iowa’s EPSDT Care for Kids provider website which suggests screening tools and billing codes for developmental and social-emotional screening tools. Some tools—including the Ages and Stages Social Emotional tool, the Brief Infant-Toddler Social and Emotional Assessment, the Child Development Review and Infant Development Inventory, and the Modified Checklist for Autism in Toddlers—can be billed using the 96110 CPT code for developmental screening. Other recommended tools, like the Iowa Child Health and Development Record (Iowa-CHDR, a state-developed tool) and the Pediatric Intake Form, are not billed separately from a comprehensive physical examination.

 

Iowa’s Medicaid provider manual for physicians (see Chapter E, page 139) contains the Child Mental Health Screen, an optional tool developed for use in Iowa’s Medicaid benefit. The tool allows the physician to make a mental health referral based on the conclusions of the screening. Medicaid also has a specific screening center manual for agencies that wish to serve as health screening centers for children receiving Medicaid benefits. The manual discusses mental health assessments for children, beginning with compiling a psychosocial history and proceeding to the use of clinical screening tools. The manual offers several examples of screening tools for use as part of a well-child exam and their unique attributes—including the Pediatric Intake Form, the Pediatric Symptom Checklist, Conners’ Rating Scales for ADHD, and the Children’s Depression Inventory—but does not recommend a specific tool.

 

The state’s behavioral provider manual also contains codes that providers in Iowa can bill for health and behavior assessments, including 96510 and 96511 (health and behavior assessment, initial assessment and re-assessment). Since 2008, the Medicaid fee schedule for physicians has also covered screening and brief intervention for alcohol and drug use under CPT codes 99408 and 99409; an informational letter to providers identified the AUDIT (Alcohol Use Disorders Identification Test) and DAST (Drug Abuse Screening Test) as the preferred tools to be used for these screenings.

 

Through Iowa Medicaid’s relationship with the Department of Public Health and local Title V agencies, Iowa has defined a referral process using local care coordinators that assures all children are referred to and connected with appropriate services. Care coordinators at the Title V agencies assist families with referrals and help link them to needed follow-up services under the Medicaid children’s benefit.

 

Treatment

Iowa’s Medicaid program offers three primary sources of mental health services for children: the Iowa Plan, Behavioral Health Intervention Services, and a Children’s Mental Health Waiver. While there is technically no age restriction on Iowa Medicaid’s habilitation services program for beneficiaries with chronic mental illness, in practice children often do not meet the program’s needs-based criteria.

 

The Iowa Plan is managed by Magellan Behavioral Care of Iowa. Magellan is responsible for arranging access to a range of Medicaid-covered behavioral health services, including mental health services and substance abuse treatment services determined necessary following a screening. The Iowa plan also provides services to the families of some children with mental illness, offering parent support services for families of children and youth with a serious emotional disturbance. Behavioral services reimbursed by Magellan include those offered at community mental health centers, such as day treatment programs for children.

 

Magellan is also responsible for Behavioral Health Intervention Services (formerly the Remedial Service Program), a set of services provided in community-based or residential group care environments to improve a child’s level of functioning as it relates to mental illness. These services include: behavior intervention to modify a range of factors that affect a child’s functioning and to teach and develop skills; crisis interventions to stabilize acute symptoms of mental illness or emotional distress; and family training to enhance the family’s ability to interact with the child and support his functioning at home and in the community.

 

Iowa’s Children’s Mental Health Waiver is aimed at providing home and community-based services to children with serious emotional disturbance (SED). Medicaid-eligible children with an SED diagnosis can choose to enroll in the waiver, at which point a targeted case manager helps to coordinate services for the child and her family and convenes an interdisciplinary team. The team draws from professionals in or near the child’s community and includes: the child and family; the targeted case manager; one or more service managers; mental health professionals; others that the child and family choose to include. Children enrolled in the waiver have an individualized outcome achievement planned, developed in collaboration with the interdisciplinary team, to identify goals and service activities.

 

Acknowledgements

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.