Access to behavioral health services (which includes mental health treatment and substance use disorder services) is particularly important for children and youth. Early identification and treatment of behavioral health conditions, like many chronic conditions, can prevent these conditions from worsening and causing more serious symptoms later in life.
Ensuring access to these services for low-income children and youth in Medicaid, like A.A., is especially important, since low-income youth are more likely to have experienced trauma, and are also more likely to experience long-term adverse effects from that trauma. Youth in Medicaid often experience chronic stress due to poverty and racism, which can affect their development and lead to behavioral health conditions. Youth in the child welfare system, who are eligible for Medicaid, are particularly likely to have behavioral health conditions.
Without the necessary services, children and families suffer. For example, A.A., an eleven-year old Louisiana Medicaid beneficiary needs a variety of behavioral health services to treat his multiple mental health conditions.
For the last three years, A.A.’s family and providers have asked for these services many times, but he has still hasn’t received them, getting only occasional counseling and medication management. As a result, A.A. has frequently been institutionalized in a psychiatric facility, and has also been suspended, expelled, sent to an alternative school, and brought home by the police multiple times.
The Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) provisions of the Medicaid Act are designed to ensure that youth in Medicaid have access to the services they need to prevent, ameliorate, and treat their behavioral health conditions.
The EPSDT mandate is extremely broad, and requires Medicaid programs to cover health services for youth under age 21 when they are necessary to correct or ameliorate a behavioral health condition. Despite this important legal mandate, too often, Medicaid programs fail to provide children and youth with the behavioral health services they need, putting these youth at greater risk of strained family relationships, struggling in school, and becoming involved with the juvenile justice system.
In addition to the requirements imposed by EPSDT, the law requires behavioral health services to be covered similarly to medical services; this is known as behavioral health parity. Parity rules apply in Medicaid managed care in addition to private health coverage programs. For youth under age 21, parity and EPSDT require the same thing: ensuring access to all services needed to correct or ameliorate a youth’s behavioral health condition.
Because, unlike other health coverage programs, in Medicaid EPSDT already provides a strong foundation that requires states to provide youth with a broad range of behavioral health services, and applies the same medical necessity standard to both behavioral health and physical health services, parity compliance in Medicaid is readily met when Medicaid programs comply with EPSDT.
Unfortunately, the federal Medicaid Agency, CMS, has provided little oversight of states’ compliance with this requirement. Instead, it has allowed states to merely attest that their Medicaid programs comply–taking states at their word that they are providing critical mental health and substance use disorder services when necessary to correct or ameliorate the behavioral health conditions of children and youth in their Medicaid programs.
And the evidence suggests that many state Medicaid programs do not provide the range of behavioral health services youth under age 21 need. Children may face a variety of barriers to behavioral health services that are different than for medical services, such as more limited visits, in-network restrictions, more stringent prior authorization criteria, or strict limits on who can provide services.
In addition, some behavioral health services are less likely to be clearly authorized, e.g., they are not listed, therefore they can be difficult to access through the EPSDT process. Even if services are listed, the services are often difficult to find due to a lack of providers. Too often, families and their advocates have had to resort to litigation to ensure that youth in Medicaid programs receive the behavioral health services to which they are entitled.
The new Administration must hold states to a higher standard, and independently analyze whether Medicaid programs are providing their beneficiaries under age 21 with all the behavioral health services they need. The requirements of EPSDT and behavioral health parity are clear and unequivocal when it comes to ensuring access to behavioral health services for children in Medicaid.
But a state’s simple assurance that it complies with EPSDT is not enough without further evidence that behavioral health services are provided with parity to children in that state. For example, not only information about available services to children be provided along with any coverage guidelines, but also denial rates, complaints about lack of services, network capacity data, provider qualifications and restrictions for comparable services, and other factors that indicate whether there are barriers to care that affect parity.
But without clear oversight and enforcement, those legal entitlements are just empty promises, and youth like A.A. continue to go without the services they desperately need. Making good on those promises to protect the behavioral health of low-income children and youth, requires much more.