Preserving Youths’ Entitlement to Care (EPSDT & Realignment)
Some of the most important rights to mental healthcare for children and youth come from federal “entitlement” programs. Generally, an entitlement is a guarantee of access to a benefit that is established by law. In other words, the prescribed benefit is a legal right that must be provided to anyone who meets the criteria for receiving it. In the context of mental health, eligible children have a right to receive particular mental healthcare services if they meet the qualifications for those benefits.
Many children have an entitlement to mental healthcare under Medicaid’s Early Periodic Screening, Diagnosis and Treatment (EPSDT) provisions. Medicaid is a public health insurance program covering over 20 million low-income children nationwide. States that choose to participate in the Medicaid program (all 50 states do) are required under federal law to provide specific physical and mental health services to all Medicaid eligible youth under age 18, or in many states, under the age of 22. Under the EPSDT provisions, states are required to screen youth for health needs, including mental health disorders, and also provide necessary diagnosis and treatment services to help improve conditions that are discovered. If a service is medically necessary for a child, the state must provide the treatment. It is often said that when it comes to a federal entitlement, no money is no excuse for refusing or delaying care.
California’s Medicaid program is known as Medi-Cal. During the 1990s, California created a program to deliver mental health services required by the EPSDT provision, known as the EPSDT Specialty Mental Health Services (SMHS) program.
In 2011, California “realigned” funding and oversight of a number of important programs and functions in the public safety and health and human services arenas, including the EPSDT specialty mental health services program. This means that the State transferred greater responsibility for this program, and many others, down to the counties.
Supporters of “Realignment” believe it gives counties more autonomy and increased flexibility to manage their own budgets and serve young people in need. However, Young Minds and many other youth advocates are deeply concerned with the unintended consequences of the law. The concern centers on whether Realignment results in disinvestment in mental health services and supports for young people and reduced access to care.
Young Minds’ Impact
In the first phase of Realignment, the state transferred $861 million from the Mental Health Services Act (MHSA) Fund to pay for EPSDT specialty mental health services, adult Mental Health Managed Care, and other services for FY 2010-11. This transfer violated the MHSA’s prohibition on using its funds to pay for services previously paid for with state funds. Young Minds’ President, working with a coalition of providers, advocates, parent representatives and youth groups, sent a letter to the Governor detailing concerns and requesting action. Talks ensued, and over several months the stakeholders and the Administration came to agreement on five specific commitments:
- Ensuring that there was sufficient funding in the realigned fund accounts to reimburse counties for EPSDT services they provide;
- Providing additional “growth” funding in future years for EPSDT services;
- Issuing an All County Letter (ACL) that reaffirms that EPSDT services, post realignment, continue to be a federal entitlement;
- Developing and implementing a Performance Outcome System that measures and reports on access to and benefits from EPSDT services; and
- Once and for all, addressing the disparate (and inadequate) access to mental healthcare experienced by foster youth who are placed in homes outside the county in which they enter foster care.
The State has been working to fulfill these commitments since 2011. However, several remain unresolved, requiring continuing advocacy efforts by Young Minds and others to ensure that young people with unmet mental health needs are not disadvantaged by Realignment.
How’d we get here? Issue Background
Historically, counties delivered EPSDT services to Medi-Cal beneficiaries and were reimbursed for their actual costs using federal Medicaid and state general funds. As a result of the 2011 Realignment, however, counties now have primary responsibility to fund the state share of costs using dedicated state tax revenues.
The new funding stream is divided among several behavioral health programs and allocated to the counties by the state. SB 1020, enacted in 2012, directed the Department of Finance (DOF) and the Department of Health Care Services (DHCS) to develop a methodology for distributing the funds. Using past spending [PG2] data, the departments have set a yearly allocation for each county, but have yet to propose a permanent formula for allocating either historic funding, referred to as “base funds”, or additional new funding, referred to as “growth funds.” Gross funding in 2011-12 was $1.36 billion for children’s specialty mental health services. Growth funds are estimated to be $27.9 million in fiscal year 2012-13, $52.8 million in 2013-14, and $184.3 million in 2014-15.
For the latest news on this issue read the blog posts below!