Q&A – 4/18/13

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Q&A – 4/18/13

Young Minds received a question from Toni Hoy on our Facebook page.  Toni is the parent of a child with intensive mental health needs.  Toni adopted her son, Daniel, through Illinois’ foster care system.  Under the Adoption and Safe Families Act (ASFA), Daniel is eligible to receive adoption assistance to help support his family in providing him a permanent home, which includes Medicaid coverage.  Unfortunately, Daniel was denied medically necessary mental health services required under the EPSDT provisions and, as a result, his condition declined to the point where it was no longer safe for him to remain with his family.  Toni is a member of the Attachment & Trauma Network, a committee of parents working to provide treatment for children while preserving their permanency to prevent “second time foster children.”

Toni’s Question:  

Children received permanency through adoption under ASFA which gave them Medicaid as part of the adoption subsidy. Medicaid holds the EPSDT provision which entitles the children to medically necessary services. While the federal government entitled the treatment, the states are failing to implement it, violating federal law and destroying permanency by forcing relinquishment in exchange for care. How can we get ALL states to adhere to EPSDT (other than suing the state as we are doing in Illinois)? I had the thought of writing the EPSDT wording directly into the Adoption & Safe Families Act, so that if states deny residential or other “medically necessary” treatment, it makes for a bulletproof lawsuit.

Our Response:

Dear Toni,

Your question about how families and advocates can make sure that states adhere to EPSDT requirements is recurring and important question. The advocacy strategies Young Minds Advocacy Project uses to enforce young people’s EPSDT entitlement at the state level could be effective in a broader, nationwide approach.  We can’t say that there is any one “best” approach, but the strategies summarized below may be helpful to your Network.

Statutory Changes: Your idea to add EPSDT wording to the Adoption & Safe Families Act may be an effective strategy.  The Medicaid Act already requires that states provide EPSDT services to children with Title IV-E adoption assistance, foster care or guardianship care as a condition for receiving federal funding.  Children who fall into these groups are known as “mandatory categorically needy,” which means that states must provide necessary services to any child involved in these programs that needs care.  Although this requirement is already federal law, your idea to incorporate EPSDT requirements could help strengthen the state mandate and help protect children’s entitlement.  Passing federal legislation is a heavy lift that requires time and substantial resources, but the legislative process itself provides an opportunity to focus national attention on the tragedy of “second time foster children.”  Legislative hearings may give you a chance to tell your story, which helps to humanize the abstract goal of ensuring Medicaid’s mandate.

Actually compelling states to abide by EPSDT requirements is another challenge.  The Centers for Medicare and Medicaid (CMS) is charged with enforcing this federal mandate, including making sure that states provide EPSDT services to children receiving adoption assistance.  Historically, CMS has not played a strong enforcement role, and as a result, efforts to enforce the EPSDT entitlement in the courts have been spearheaded by advocates such as yourself. However, CMS recently released an Informational Bulletin regarding EPSDT with the purpose of “help

[ing] inform states about resources available to help them meet the needs of children under EPSDT.” The bulletin, which provides a long list of resources across the country for clinical guidelines, professional development and training, is a strong step in the right direction.

Alternatives to Litigation: Litigation is an important tool, but not without  limitations.  Lawsuits are expensive and often drawn out, which may further delay children’s access to mental health services.  Also, system reform requires “buy-in” by the people who work within the system—managers, supervisors, clinicians, technicians, etc.  Lawyers alone cannot win the hearts and minds of these essential actors.  In order to transform practice, there must be a collaborative willingness to change, and that usually requires alternatives to adversarial lawsuits.   Based on the circumstances, there are a range of alternative advocacy strategies that may encourage or incentivize states to more successfully implement EPSDT and thereby improve children’s access to individualized, appropriate and effective mental health services.

Improved Transparency in System Performance and Outcome Monitoring: One strategy for encouraging EPSDT access is to encourage states, counties and providers to collect and disseminate data on the children’s mental health system’s performance.  This may include information on the number of eligible children who are able to access EPSDT services, whether provided services were appropriate to their needs and delivered in a timely manner, and whether children’s outcomes improved as a result of receiving services.  YMAP is currently involved in an effort to develop an EPSDT performance and outcomes monitoring system in California.  Although still in the preliminary planning stages, California’s system is intended to allow stakeholders to evaluate performance at every level of the system from the child and family’s clinical experience up to the state’s overarching system.  We believe data collection and reporting systems are critical tools for improving system performance and quality, and ensuring state compliance with EPSDT.

Improved Coordination between Child-Serving State Agencies: Another strategy for improving children’s access to EPSDT services is to require state agencies that serve children to better coordinate their service delivery systems.  This strategy doesn’t directly address enforcement of Medicaid mandates, but instead focuses on one of the key barriers to effective treatment.  Children with more intensive mental health needs are often served by multiple state and local agencies, including child welfare, special education, and juvenile justice systems.  Without an intentional and concerted effort to coordinate service delivery, children’s mental health care becomes fragmented, inefficient and less effective.  Additionally, many children fall into the gaps between these system and may not be served at all.

State agencies can achieve far better outcomes for young people by coordinating service delivery and sharing responsibility and accountability for the mental health care of their mutual clients.  , Reforms are under way in California and Washington that stress shared governance and practice in order to better coordinate mental health care for young people.  Advocates could pursue similar policies on the national level to help facilitate more coordinated delivery systems, including developing more flexible federal funding requirements for children served by multiple agencies.

These are just a few suggestions that your organization might consider.  And keep in mind that whatever path you take, it helps to encourage others to join you.  Only by working together will we achieve appropriate access to mental health care for every eligible young person. 

If you have a question you would like answered please email info@youngmindsadvocacy.org. Any personal information you share with us will be kept anonymous in the absence of direct consent.

Disclaimer: The Q&A segments and the YMAP Hear Me Out Blog are intended to be used for informational purposes only. The information provided should not be relied on as legal advice. Although YMAP appreciates and welcomes your feedback and questions, we do not seek to legally represent any of our readers based on a visit to our website or blog. No attorney-client relationship is formed. Any information submitted at YMAP’s website and blog will not be confidential.  

By |2016-11-17T17:26:29-08:00April 18th, 2013|Featured Posts, Q&A|0 Comments

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